A critical review of the impact of reconstructive A critical review of the impact of reconstructive surgery following massive weight loss on patient surgery following massive weight loss on patient

QoL & a pilot study plan.QoL & a pilot study plan.

Jo Gilmartin, Mark Soldin & Prof Andrew Long

Global Obesity Epidemic Global Obesity Epidemic

A major health problem& a growing number of morbidly obese patients are seeking surgical solutions-bariatric surgery

Experience ‘prejudice’ & ‘social exclusion’MWL often leads to excess of lax,

overstretched skin causing physical dysfunction/ Psychosocial –QoL problems

Risk of Co-morbidities

For example, health consequences such as:Stress on joints, Fatigue, InsomniaDiabetes, HypertensionHigh blood cholesterolStrokes, DVT’sHeart attacks & kidney failureAnxiety & depression, Powerlessness

Fat PoliticsFat Politics

Media ideal of thinness, denigrates fatness by linking it to negative characteristics such as ugliness, laziness, failure & anti-social.

Marginalised by societyProminence of surveillance-power

inequalitiesGovernment public health campaigns-

lifestyle choices (Tischner & Malson 2008)

Background

Patients seeking body contouring after MWL constitutes a rapidly growing patient population in plastic surgery practice (Song et al 2006).

However, QOL outcomes following body contouring appears to remain largely unexplored territory.

Literature ReviewLiterature Review

Yielded 12 papers that met the inclusion criteria

7 studies reported that reconstructive surgery following MWL correlated with QoL in several areas (Migliori et al 2006, Song et al. 2006, Pecori et al. 2007, Cintra et al. 2008, Mitchell et al. 2008, Lazer et al. 2009 and van der Beek et al. 2010)

ResultsResults

7 of the studies utilised a retrospective approach. For example,

Au et al .(2008) undertook a retrospective random chart review on patients who underwent body contouring from 1993-2002.

Other studies used a more scientific approach Van der Beek et al. (2010) used OPSQ & Mitchell et al (2008) employed an appearance questionnaire.

A few studies used a prospective approach

3 Themes emerged3 Themes emerged

1. Improved QoL improved physical functioning, improved mental well-being, improved self-efficacy towards eating, improved social

acceptance, fewer problems of intimacy and sexuality (van der Beek et al. (2010).

Lower scores in body uneasiness (Pecori et al. (2007) positive thinking, body image satisfaction, sexual life resumption or

improvement (Migliori et al. (2006)

Improved QoL (Cont’d)Improved QoL (Cont’d)

Cintra et al. (2008) reported that 87.5% had a positive self-esteem & a very good self image,

68.5 % declared freedom from dependence or disability & a better sex life.

Lazar et al. ( 2009) found that 84.6% had improved QoL- better sexual relations (74%), aesthetics (79.5%), psychological status (86.5%) & current life (100%).

Improved QoL (Cont’d)Improved QoL (Cont’d)

Song et al. (2006) found that body contouring improved QoL significantly, with a mean 55% overall improvement in QoL measurements (n=13), p.<0.01).

Mitchell et al. (2008) found some congruency between perceptions of attractiveness & improved QoL.

2. Dissatisfaction from Body 2. Dissatisfaction from Body ContouringContouring

For example, Occurrence of dogs ears in the scar. Results did not match expectations based on Internet

examples (van der Beek et al (2010) Dissatisfaction with skin breakdown, most commonly

reported being sores, Rashes and skin breakdown in the waist/abdomen area

(25%), Chest/Breasts (19%), Thighs (16%), Rear/buttocks area (7%) (Mitchell et al. (2008)

Body Contouring Body Contouring

Body ContouringBody Contouring

3. Complications3. Complications

The majority appeared to be related to:- Wound dehiscence – ‘wound distruption’ Tissue necrosis Wound infection Serious Fluid collection Seroma Hematoma/DVT/PE Anemia because of blood loss (Mustoe 2005; Au et

al 2008; Cintra et al. 2008 & de Kerviler et al. 2009)

Implications for health Implications for health professionalsprofessionals

1. Development of NSF & an ‘ideal’ care pathway to empower this client group.

2. Educate patients about deciphering appropriate sources of information to make a properly informed decision about going ahead.

3. Regulation of cosmetic surgery is concerned with

enhancing standards of clinical excellence but excluding ‘professional awareness of cultural & social pressures on women patients’ ( Latham 2008, p.438).

