Upper arm deformities following MWL, described as "bat wings," are embarrassing for patients and are difficult to conceal. Brachio-plasty is usually performed to treat this problem, using an elliptical excision from the axillary crease extending to the region of the elbow. An L or T-shaped excision may be used where excess skin is contiguous with the lateral chest wall. Incisions are made in the inferior-most aspect of the abducted arm or the bicipital groove; the latter usually offers a better scar position.

Patient evaluation and preparation

Optimization of the MWL patient undergoing body contouring is necessary to ensure the best possible results. Patients should be at a stable weight for 6 to 12 months with no further weight loss expected.

Preoperative evaluation should include an assessment of the patient's medical and psychological status. A comprehensive health history should be obtained from patients early in the evaluation process and should aim to identify any comorbid conditions, as well as assess for the acuity, stability, and complications of these comorbidities. The patient should be evaluated for any psychopathologies as well. A medication history including over-the-counter and herbal supplements should be obtained, and the patient counseled to discontinue any supplements that may compromise hemostasis.

The skin surrounding or overlying the intended surgical site should be inspected for evidence of infection or ulceration; any positive findings should be treated prior to surgery. The abdomen should be examined for any surgical scars that might compromise blood supply and result in skin or tissue loss. High-risk patients should be referred to specialists for medical clearance prior to surgery.

Patients should be educated about surgical options and the potential benefits and risks of individual procedures. Informed consent should be obtained as well. Patients need to have realistic expectations and understand that perfection isn't likely and scarring is unavoidable.

Postoperative discomfort and an extended period of recovery should be anticipated. Patients should be provided with written preoperative and postoperative instructions, including care of drains where appropriate. Preoperative photographs can provide the patient and surgeon with perspective postoperatively.

Financial considerations

The costs of surgical procedures, including facility and anesthesia fees, require discussion and full disclosure to the patient preoperatively. Although insurers provide coverage for the surgical procedure to induce weight loss, patients may be surprised to learn they may have to pay out-of-pocket for body contouring, which is often considered cosmetic.

Perioperative considerations

Patients undergoing body contouring procedures following MWL need special perioperative consideration. Despite significant weight loss, many patients will still have a large body habitus, rendering them at high risk for serious postoperative complications such as pneumonia, deep vein thrombosis (DVT), and pulmonary emboli (PE).

Facilities performing body contouring procedures must have equipment that can accommodate patients who weigh more than 350 lbs. The OR beds and stretchers must be able to rotate and tilt to gain adequate exposure. Extra-large patient gowns and BP cuffs should be routinely stocked. Positioning the patient is a challenge, so additional padded safety belts, gel or foam pads, and large elastic bandages are needed to prevent injury and movement of the extremities during surgery.

Marking the areas to be excised is often performed first with the patient standing, and then with the patient lying down. These markings provide a blueprint for the surgeon, and are critical to the success of the body contouring procedure.

Certain procedures will require the patient to be repositioned during surgery. At each position change, adequate padding should be used for all pressure areas, and the cautery pads and indwelling catheter should be in the proper position.

Following surgery, movement should be minimized until the patient is fully awake. Early ambulation can help prevent both pulmonary and thromboembolic events postoperatively. Options for pain management include epidural administration of analgesia, patient-controlled analgesia, or I.M. analgesics, and will depend on the extent of the surgical procedure. Compression bandages or garments may be utilized postoperatively to minimize bleeding and seroma formation.

Complications