Purpose: Body contouring after massive weight loss is one of the fastest growing areas of plastic surgery.  As no single procedure can address all deformities, patients frequently seek to have multiple procedures performed concomitantly in order to reduce costs and recovery time.  We aimed to study how procedures are combined in a high volume body contouring center and what impact procedure combination has on outcomes.

Methods: 449 body contouring patients were enrolled in a prospective registry over 6 years.  Separate surgical categories included breast (mastopexy or augmentation), thigh lift, lower or upper body lift, brachioplasty, and abdominal contouring.  ANOVA and ordinal logistic regression were used to analyze differences between procedure combinations while the t-test was used for two-group comparison.

Results: 449 patients (407 female, 42 male) had 511 operations.  44 cases (9%) were excluded due to involving procedures outside the six major categories of analysis.  Patients undergoing multiple procedures were not significantly different in pre-weight loss BMI or incidence of comorbidities (hypertension, diabetes, anemia, CVD).  Patients undergoing more procedures tended to be thinner (p = 0.001) and were likelier to be female (p = 0.068).

Multiple procedure patients were slightly older (45.6±10.1 versus 42.6±10.2) and had longer cases (6.3±0.2 hours versus 2.2±0.1) with higher complication rates (51.8% versus 25.4%) than patients undergoing one procedure.  Intraoperative time was linearly correlated with the number of procedures performed (p < 0.001; Figure 1).  Hospital stay also increased with the number of procedures (1.4 days for 1 procedure to 2.4 in 4+ procedures; p < 0.001).

Fifty eight cases (13%) involved a patient undergoing a second stage operation while 4 cases (1%) involved a third stage.  Second stage cases were likelier to involve more procedures (1.7 versus 1.2; p < 0.001) but did not have higher complication rates (p = 0.8).  Hospital stay was not significantly different between second stage and unstaged cases (1.6 versus 1.4 days; p = 0.17).

Seroma and dehiscence were significantly affected by the number of procedures performed (p < 0.001; Figure 2).  Infection and hematoma were not correlated to the number of procedures, while there was a trend towards increased tissue necrosis (p = 0.07).  There were no occurrences of thromboembolism.

Conclusions: Concomitant procedures can safely be performed in selected massive weight loss patients.  We did not find a correlation between major complications and the number of procedures performed.  While minor complication rates are predictably higher than in single procedure cases, this must be weighed against the combined risks of multiple surgical events.  Knowledge of the specific complications increased by concomitant procedures may be of use in surgical planning.  Staging offers a viable alternative for patients who are poor candidates for large cases or who desire procedures that cannot be combined.

Figure 1. The number of major procedures performed and intraoperative duration are correlated.

Figure 2. Complication rates versus the number of procedures performed.