- Key Points Proper evaluation of the weight loss patient includes the following key components.
- Calculating BMI at time of presentation and assessing stability of weight. • Screening for residual medical problems associated with obesity and gastric bypass.
- Elucidating relevant psychosocial issues.
- Diagnosing the deformities that result from massive weight loss.
- Understanding the patient’s goals and expectations.
- Formulating a safe treatment plan.
With the universal increase in morbid obesity and the concomitant development of advanced laparoscopic techniques, a large number of patients are opting for surgical therapy to reduce excess body weight and ameliorate the myriad of associated medical problems. The US Centers for Disease Control and Prevention estimate that in excess of 64% of the US population is either overweight or obese.1 On a global scale, the International Obesity Task Force estimates that more than 1 billion individuals are overweight.2 The American Society for Bariatric Surgery estimated that greater than 150000 weight loss procedures would be performed in the USA alone in the year 2005.3 As surgical techniques have evolved, and weight loss surgery has been performed with greater frequency, the tremendous health benefits have been noted in many studies.4–13 However, the enormous benefits that the patients receive also come at the cost of redundant, loose, hanging rolls of skin and fat. Nearly every region of the body can be affected. This has fueled a rapid increase in the number of patients presenting to the plastic surgeon’s office for body-contouring procedures. It is essential that the plastic surgeon approach these patients in a concise, well-thought-out fashion with safety as the primary concern.
The individuals who seek the advice and expertise of a plastic surgeon regarding the removal of excess skin after massive weight loss have undergone a major life-altering event. While their overall body shape has changed dramatically, they retain a daily reminder of their obese state in the form of loose, hanging skin. It is important for the clinician to realize this, and to recognize that patients may still view themselves as ‘fat’ and ‘different’. Despite successful weight loss, self-esteem may be low. These patients often state that they feel triply stigmatized: • first for being morbidly obese, • second for choosing surgical therapy to lose weight (the ‘easy way out’), and • third for being considered vain and seeking the help of a plastic surgeon. Patients will be looking for a specialist who understands the emotional as well as the physical needs of the postbariatric patient, and their comfort with you will be influenced by your sensitivity to self-esteem issues. We often start the interview by congratulating patients on the progress they have made in the process of weight loss and for taking steps to reclaim their lives. Key historical components specific to the weight loss patient are described in detail below, and provide the basis for a thoughtful assessment. Figure 2.1 shows an office data collection sheet that we use in our center to summarize some of the important data points.
Weight loss history and nutritional assessment
While the initial interview is an excellent time to establish a rapport with your patients, it is also an opportunity to elicit a detailed history of their weight loss surgery and compliance with the nutritional regimen after weight loss. The surgeon should know what type of procedure the patient had, as different operations will have varying potential to cause nutritional deficits. Other important data points include:
• the timing of the weight loss surgery relative to the plastic surgery consult, • Body Mass Index (BMI) prior to surgery,
EVALUATION OF THE MASSIVE WEIGHT LOSS PATIENT WHO PRESENTS FOR BODY-CONTOURING SURGERY
James P. O’Toole and J. Peter Rubin
Key Points Proper evaluation of the weight loss patient includes the following key components.
• Calculating BMI at time of presentation and assessing stability of weight.
• Screening for residual medical problems associated with obesity and gastric bypass.
• Elucidating relevant psychosocial issues.
• Diagnosing the deformities that result from massive weight loss.
• Understanding the patient’s goals and expectations.
• Formulating a safe treatment plan.
• lowest weight reached since bariatric surgery,
• current BMI,
• goal weight, and
• the last time the patient has met with his or her bariatric team. We ask specifically about weight loss (or gain) in the 3 months prior to the plastic surgery consult to assess stability.
