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Page 2 of 8 Bota et al. Plast Aesthet Res 2018;5:30 I http://dx.doi.org/10.20517/2347-9264.2018.47

strictions and physical activity as well as pharmacotherapy are the first choices in reducing the body weight.
In advanced cases the bariatric surgery comes into play, especially the laparoscopic procedures being able
[3]
to provide weight loss with reduced complication rates . According to the German guideline for Adiposity
and Metabolic Disease Surgery, 2018, the surgical therapy is recommended in patients with a BMI ≥ 40, in
patients with a BMI between 35 and 40 and comorbidities associated with obesity and in patients with a BMI
[4]
between 30 and 35 and type 2 diabetes mellitus . In 2013 there were about half million bariatric surgical in-
[3]
terventions performed worldwide, which implements the need for these procedures.
After a long process of reducing the BMI and achieving the ideal body weight, patients still have to face
the next challenge. Regardless of the methods used to successfully reduce the weight, massive weight loss
patients often develop redundant, hanging skin and fat depots which cannot be removed by diet, physical
exercise or medication. Functional handicaps, rashes, skin infections, difficult body hygiene, self-confidence
or daily problems finding appropriate clothing motivate the patient to go to the plastic surgeon. Although
the successful weight loss reduces some of the medical risks, the psychosocial and functional problems often
[5]
remain a problem for these patients . Up to 89% of the postbariatric patients complain of problems with the
[6]
redundant skin and up to half of these patients find this condition to be worse than the initial obesity . In
the era of bariatric surgery, the body contouring surgery (BCS) plays a key role in achieving the final result
for the obese patients.

The postbariatric BCS uses reconstructive procedures to improve the physical and psychological status of the
patient and by having a medical indication, it distinguishes itself from the sheer aesthetic interventions. Up
[7]
to 74% of patients who underwent bariatric surgery opt for a body contouring procedure . Although it has a
medical indication, the health insurances only cover a fraction of the treatment of these patients and there-
fore the demand for postbariatric body contouring remains higher than the actual performed interventions.
[8]
In a large populational study, Lazzati et al. found that only 21% of bariatric patients undergo BCS.
Several studies have proven that BCS in postbariatric patients is prone to more complications than in pa-
tients who did not receive weight loss surgery [9,10] . The overall early complication rate in the literature varies
from 45% to 70% and includes hematoma, seroma, wound dehiscence, infection, deep vein thrombosis and
pulmonary embolism, whereas wound healing disorders and seroma formation appear to be by far the most
common [10,11] . Several factors seem to be involved in the development of these wound complications, includ-
ing preoperative factors, intraoperative factors and surgical procedure factors.

PREOPERATIVE FACTORS
Patients losing weight after a bariatric procedure are known to have nutritional deficiencies. Patients under-
going postbariatric body contouring have been proven to have low prealbumin and hemoglobin, vitamin A, C,
B complex, iron, zinc and selenium deficiencies as well hyperhomocystinemia [12,13] . These factors are known
to be essential for wound healing and therefore leave the postbariatric patient at risk for wound healing dis-
orders. There is evidence that the perioperative nutritional supplementation can improve the wound healing
process in these patients and decrease the complication rate. Some authors even recommend an extended
[14]
nutritional evaluation before beginning the body contouring procedures .

One of the most significant risk factors for the BCS appears to be the BMI at the time of surgery. In spite of
weight loss surgery, physical exercise and strict diets, the BMI in some patients reaches a stationary level,
which cannot be improved anymore. The existence of large abdominal aprons, excessive medial thigh skin
and fatty tissue as well as macromastia prevent the patient from performing daily activities and exercise and
result in a vicious circle, where further weight loss is not possible. Most studies have proven a high BMI to be
[10]
an important risk factor for developing complications after BCS . As a matter of consequence, the amount
[14]
of tissue removed is also correlated with increased wound complications . The combination of large opera-