Summer 2012 by The GI and Bariatric Nutrition Center

Summer 2012 Volume 1, Issue 2

A peer-reviewed e-journal providing lifestyle and health information for weight loss surgery patients and candidates

BEGINNING YOUR BARIATRIC JOURNEY: Dynamics of a Healthy Partnership with Your Surgeon and Staff

Obesity and the Brain

Going Under: Anesthesia in the Individual with Obesity

Fighting Obesity One Calorie at a Time: An Interview with NFL Veteran Jamie D. Dukes

Volumetry: A New Dimension in Contouring the Massive Weight Loss Individual

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Editorʼs Message Summer 2012 Volume 1, Issue 2

Dear Readers: I welcome you to the second edition of Body, Mind, Inspiration, and share with you some great news. Finally after 13 years of research, the United States Food and Drug Administration (FDA) has approved a weight loss drug. Lorcaserin was approved for individuals with a BMI of 30kg/m2 or more or 27kg/m2 or more with an overweight-related comorbidity. It works by blocking the appetite signals in the brain creating early satiety. Treatment should be stopped if patients do not lose five percent excess body weight (%EBW) at 12 weeks of daily use. It will be commercialized by Arena Pharmaceuticals (San Diego, California) and Eisai Inc. (Woodcliff Lake, New Jersey) under the brand name Belviq. This month, we present “Beginning Your Bariatric Journey: Dynamics of a Healthy Partnership with Your Surgeon and Staff,” by Dr. Barbara McGraw, a bariatric patient who has undergone Roux-en-Y gastric bypass, four plastic surgeries, and a revisional surgery. In this commentary, McGraw outlines the preoperative process of the weight loss surgery (WLS) journey and provides advice on how to establish good communication with your surgeon and the bariatric staff. She addresses the importance of approaching the WLS journey with a positive attitude and patience, communicating your needs and concerns effectively during appointments, getting to know your surgeon and staff, and utilizing all available resources. This commentary is helpful for anyone considering WLS, as well as for those who are already on the journey. Next, we present an article by Kimberly E. Steele and colleagues elucidating the role of the hypothalamus, dopamine, and dopaminergic receptors in the development of obesity. I found this article fascinating. I Raul J. Rosenthal, MD, FACS, Clinical Editor, Body, Mind, Inspiration, Program Director of Minimally Invasive Surgery, Director of the Minimally Invasive Fellowship Program, Director of the Bariatric and Metabolic Institute, and Director of the General Surgery Residency Program, Cleveland Clinic Florida— Weston, Fort Lauderdale, Florida.

feel it is important to remember that phenotype plays a major role as well. Our ancestors did not have a refrigerator in their caves to store food and eat three or four times a day and they did not have food available on a daily basis either. Our stomachs are far too big for the quantity and quality of food available to us in the 21st century, and sedentary lifestyles make it even worse. Think about how little the Chilean miners had to eat on a daily basis and yet they all survived for so long underground. My patients sometimes say to me, “I never thought we needed so little to function.” Also in this issue, Drs. Vipul Shah and Stephanie B. Jones give an overview of the challenges individuals with obesity might face when undergoing anesthesia. They outline techniques and products that anesthesiologists can use to make going under more safe for the individual with obesity. Dr. Terrence Fullum presents an interview with Jamie D. Dukes, an NFL veteran who underwent WLS. Dukes talks about the Put Up Your Dukes Foundation, a program dedicated to fighting obesity. For example, Duke’s foundation has been instrumental in bringing healthier food services to former NFL players and strenghening physical education programs in schools throughout the Untied States. Finally, Dr. Michele Shermak writes on reconstructive surgery after massive weight loss and explains how important it is to not only trim the redundant skin, but also to add some volume to patients when performing body contouring procedures. Wherever you may be in your quest to get fit and healthy, we hope BMI offers you helpful information, encouragement, and support. BMI Sincerely,

Raul J. Rosenthal, MD, FACS Clinical Editor, BMI

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Editorial Advisory Board CLINICAL EDITOR Raul J. Rosenthal, MD, FACS Program Director of Minimally Invasive Surgery, Director of the Minimally Invasive Fellowship Program, Director of the Bariatric Institute, and Director of General Surgery Residency Program, Cleveland Clinic Florida—Weston, Fort Lauderdale, Florida EDITORIAL ADVISORY BOARD Susan Gallagher Camden, RN PhD WOCN, CBN, HCRM CSPHP Senior Clinical Advisor, Celebration Institute, Inc., Houston, Texas Tracy Martinez, RN, BSN, CBN Program Director, Wittgrove Bariatric Center, La Jolla, California Melodie K. Moorehead, PhD, ABPP Board Certified in Clinical Health Psychology, JFK Medical Center, Bariatric Wellness and Surgical Institute, Atlantis, Florida