The plastic surgeon takes a nutritional history relevant to the weight loss surgery patient. Most weight loss patients will have adequate food intake for the unstressed state. Indeed, it is rare to see a weight loss surgery patient with overt signs of malnutrition. The plastic surgeon should determine if nutritional intake is adequate to meet the demands of a major surgical procedure. This begins by inquiring about any prolonged
problems, such as nausea, which may preclude adequate protein intake to heal large surgical wounds. Beware of patients with persistent nausea at a year or more following gastric bypass; they may have a mechanical problem warranting treatment by the bariatric surgeon. The surgeon should inquire if the patient is taking all recommended supplements. Calcium, vitamin B12, and iron are usually prescribed by the bariatric surgeon after Roux-en-Y gastric bypass to prevent micronutrient deficiencies.14 It is valuable to get an assessment of the patient’s daily protein intake. Three ounces of lean poultry or fish provides approximately 20g of protein, 3 ounces of beef provides 25g, 8 ounces of cottage cheese contains 28g, 8 ounces of milk contains 8g, and most hard cheeses contain about 7g per ounce.15
2 Evaluation of the massive weight loss patient who presents for body-contouring surgery
Date of consult: GBP GBP
Date of GBP: Surgeon: Complications:
Lowest post-GBP weight: Referral source:
Goal weight: Max BMI:
Current weight: Current BMI:
Recent weight loss
Last month: Previous body contouring: History of DVT/PE? (Circle one) Y N
Last 3 months: Therapy:
Nutritional status (circle one): Adequate protein Inadequate protein Significant nutritional risk
Patient’s primary concern (circle one): Abdomen Arms Chest Buttock Thighs Face Neck Flank
Patient’s order of priority/goals:
Physician notes/surgical plan:
Photos taken and date:
Abdomen: Breast: Arms:
Full body: Thighs: Face/neck:
Figure 2.1 Sample clinic data sheet for quick reference, evaluation of patient’s goals, and surgical plans. GBP, gastric bypass procedure.
Ask about any food aversions. Many patients will struggle with concentrated animal protein after gastric bypass and may have a difficult time maintaining a high protein intake.16 In our center, we require patients to take at least 50–70g of protein per day before elective body-contouring surgery. A referral for formal nutritional evaluation and counseling, followed by dietary modification and repeat assessment, would be recommended if protein intake is poor. Even patients with food aversions can find protein sources that they can tolerate well if they are coached through the process. It is essential for the surgeon to understand that a weight loss patient with a favorable BMI does not necessarily represent a good surgical candidate. Major surgery can increase the body’s nutritional requirements by 25%, and many weight loss patients may have to adjust their oral intake.17
Screening for medical problems The initial patient interview also provides the clinician with the first opportunity to appreciate any medical issues that may increase the risk of surgery. While body-contouring surgery after massive weight loss may make a patient look and feel better, it does not have the same level of overall health benefit as gastric bypass does.18 The key focus is patient safety, and a history of significant medical problems, including hypertension, ischemic cardiac disease, sleep apnea, and diabetes, must be fully delineated and addressed before body-contouring surgery. While most medical comorbidities of obesity are significantly improved, if not resolved, following weight loss, the plastic surgeon must search for residual disease. Exercise tolerance is a useful indicator of surgical risk. Patients who routinely do 45min of vigorous exercise without shortness of breath or other symptoms will likely tolerate the stress of surgery. However, beware of the inactive patient. These patients may have cardiac disease that will be unmasked by a major surgical procedure. We advise liberal use of medical consultants, as warranted, for preoperative evaluation and recommendations for managing chronic disease states. Patients who smoke are encouraged to take responsibility for stopping in order to decrease their perioperative risk.