Implications for health professionals cont’d

1. Emphasise patient choice, & promote a stronger patient voice to create autonomy enhancing conditions.

2. The medical power relations appear to be asymmetrical-scientific knowledge & medicalization.

3. Transactional notions of power exploited-problematic

4. Empower potential consumers to access counselling or support networks.

Mapping- Hierarchy of Mapping- Hierarchy of EvidenceEvidence

Review LimitationsReview Limitations

1. Lack of Systematic Reviews & RCT’S.2. Small Sample size.3. Single centre database used in all of the studies.4. Methodology is poorly articulated in some

studies (e.g. Mustoe 2005).5. Many of the studies did not appear to

incorporate validated instruments.

Review Limitations Review Limitations

Some studies were preoccupied with describing surgical procedures

Others only used a case note reviewSome studies only included women in the

sampleThe majority used a retrospective approachThere is a huge scarcity of high-level

evidence in regard to QoL Outcomes

Pilot StudyPilot Study

Aim:1. To identify tools & procedures to inform a large

scale multicentre study.2. To identify QoL outcomes from body

contouring following massive weight loss. 3. Intent To gain preliminary data for national

competitive grant applications to be submitted in the 2011/2012 rounds.

Pilot Study- ApproachPilot Study- Approach

Mixed Methods1. Questionnaire- Obesity Psychosocial State

Questionnaire

2. Scales3. Physical health, mental well-being, external

contentment, self-esteem, social judgements, self-efficacy towards eating habits, intimacy & sexuality, social network

Method’s Cont’dMethod’s Cont’d

2 Semi- structured interviews to explore the participant's experience before and after surgery,

focusing on general well-being, body image/identity emotional well-being, levels of function and activity. 3. Demographics & weight characteristics - Medical

Records4. Sample: 20 –25 patients 5. Study Site: Plastic Surgery Dept, St George’s Hospital,

London

Pilot Study – Phase 1Pilot Study – Phase 1

Preparation & submission of Pump Priming BID –Successful Outcome.

Preparation & submission of Ethical application for approval –was gained from South West London REC 4.

Preparation & submission of R&D application for approval –was gained from St George’s Hospital, London.-Dec 2010

Pilot Study- Phase 2Pilot Study- Phase 2

We are setting out to:1. Identify & recruit 20-25 patients for the

pilot work- Invitation letters sent out2. Undertake the field work- data collection3. Undertake a rigorous data analysis4. Disseminate the results 5. Prepare a grant application for a large

scale study

Large Scale StudyLarge Scale Study

We are setting out to: Develop a large scale Multicentred study in the

UK. Establish a user group to inform the research &

ensure it addresses issues of importance to users. Design a rigorous methodology. Establish a dynamic research team. Prepare a robust grant application.

ReferencesReferences Cintra W, Modolin, MLA, Gemperli R, Gobbi CIC, Faintuch J, Ferreira MC (2008)

Quality of Life after abdominoplasty in women after bariatric surgery. Obesity Surgery. 18:728-732.

Lazar CC, Clerc I, Deneuve S, Auquit-Auckbur I, Milliez PY (2009) Abdominoplasty after major weight loss: improvement of quality of life and psychological status. Obesity Surgery 19:1170-1175.

Migliori F, Rosati C, D’Alessandro G, Giacomo G, & Cervetti S 2006. Body Contouring after Bilopancreatic Diversion. Obesity Surgery, 16, 1638-1644.

Mitchell JE, Crosby RD, Ertlet TW, Marino JM, Sarwer DB, Thompson JK,Lancaster KL, Simonich H, Howell LM (2008) The desire for body contouring surgery after bariatric surgery. Obesity Surgery 18:1308-1312.

Mustoe TA (2006) Abdominoplasty:a comparison of outpatient and inpatient procedures shows that it is a safe and effective procedure for outpatients in an office-based surgery clinic. Journal of Plastic and Reconstructive Surgery. 523-524.

Tisschner I & Malson H. (2008) Exploring the politices of women’s in/visible ‘Large’ , Bodies. Feminism & P sychology , 17 (4). 260-267.

ReferencesReferences

Pecori L, GiacomoG, Cervetti S, Marinari G M, Migliori F, Adami G F (2007) Attitudes of morbidly obese patients to weight loss and body image following bariatric surgery and body contouring. Obesity Surgery 17, 68-73.

Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH (2006) Body

image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring) 14:1626-1636.

Van de Beek ESJ, te Riele W, Specken TF, Boerma D, van Ramshorst B (2010) The impact of reconstructive procedures following bariatric surgery on patient well-being and quality of life. Obesity Surgery 20: 36-41.