1. Plastic Surgery After Bariatric
Weight Loss…
The Final Step in Recovery
Joel A. Aronowitz, MD
Chief, Division of Plastic Surgery
Cedars Sinai Medical Center

2. How Will I Look After the
Weight Is Gone?
 Skin laxity, redundancy. Failure of skin to shrink back adequately.
 Descent of normal fat pads
 “Empty Bag” effect
 Changes depend on many factors; individual fat storage pattern, gender
pattern, limit of skin elasticity, skin attachments to muscle, age

3. Principles of Bariatric Changes
 DEFLATION
– Breasts, abd pannus lose
volume and deflate. Minimal
shrinkage of skin envelope.
 FIXED ATTACHMENTS
– Fibrous landmarks define fold
points, deflated skin drapes
and descends over these
points of fixation

4. Bariatric Changes in Body
Morphology
 Adipose or Fat Tissue
– Fibrous supports connecting skin to muscle stretch and tear,
leading to…
– Downward migration of anatomic adipose units, such as
saddlebags, buttocks
 Muscle
– Anterior abdominal wall muscles and fascia stretch and
weaken resulting in distension and hernias
 Skin
– Skin accomodates weight gain by stretching, thinning and
loss of elasticity. Final skin redundancy represents a
distortion of premorbid pattern
– Excess stretching results in dermal tears, i.e., striae or stretch
marks

5.  Non Surgical Treatments
– Fraxel laser useful for stretch
marks, face, and minor tightening
– Futile for large skin folds
 Diet/Exercise
– Attention to iron, protein intake
– Muscle firming and cardio
– Little effect on skin laxity
 Work Schedule/ Family Care
 Psychologic prep
– Reward strategy/ depression
Patient Preparation for Body
Contouring Surgery

6. Medical Clearance for Body
Contouring Surgery
 Bariatric History
– Stability of weight loss, lifestyle changes
 Medical Clearance
– Preop physical, EKG, blood work
– Management of medical issues such as diabetes, iron
defic., anemia, etc. coordinated with bariatric care team
and internist
 Physical Exam
– Preop diagnosis of important findings; hernia, mass
– Body contouring strategic plan…

7. Aronowitz Surgical Worksheet
1 2 3 4
Stage
Procedure
Assessment of each
body area on Aronowitz
Bariatric Scale
Individual plan for each
body area
Prioritize various
procedures accommodate
patient priorities and
surgical realities
Assemble prioritized
procedures into 1-3
staged surgery dates

8. Patient TC, a 32 yo woman
155 lb weight loss after gastric bypass

9.  Single Stage: Breast lift, abdominoplasty, elevation
of Mons pubis, liposuction of love handles
Before After

10.  Final result; 11 months post op, note
elevation of vulva
Before After

11.  Stage 2; Buttockplasty, liposuction of love handles,
medial thighplasty
Before After

12. Brest lift (mastopexy)
Before After

13. Nipple elevation with mastopexy
Before After

14. Why the Keyhole Pattern?

It is the best method of predictably tailoring the skin envelope

15. Breast Reduction
 23 yo GoPo with large pendulous breasts

16. Case 2: 38 yo woman
210 lb wt loss gastric bypass

17.  Surgical benefits; relief of severely drooping breasts
and abdominal folds pannus
– Improves musculoskeletal system
– Improves posture
– Allows increased physical activity level
– Prevents intertriginous rash and infections
– Lowers insulin requirements in some cases
Before After
Case 2

18. Before
After
Case 2 breast
and arm lift

19. Before After
Case 2 breast and arm lift

20.  Breast lift (mastopexy)
Before After
Case 2

21.  Brachioplasty and
breast lift
Case 2

22. Case 3; 28 year old
90 lb weight loss after gastric bypass and
breast reduction

23.  Stage 1; abdominoplasty with belt lipectomy
and pubic rejuvenation, breast implants,
liposuction and brachioplasty,
Before After
Case 3

24. Case 3
 Stage 1; Belt lipectomy, brachioplasty,
liposuction
Before After

25. Case 4; 31 year old with
abdominal wall laxity after twins

26. Case 4
 Abdominoplasty
Before After

27.  Abdominoplasty with repair of rectus diastasis
Before After
Case 4

28.  Fat injection to buttocks for dimpling,
liposuction of thighs, hips and love handles
Before After
Case 4

29. GF a 28 yo woman with abd. wall
deformity after twins

30. Patient GF
Before After

31. Patient GF
Before After

32. Alterations in Abdominal Surgical
Anatomy After Plastic Surgery
 Plication of
anterior rectus
sheath fascia in
midline and
sometimes
laterally
 Plication draws
rectus muscles
across midline
raphe
Before plication After plication

33. Case 5: 35 yo woman with 155 lb wt
loss after gastric bypass

34. Case 5
 Stage 1; Belt lipectomy, pubic rejuvenation,
breast lift, liposuction thighs, buttock lift
Before After

35. Case 5
Before After

36. Case 6; 34 yo man with stable 145
lb wt loss on diet alone

37. Case 6 Surgical Plan
 Stage 1; abdominoplasty, thighplasty and
gynecomastia (breasts)
 Stage 2: completion of belt lipectomy,
removal of redundant chest skin and chest
tightening
 Stage 3 Touch up scar revisions and
liposuction