Psychosocial and lifestyle issues Permanent lifestyle modifications are essential to long-term weight loss success for patients after bariatric surgery. Do they have a definitive exercise regimen? Do they have an exercise ‘buddy’ or at least a source of encouragement from friends and family? Does the patient attend support group meetings? Delineate the follow-up routine the patient has with their bariatric surgeon. The majority of trained weight loss surgeons have well-developed postoperative routines and support groups. If your patient has gone to such a surgeon, and has not been faithful with the postoperative regimen, explore the reasons. Issues with compliance may be elucidated. These queries give a reasonable assessment of how invested the patient is in her or his own care. We find that the more motivated patient generally represents a better candidate for elective bodycontouring surgery. We look for patients who understand that
it is not just the gastric bypass surgery that made them lose weight, but rather their own personal commitment and responsibility to the process. Weight loss can often be accompanied by major changes in interpersonal relationships. Relationships may be strengthened as family and friends rally behind the successful bariatric patient. However, the radical change in appearance and lifestyle of the patient also has the potential to evoke feelings of envy, jealousy, and abandonment in people close to them. Turmoil may ensue. While patients may be reluctant to discuss these issues, it is vital to understand the stability of their support network and the stressors that may be active before adding the additional burden of recovering from surgery. Our approach is to ask patients about their personal lives, their marriages, their living arrangements, their level of contentment with their lives personally and professionally, and their support network. Example questions include the following.
• ‘Who lives at home with you, and are they able and willing to help?’
• ‘Who are the other people available to help you in the first few days to weeks?’
• ‘Who can drive you to post op visits?’ Observe the affect of the patient during the interview. Individuals who have triumphed over the problems associated with obesity can reasonably be expected to be proud of their accomplishments. Be cautious of the patient who gives elusive or vague answers to questions about their social situation. The withdrawn individual should prompt further questioning about symptoms of depression. While it is common to see patients treated with antidepressants after a gastric bypass procedure, simple depression is not a contraindication to surgery. Inquire about general mood and any depressive episodes during the past year. Patients with poorly treated (or untreated) depression should be referred for psychiatric clearance. Additionally, any patients with bipolar disorder or schizophrenia should also have formal psychiatric clearance.
All aspects of a thorough physical examination should be included in the initial patient evaluation in order to fully appreciate the deformities and screen for residual medical problems. The massive weight loss patient will present with a wide range of physical anomalies. BMI, overall body type (truncal versus peripheral), remaining adipose tissue, and rolls and folds should be noted. Body fat distribution will vary greatly in this patient population and will influence surgical options. Attention should be given to the patient’s skin tone and elasticity, as well as regional variations in skin elasticity. On the abdominal examination, make note of:
• thickness of the subcutaneous tissue,
• presence of any hernias,
• degree of diastasis, and
• overall laxity of the abdominal wall.
To facilitate analysis of deformities in each anatomical region of the body, a four-point rating scale can be applied. Table 2.1 shows the Pittsburgh Weight Loss Deformity Scale, which serves as a tool to delineate the severity of deformities.19 During the examination, consideration may be given to the number of procedures required, the interactions of each procedure, and whether staging would be appropriate. Look for stigmata of nutritional depletion, including thin hair, brittle nails, and BMI <23kg/m2 (it is rare for patients to reach this level). Be observant for any physical limitations that will make the recovery period too physically demanding or be aggravated by surgical trauma. For example, a patient with chronic shoulder pain that limits range of motion may have a difficult time recovering from a brachioplasty.
