Tuesday, September 13, 2011

Massive weight loss and breast reduction surgery

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Obesity is another term for being overweight. It is medically defined as a weight to body surface ratio (BMI) of 30kg/m2 or more. Morbid obesity is defined as being 100 pounds or more above one's ideal body weight which in turn is defined relative to one's height. This correlates to a BMI of 35 to 45. Higher BMIs are referred to as super obesity. The incidence of obesity in general has been steadily increasing in North America, Australia, Europe, the Middle East and South America (i.e. worldwide) over the last few decades leading to a rise in weight loss surgery procedures performed and profitability of weight loss groups like Weight Watchers, Jenny Craig etc.

The frequency of large breasts and medical problems related to them like back, neck and shoulder pain as well as skin breakdown is of course higher in the obese population. The question that is increasingly coming up for review of health insurance coverage is whether or not patients with higher BMIs should have breast reduction surgery before weight loss surgery or diet/exercise induced weight loss. Having the breast reduction first does relieve the large breast associated pain and does increase the ability of these women to exercise. However, after losing the excess weight almost 90% of these women who had breast surgery first were unhappy with the look of their breasts after the weight loss. Around half of these women said they would have additional surgery to improve the look of their breasts. Had they waited until after the weight loss to perform the breast reduction surgery they most likely would not need a second breast operation. In contrast only 70% of women who only had bariatric weight loss surgery were unhappy with the appearance of their breasts after the weight loss.

Insurance claims data from seven Blue Cross and Blue Shield plans were examined for patients who underwent elective breast procedures (breast reduction, breast reconstruction, breast augmentation, breast lift) covered by insurance between 2002 and 2006. 2,403 patients of these patients were obese and 5,597 were of normal weight. Within 30 days of surgery, 18.3 percent of the obese patients experienced at least once complication, while only 2.2 percent of patients in the control group did so. The differences between the two groups of patients were most pronounced in complications, such as inflammation (with obese patients 22 times more likely to suffer a complication), infection (13 times more likely) and pain (11 times more likely).

My personal feeling is the only elective procedure (that includes cosmetic surgery other than minor procedures) a morbidly or super obese individual should have are weight loss surgery. The risks of surgery in these patients in my mind clearly outweighs any benefit from the cosmetic procedure. They are prone to complications after surgery and many are malnourished despite being obese so they cannot heal properly.

A morbidly obese patient came to me after her cosmetic abdominoplasty performed by another surgeon reopened and failed to heal. After an examination and diet history it was clear to me that although she was morbidly obese she was also malnourished and therefore could not heal. That surgeon kept placing sutures and prescribing antibiotics for almost 2 months with little change in her condition. After forcing her to change her diet she healed up completely in less than 2 weeks.

Aaron Stone MD - twitter
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