38. Before After
Case 6

39. Before After
Case 6

40. Case 6
Before After
Scar at 8 weeks
postop

41. Case 7; 48 yo woman with 115 lb
wt loss after gastric bypass

42. Case 7
 Stage 1; abdominoplasty, breast lift,
liposuction thighs
Before After

43. Case 7
Before After

44. Case 9; 26 yo gastric bypass,180 lb loss
Before After

45. Case 9
 Stage 1; Abdominoplasty, pubic
rejuvenation, thighplasty
Before After

46. Case 9
Before After

47. Case 9
 Stage 1; Abdominoplasty, pubic
rejuvenation, medial thighplasty
Before After

48. Case 9
Preop Postop
 Medial Thighplasty

49. Case 10; 33 yo woman with 165
lb wt loss after gastric bypass

50. Case 10
 Stage 1; Abdominoplasty, breast lift, brachioplasty
Before After

51. Case 10
 Brachioplasty

52. Are There Health Benefits to
Bariatric Plastic Surgery?
 Removal of abdominal and truncal folds
– Relief of ventral hernia & rectus diastasis
– Relief from chronic rash and intertriginous infections
– Improvement in insulin resistance in some cases
– Improvement in ambulation, exercise freedom
 Relief of severely pendulous breasts
– Improves upper back pain and posture
– Relieves bra strap shoulder grooves
– Allows increased physical activity level
– Prevents intertriginous rash and infections

53. Case 11; 44 yo man s/p gastric bypass,
weight loss > 400 lb.,wheelchair to walker
 Multiple Stage Plan; Belt Lipectomy with elevation of
pubis, flank excision, chest/breast excision,
brachioplasty

54. Stage 2
Stage 1 Stage 3 (free of walker)
 Procedures;
– Brachioplasty (arms)
– Gynecomastia, breast surgery
– Belt abdominal pannus resection
– Elevation of pubis

55.  Activity improved after 3 stage procedure
and continued physical therapy
Preop Postop

56. When Am I Ready for Surgery?
(Should I lose more weight?)
Weight Stable
1: Weight goal reached
after surgery or diet;
Plastic surgery OK.
2: Weight goal not reached
but stable plateau
achieved; Plastic
surgery OK.
3: No loss but weight
stable; Plastic surgery
an option with medical
clearance.
Weight Unstable
1: If weight unstable after
bariatric surgery or
diet, best to delay
surgery until plateau
reached.

57. Case 12; 48 year old woman

58. Case 12
 Procedures; Mastopexy (breast lift), abdominal
belt lipectomy, pubic rejuvenation
Before After

59. Case 12
Before After

60. Case 12
Before After

61. Case 12
Before After

62. The Role of Liposuction
 Liposuction is excellent technique for
contouring fat deposits
 Liposuction removes max. 14 lbs of fat
 Liposuction tightens skin minimally
 Excess, redundant skin must be removed
surgically to restore body contour

63. Case 15; 40 yo nurse, no excess skin, but
excess fat of love handles, abdomen, flanks

64. Before After
 Liposuction; love handles, abdomen, flanks,
total 4,800 cc

65. Before After
 Liposuction; love handles, abdomen, flanks,
total 4,800 cc

66.  Improvement in body shape by liposuction
of love handles and flank rolls
Case 15

67. Case 14
 Stage 1; abdominoplasty, breast implants,
and brachioplasty
Before After

68. Restoration of the Abdomen after
Massive Weight Loss
 Correction of anterior abdominal wall
integrity, repair of hernia and diastasis
 Removal of excess skin
 Restoration of umbilicus
 Elevation and thinning of pubic area
 Thinning of flanks

69. Case 15; 35 yo with 120 lb loss

70. Case 15

71. Case 15

72. Case 15

74.  Revision of breast reduction with reduction
of areola and lift, 6 weeks postop

75. Patient MP. 55 yo woman with
severe implant capsular contracture

76. Patient MP

77. Patient 16: 50 yo woman 90 lb
weight loss with gastric bypass

78. Case 16
 Breast lift and augmentation with 225 cc
silicone gel, Note; removal of xiphoid process

79. Case 16

80. Case BS; 36 yo with 50 lb loss

81. Patient BS

82. Patient BS

83. Patient BS

84. Patient CS; 45 yo gastric bypass, 162
lb wt loss; Brachioplasty

85. Patient SC
Before After

86. Patient BT
Before After

87. Patient BT
Before After

88. Abdominal Scar Contour Irregularity, Excessive
Removal of Tissue with Breast Reduction
 Breast augmentation, 225 silicone gel
 Repair adipose disruption w/ scar revision
Before After

89. Related Problems
 Umbilical deformity PO
 Umbilical Hernia
 Ventral hernia

90. PK; 45 yo with Postoperative
Rectus Diastasis/Ventral Hernia
At Rest During straining

91. S/P Repair Midline Diastasis and
Scar Revision
3 weeks postop 8 months postop

92. Case SA; 60 yo woman with 175
lb wt loss after gastric bypass

93. Case SA
 Stage 1; breast lift with implant (250 cc)
abdominoplasty with pubic rejuvenation
 Stage 2; thighplasty, buttock lift

94. Case SA

95. Case AS
Before After

96. Case AS
 Procedure; buttockplasty, thighplasty
Before After

97. Questions…
 When am I ready for plastic
surgery?
 What is the recovery period?
 How much pain is involved?
 How much does it cost?
 Does insurance contribute?
 What are the complications?
 Can I speak to someone who
has undergone the surgery?