MANAGING PATIENT EXPECTATIONS
Our approach is to ask patients to list the regions of their bodies that they would like to correct in order of priority. We then discuss surgical options that would effect changes in these regions, including the location of the scars and the extent of recovery. We emphasize the concept of trading excess skin for scar, and assess the patient’s willingness to accept these scars. We also emphasize the concept that, in general, body-contouring procedures are major surgical procedures. Having adequate time available to recover from the procedure is something that should be addressed before surgery; this will allow patients to make arrangements with their employer or, if necessary, delay surgery until a more suitable time. Patients are also informed that skin relaxation (relapse of skin laxity) is unpredictable and can be severe enough to lead to operative revision. We recommend advising patients about any office policies regarding fees associated with revision surgery. We find it useful to stand patients in front of a mirror and review how areas of skin laxity might be improved on their body, including a demonstration of how the surgeon pulls on the skin to estimate the amount of resection and the resultant impact on contour. During this part of the examination, limitations of the procedures, given the patient’s body type, are discussed. This often includes an explanation of which anatomical regions can be changed with a given procedure and, importantly, which adjacent regions will not be impacted. How existing scars will be handled, and the effect of the procedure on stretch marks inside and outside the area of planned resection, is explained. The quality of previous scars is noted and used as a guideline to predict how future scars may appear. To further emphasize the issue of surgical scars, a skin marker is often used to draw the location of the scars directly on the patient’s body and photographs are taken. This also helps the patient review scar location with their spouses or significant others after the consultation. Patients who comprehend these issues and whose priorities are addressed first are likely to be satisfied with the procedures performed. If the points outlined in this section are thoroughly conveyed by the surgeon, unrealistic expectations on the part of
the patient will emerge during the discussion. If these expectations cannot be balanced, an unsatisfactory result is likely.
Patient selection must be focused on maximizing safety. With that goal in mind, the following key principles should be applied.
• The patient should be weight-stable.
• BMI should be favorable.
• Nutrition must be adequate.
• Medical and psychosocial issues should be stable.
• The patient should have reasonable goals and expectations considering their age, health, and body habitus. It is also desirable for the patient to be on a definitive exercise regimen. One may be lured into operating on a patient whose anatomical deformities are easy to correct. However, underappreciated nutritional, medical, and psychosocial issues may lead to an unfavorable outcome. Any issue that may influence the safety of the planned procedure must be remedied prior to operative intervention. If surgery is not to be offered at the initial consultation, remain the patient’s advocate and encourage his or her continued progress. Inform patients that you respect all that they have accomplished.
We emphasize that there is a correct time for elective surgery, and that this may not be the best time. While they may be disappointed, they will understand and appreciate that you are keeping their best interests in mind. It is a common practice in our center to have patients work on problematic nutritional or medical issues after the initial consultation and follow-up for another evaluation in 1–3 months. Figure 2.2 shows a checklist of the important components to consider. All patients considered candidates for body-contouring surgery must be weight-stable for 3 months (this usually occurs between 12 and 18 months after a gastric bypass procedure). This is important for several reasons.
• For large surgical wounds, nutritional homeostasis and a positive nitrogen balance are necessary to facilitate the healing process.
• A more predictable outcome can be achieved when the patient is not actively losing weight.
• A high BMI is associated with increased wound-healing complications.21,22 The BMI at presentation is an important factor. As the patient’s BMI decreases, we are able to offer more safe surgical options and expect better aesthetic outcomes.
The best candidates have a BMI of 28kg/m2 or less. We are more cautious in our level of aggressiveness with patients who have a BMI between 29kg/m2 and 32kg/m2. Patients whose BMI is between 32 and 35kg/m2 should be selected with great care, and procedures may be more limited than for patients with a lower BMI. If a patient in this BMI range desires significant contouring, we recommend delaying the operation until further weight loss can be achieved. The technical challenge and subsequent outcome are impacted by body fat distribution.
