Breast Reduction and Bariatric Surgery - which should be done first?

Final Results May Be Better When Weight Loss Comes First
For Immediate Release: 08/26/2011

ARLINGTON HEIGHTS, Ill. - For very obese women considering both bariatric procedures and breast reduction surgery, optimal results are achieved when weight loss is achieved first, suggests a study in the September issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Although initial breast reduction has some benefits, women may be disappointed with the appearance of their breasts after massive weight loss. "Thus, patients who are considering bariatric procedures should be encouraged to pursue that operation before proceeding with reduction mammaplasty," according to the new study by ASPS Member Jeffrey A. Gusenoff, MD, and colleagues of University of Rochester Medical Center.

Best Results when Bariatric Surgery Performed before Breast Reduction
The researchers analyzed patient satisfaction and other outcomes in severely obese women who had massive weight loss of more than 50 pounds. Obesity is defined as a body mass index of 30 or higher, and the women in this study had an average body mass index of about 54. All but one of the women needed bariatric surgery to achieve massive weight loss.

The study included two groups of women: 15 who underwent breast reduction surgery before massive weight loss and 14 who did not have breast reduction surgery before massive weight loss. All of the women who underwent reduction mammaplasty thought their breasts looked better after the operation. In addition, most felt better able to exercise and to lose weight on their own after breast reduction surgery. However, all 15 women needed bariatric surgery to achieve their weight-loss goals. Further reductions in breast size followed bariatric surgery.

Bariatric procedures for obesity can affect the appearance of the breasts as a result of excess skin and other changes. After massive weight loss, 86 percent of the women who previously had reduction mammaplasty thought their breasts looked worse. About half of the women planned to have further surgery to improve the appearance of their breasts. Others said they would have further surgery if it was covered by insurance.

Because of the benefits of breast reduction – including relief from severe breast-related symptoms – most of the women did not regret their decision to have reduction mammaplasty first. However, if giving advice to a friend, they said they would recommend losing weight before undergoing breast reduction surgery.
Of the women who did not undergo reduction mammaplasty, 71 percent felt the appearance of their breasts was worse after bariatric surgery. Half planned to have breast reduction surgery, while more said they would if they could afford it.

The new results suggest that most women are dissatisfied with the appearance of their breasts after massive weight loss, whether or not they undergo breast reduction surgery before bariatric procedures.

Dr. Gusenoff and colleagues suggest that, in women who are candidates for both procedures, it may be a good idea to consider having bariatric surgery first. While reduction mammaplasty has benefits – including reduced pain and increased ability to exercise – the final appearance of the breasts seems better if breast reduction surgery is performed after massive weight loss. "These options must be weighed and individualized treatment plans made for obese patients seeking breast reduction prior to weight loss," the researchers conclude.

Plastic and Reconstructive Surgery® is published by Lippincott Williams & Wilkins, part of Wolters Kluwer Health.

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Skull Reconstruction

For years, patients for whom traditional skull reconstruction was not on option, due to complications post cranial surgery, were left with noticeable skull deformities or a unsightly helmet. However, a team of plastic surgeons led by Chad R. Gordon, D.O. of John Hopkins University recently performed a game-changing surgery using a technique they developed to reshape the outer lining of the brain (the dura) in such difficult cases.

In this case, the patient developed an infection of the skull after having neurosurgery to remove a brain tumor. The infected part of the skull was removed and the patient was prescribed helmet therapy to prevent further injury to his brain, while the infection was cleared. However during this time the patient's brain became swollen and expanded outside the remaining skull cavity, making traditional reconstructive surgery impossible.

Using a new approach Gordon calls "bipolar duraplasty," the team directed low heat to the brain and shrunk it enough to proceed with a cranioplasty-- a procedure in which metal and plastic are used to replace missing skull.

According to Hopkins Medicine, "Bipolar cautery, as used here is the first-ever reported case worldwide of craniofacial surgeons using bipolar electrocautery to temporarily reshape the brain."

The entire study was published in the Journal of Neurosurgery on August 19, 2011.

Fat transfer for younger eyes may last 3 years

updated 7/22/2011 2:27:37 PM ET

NEW YORK — Fat transferred under the eyes to create a younger-looking face can last for at least three years, suggests a new study of people who had the surgery.

The procedure involves taking fat from the belly or thighs and injecting it below the lower eyelid, to puff up an area that surgeons say generally begins to lose its shape by the time people are in their 30s.

Doctors say it's more "natural" and lasts longer than injecting commercially-made wrinkle fillers, but there's also a risk of complications and a higher price tag that comes along with the fat-transfer surgery.

"It's becoming a very common procedure and a way to naturally rejuvenate especially the lower eyelid area," said study author Dr. Cory Yeh, a plastic surgeon from Laguna Woods, California.

"The vast majority of patients are seeing results up to three years," Yeh told Reuters Health.

"The question is always, are we going to be seeing results past that point?"

Surgeons said the procedure typically takes an hour or more, and costs $3,500 to $4,000.

For the new study, published in Archives of Facial Plastic Surgery, Yeh and Dr. Edwin Williams, from the Albany Medical Center in New York, tracked photos of 99 people who had the fat-transfer surgery between 2004 and 2008.

Patients were between 35 and 71 years old, and almost all were women.
Those patients came back to the office for photos of their eye area every few months for up to four years following the surgery. Without knowing when the photos were taken, other members of the study team rated how much improvement, if any, they saw in patients' faces from their original, pre-surgery photos.

In pictures taken a year or less after the surgery, 5 percent of patients showed no improvement, 51 percent had mild improvement, and 44 percent had marked improvement.

By two to three years post-surgery, 14 percent of patients had no improvement from their original photos, 68 percent had mild improvement and 18 percent had marked improvement -- but the researchers only had data on 22 patients that far out.

The most common complication of the surgery was swelling lasting more than a couple weeks. Some patients also had bruising under the eyes or minor "asymmetries" -- meaning one under-eye had more volume than the other after surgery. Patients can also get little lumps under their eyes post-surgery, doctors said.

Yeh said the findings "matched our expectations" in terms of how long the results would hold up after surgery.

"We know that the person's going to continue to age, and that they're going to continue to lose volume" under the eyes, he said. "I would have been shocked if we'd said, 'No, everybody remains perfect.'"

Dr. Jason Meier, a plastic surgeon from Jacksonville, Florida, said the procedure is a few times more expensive than typical commercial injections, but that those injections need to be repeated about every year.
The current study did not look at any results from patients who got those injections.

"Fat transfer is an excellent, permanent option for patients who want a natural, rejuvenated look in the under-eye area," Meier, who was not involved in the new research, told Reuters Health.

"Some things don't end up perfectly precise," but that can be corrected with follow-up procedures, he added. "Uniformly, everyone is very satisfied."

Yeh said the extra volume may not last as long in elderly patients, or those that smoke or exercise a lot.

But he said the fat-transfer procedure is becoming more common, and that it's "appealing to many patients because this is a natural way of using their own body fat."