2 Evaluation of the massive weight loss patient who presents for body-contouring surgery
Table 2.1 Pittsburgh Weight Loss Deformity Scale
Area Scale Definition Preferred procedure(s)
Arms 0 Normal None 1 Adiposity with good skin tone UAL and/or SAL 2 Loose, hanging skin without severe adiposity Brachioplasty 3 Loose, hanging skin with severe adiposity Brachioplasty with UAL and/or SAL Breasts 0 Normal None 1 Ptosis grade 1 or 2 or severe macromastia Traditional mastopexy, reduction, or augmentation techniques 2 Ptosis grade 3, or moderate volume loss, or Traditional mastopexy ± augmentation constricted breast 3 Severe lateral roll and/or severe volume Parenchymal reshaping techniques; loss with loose skin consider autoaugmentation Back 0 Normal None 1 Single fat roll or adiposity UAL and/or SAL 2 Multiple skin and fat rolls Excisional lifting procedures versus liposuction 3 Ptosis of rolls Excisional lifting procedures Abdomen 0 Normal None 1 Redundant skin with rhytids or moderate Miniabdominoplasty, versus full adiposity without overhang abdominoplasty 2 Overhanging pannus Full abdominoplasty 3 Multiple rolls or epigastric fullness Modified abdominoplasty techniques, including fleur de lis and/or upper body lift Flank 0 Normal None 1 Adiposity UAL and/or SAL 2 Rolls without ptosis UAL and/or SAL 3 Rolls with ptosis Excisional lifting procedures Buttocks 0 Normal None 1 Mild to moderate adiposity and/or mild to UAL and/or SAL moderate cellulite 2 Severe adiposity and/or severe cellulite UAL and/or SAL ± excisional lifting procedure 3 Skin folds Excisional lifting procedure Mons 0 Normal None 1 Excessive adiposity UAL and/or SAL 2 Ptosis Monsplasty 3 Significant overhang below symphysis Monsplasty Hips/lateral thighs 0 Normal None 1 Mild to moderate adiposity and/or mild to UAL and/or SAL ± excisional lifting procedure moderate cellulite 2 Severe adiposity and/or severe cellulite UAL and/or SAL ± excisional lifting procedure 3 Skin folds Excisional lifting procedure Medial thighs 0 Normal None 1 Excessive adiposity UAL and/or SAL ± excisional lifting procedure 2 Severe adiposity and/or severe cellulite UAL and/or SAL ± excisional lifting procedure 3 Skin folds Excisional lifting procedure Lower thighs/knees 0 Normal None 1 Adiposity UAL and/or SAL 2 Severe adiposity UAL and/or SAL ± excisional lifting procedure 3 Skin folds Excisional lifting procedure
SAL, suction-assisted lipectomy; UAL, ultrasound-assisted lipoplasty. (Adapted from Song et al 2005,19)
The patient should be counseled that additional weight loss allows for a safer operation with better aesthetic outcomes. Work on a weight loss plan with the patient and nutritionist, and schedule a 2- to 3-month follow-up appointment. This way, the patient will remain under your care and not feel abandoned; moreover, you are able to serve as a motivating source. Some patients in this BMI range may benefit from a first-stage breast reduction or simple panniculectomy if such a procedure would improve their ability to exercise and progress with further weight loss. For patients with a BMI greater than 35kg/m2, our practice is, in most cases, to avoid operations because of increased risk of complications and less potential for satisfying aesthetic results.22,23 Patients in this BMI range would generally be offered only a truly functional panniculectomy, with strict indications of severe panniculitis or a profoundly disabling pannus. The importance of the nutritional status of the postbariatric patient cannot be overstressed.24–27 If patients have symptoms consistent with a physical impedance to eating, have them see their bariatric surgeon to rule out stricture. Because gastric bypass patients have altered gastrointestinal physiology, and subsequent dietary issues are to be expected, nutritional issues should be revisited in the postoperative period if any woundhealing complications arise.28 As mentioned earlier, our practice is to require at least 50–70g of protein intake per day before surgery will be offered. A patient who is incapable of 50g per day does not represent a surgical candidate, and dietary modification is essential. Medical and psychosocial issues must also be stable prior to any operation. Patients with significant medical comorbidities are routinely sent to an appropriate medical specialist for further evaluation and clearance. An adequate support network
should be in place. Active smokers are encouraged to stop at least 1 month prior to surgery. If this is not possible, then the extent of the procedure performed, especially the amount of tissue undermining, is limited. Similar caution is exercised with diabetic patients and those treated with steroids. The final component is a reasonable set of goals and expectations. Patients should be willing to accept extensive scars in exchange for loose skin, understand both the power and limitations of the intended procedures, and appreciate which areas of the body will not be affected by the planned surgery. This last point is important because improving one area of the body may highlight deformities in adjacent areas.
COMBINATION PROCEDURES, STAGING, AND DEALING WITH ABDOMINAL HERNIAS
Performing body-contouring procedures in two or more stages should be considered if the patient has goals of reshaping multiple regions. The advantages of staging are:
• less anesthetic time,
• less blood loss,
• less surgeon fatigue,
• avoidance of opposing vectors of pull on regions of skin, and
• the ability to have a second chance to correct any contour irregularities or skin relaxation seen after the first stage. Disadvantages of staging include: • multiple anesthetics,
• increased time off work, and
• increased expense for the patient.
2 Evaluation of the massive weight loss patient who presents for body-contouring surgery
What is the current BMI?
Has the patient’s weight been stable for at least 3 months?
Active nausea or vomiting? If yes, immediate referral to gastric bypass surgeon.
Would the patient benefit from further weight loss? If yes, return in 2–3 months for weight check.
Is the patient’s nutrition adequate? If no, comprehensive nutritional evaluation.
Is the psychosocial situation stable and adequate?
Are there medical issues that preclude safe surgery and/or require further evaluation?
Is the patient willing to accept visible scars?
Does the patient understand the magnitude of the planned procedure?
Does the patient appreciate the recovery involved and have an adequate support network?
Are expectations reasonable?
Figure 2.2 Screening and evaluation checklist.
While it may be feasible to do two or three procedures in a single stage, the surgeon should be guided by his or her level of experience, experience of the operating room team, and treatment setting. Individual procedures may be performed safely at a fully equipped surgery center, assuming that adequate personnel are available for recovery and that adequate arrangements are in place should extended recovery be necessary. Great caution should be exercised in the surgery center setting if combined procedures are considered. Multiple (more than two) procedures performed in a single anesthetic should take place in a hospital setting. It is not uncommon for the plastic surgeon to encounter a massive weight loss patient with an incisional hernia. When approaching these patients, we first consider whether there has been sufficient weight loss to avoid excessive pressure on the repair exerted by a still obese intraabdominal compartment. It is reasonable to recommend further weight loss and use of an abdominal binder for comfort before performing surgery on a large asymptomatic hernia, if necessary. If the patient has reached an appropriate body weight for hernia repair, consideration is then given to the extent of the procedure. For small or moderate-sized hernias, we will combine the repair with major body-contouring procedures (e.g. lower body lift). Very large hernias may require extensive lysis of adhesions and/or separation of the abdominal wall components to achieve closure. When such an abdominal wall reconstruction is anticipated, we limit the body-contouring procedures to a concurrent panniculectomy and stage any other desired surgeries. We routinely bowel-prepare patients with hernias, and seek recommendation from the patient’s bariatric surgeon regarding the preferred method. Bariatric surgeons may be dogmatic about which gastrointestinal medications are prescribed for their patients. Moreover, the referring weight loss surgeon may want to be involved with these cases in a team approach.
Body contouring is a wonderful adjunct to bariatric surgery and completes the weight loss process for many patients. Any plastic surgeon who evaluates patients after massive weight loss will see the full spectrum of patient subtypes. The majority of patients who present to the office for contouring surgery will be well adjusted and have undertaken great measures to reclaim their lives. However, there will be individuals who are not quite prepared for surgery. A thoughtful and organized approach to the massive weight loss patient will identify the individuals who represent good surgical candidates. Carefully devised operations for the appropriate patient at the right time have the potential to provide a tremendously rewarding experience for the patient and surgeon. As the surgeon, you have the capability to eradicate the last reminders of the obesity that these patients have labored so long to be rid of.
National Center for Health Statistics. National Health and Nutrition Examination Survey. Online. Available: http://www.cdc.gov/nchs/ nhanes.htm 2006. 2. International Obesity Task Force. About obesity. Online. Available: http://www.iotf.org 2006. 3. American Society for Bariatric Surgery. Online. Available: http://www.asbs.org/ 2006. 4. Dixon JB, O’Brien PE. Changes in co-morbidities and improvements in quality of life after LAP-BAND placement. Am J Surg 2002; 184:51S–54S. 5. Dhabuwala A, Cannan RJ, Stubbs RS. Improvement in comorbidities following weight loss from gastric bypass. Obes Surg 2000; 10:428–435. 6. Choban PS, Onyejekwe J, Burge JC, et al. A health status assessment of the effect of weight loss following Roux-en-Y gastric bypass for clinical obesity. J Am Coll Surg 1999; 188:491–497. 7. Vidal J. Updated review on the benefits of weight loss. Int J Obes 2002; 26:25S. 8. Dietel M. How much weight loss is sufficient to overcome major co-morbidities? Obes Surg 2001; 11:659. 9. Goldstein DJ. Beneficial health effects of modest weight loss. Int J Obes 1991; 16:397. 10. Carson JL, Ruddy ME, Duff AE, et al. The effect of gastric bypass surgery on hypertension in morbidly obese patients. Arch Int Med 1994; 154:193–200. 11. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995; 222:339–341. 12. Sugerman JH, Baron PL, Fairman RP, et al. Hemodynamic dysfunction in obesity hypoventilation syndrome and the effects of treatment with surgically induced weight loss. Ann Surg 1998; 207:603–605. 13. Frezza EE, Ikramuddin S, Gourash W, et al. Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass. Surg Endosc 2002; 16:1027–1031. 14. Rubin JP, Nguyen V, Schwentker A. Perioperative management of the post–gastric-bypass patient presenting for body contour surgery. Clin Plast Surg 2004; 31(4):601–610. 15. US Department of Agriculture. USDA National Nutrient Database for Standard Reference, release 17. Washington: USDA; 2004. 16. Brown EK, Settle EA, Van Rij AM. Food intake patterns of gastric bypass patients. J Am Diabet Assoc 1982; 80(5):437–443. 17. Van Way CW. Nutritional support in the injured patient. Surg Clin North Am 1991; 71:537–548. 18. Gleysteen JJ, Barboriak JJ. Improvement in heart disease risk factors after gastric bypass. Arch Surg 1983; 118:681–682. 19. Song AY, Jean RD, Hurwitz DJ, et al. A classification of weight loss deformities: the Pittsburgh Rating Scale. Plast Reconstr Surg 2005; 116:1535–1554. 20. Halverson JD. Micronutrient deficiencies after gastric bypass for morbid obesity. Am Surg 1986; 52(11):594–598. 21. Matory WE, O’Sullivan J, Fudem G, et al. Abdominal surgery in patients with severe morbid obesity. Plast Reconstr Surg 1994; 94:976–987. 22. Vastine VL, Morgan RF, Williams GS. Wound complications of abdominoplasty in obese patients. Ann Plast Surg 1999; 42:33–35. 23. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: a review. J Am Coll Surg 1997; 185:592–593.
Charles P. Calcium absorption and calcium bioavailability. J Int Med 1992; 231(2):161–168. 25. Rhode BM, Arseneau P, Cooper BA, et al. Vitamin B-12 deficiency after gastric surgery for obesity. Am J Clin Nutr 1996; 63(1):103–109. 26. Lash A, Saleem A. Iron metabolism: a comprehensive review. Ann Clin Lab Sci 1995; 25(1):20–30.
Kushner R. Managing the obese patient after bariatric surgery: a case report of severe malnutrition and review of the literature. JPEN: J Parenter Enteral Nutr 2000; 24(2):126–132. 28. Halverson JD. Metabolic risk of obesity surgery and long-term follow-up. Am J Clin Nutr 1992; 55(2 suppl):602S–605S.