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Harry Pino, PhD Director of Clinical Exercise Physiology Program, RecoverHealth Center, New York, New York; Medical Center, Stony Brook, New York Craig B. Primack, MD, FAAP Medical Bariatrician/Certified Medical Obesity Specialist/Co-Medical Director, Scottsdale Weight Loss Center PLLC, Scottsdale, Arizona Wendy Scinta, MD, MS, FAAFP, FASBP Medical Director, Medical Weight Loss of NY, BOUNCE Program for Childhood Obesity, Manilus, New York; Clinical Assistant Professor of Family Medicine, Upstate Medical University, Syracuse, New York Kimberley E. Steele, MD, FACS, Assistant Professor of Surgery, The Johns Hopkins Center For Bariatric Surgery,Baltimore, Maryland Christopher D. Still, DO, FACN, FACP Director, Center for Nutrition and Weight Management, Geisinger Health System, Danville, Pennsylvania

BMI BODY MIND INSPIRATION EDITORIAL STAFF Editor Raul J. Rosenthal, MD, FACS Program Director of Minimally Invasive Surgery, Director of the Minimally Invasive Fellowship Program, Director of the Bariatric and Metabolic Institute, and Director of the General Surgery Residency Program, Cleveland Clinic Florida— Weston, Fort Lauderdale, Florida. Vice President, Executive Editor Elizabeth A. Klumpp Matrix Medical Communications West Chester, Pennsylvania Associate Editor Angela M. Hayes Matrix Medical Communications West Chester, Pennsylvania Associate Editor Kimberly B. Chesky Matrix Medical Communications West Chester, Pennsylvania

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Table of Contents Summer 2012

Volume 1, Issue 2

President/Group Publisher Robert L. Dougherty Matrix Medical Communications West Chester, Pennsylvania Partner Patrick D. Scullin Matrix Medical Communications West Chester, Pennsylvania Vice President, Business Development Joseph J. Morris Matrix Medical Communications West Chester, Pennsylvania EDITORIAL CORRESPONDENCE should be directed to Executive Editor, Matrix Medical Communications, 1595 Paoli Pike, Suite 103, West Chester, PA 19380. Toll-free: (866) 325-9907; Phone: (484) 266-0702; Fax: (484) 266-0726; E-mail: eklumpp@matrixmedcom.com ADVERTISING QUERIES should be addressed to Robert Dougherty, President/Group Publisher, Matrix Medical Communications,1595 Paoli Pike, Suite 103, West Chester, PA 19380. Toll-free: (866) 325-9907; Phone: (484) 266-0702; Fax: (484) 266-0726; E-mail: rdougherty@matrixmedcom.com

1595 Paoli Pike Suite 103 West Chester, PA 19380 BMI Body Mind Inspiration [ISSN TBD] is published digitally four times yearly by Matrix Medical Communications.Copyright © 2012 Matrix Medical Communications. All rights reserved. Opinions expressed by authors, contributors, and advertisers are their own and not necessarily those of Matrix Medical Communications, the editorial staff, or any member of the editorial advisory board. Matrix Medical Communications is not responsible for accuracy of dosages given in the articles printed herein. The appearance of advertisements in this journal is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality, or safety. Matrix Medical Communications disclaims responsibility for any injury to persons or property resulting from any ideas or products referred to in the articles or advertisements. This publication provides basic information about a broad range or medical conditions. It is not intended to serve as a tool for diagnosing illness, in prescribing treatments, or as a substitute for the physician/patient relationship. All persons concerned about medical symptoms or the possiblity of disease are encouraged to seek professional care from an approprpiate healthcare provider.

Obesity and the Brain

Going Under: Anesthesia in the Individual with Obesity

Fighting Obesity One Calorie at a Time An Interview with NFL Veteran Jamie D. Dukes

Volumetry: A New Dimension in Contouring the Massive Weight Loss Individual 20

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Body • Mind • Inspiration BEGINNING YOUR BARIATRIC JOURNEY: Dynamics of a Healthy Partnership with Your Surgeon and Staff by Barbara McGraw, PhD This article will discuss the dynamics of a relationship between a bariatric patient, surgeon, and office staff. It also lists areas of expectation required for complete adherence during the initial consultation and through a patient’s weight loss surgery journey.

MY BARIATRIC JOURNEY Dr. Barbara McGraw was born and raised in Northern California and was educated as a California public school teacher and counselor in Music and Special Education. She continued her masters and doctorate in counseling and consulting, focusing on educational institutions and nonprofits. Emphasis was centered on relationships and team building. Very athletic and active, Barb did not become obese until she developed genetic type 2 diabetes mellitus during her forties. As she became more immobile, her two adult children were saddened that her new granddaughter would not have the quality of life with her as they had. In 2004, she researched bariatric surgery and was immediately approved by her insurance to undergo an adjustable gastric banding procedure. She was followed up and received four plastic surgeries. After losing 90 percent of her excess weight by walking several half marathons and 10Ks, she suffered an unexpected heart attack in 2010. A revision from band to gastric bypass was performed and she experienced improvement of her type 2 diabetes mellitus. Her passion is now facilitating good, healing relationships between patients and surgeons. She also uses her own experiences to facilitate relationships between plastic surgeons and other caregivers in the field of bariatrics, both from a doctor’s and patient’s perspective.

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he decision to have bariatric surgery involves a lifelong relationship with your surgeon and his or her staff. Building a successful relationship is crucial to acquiring the lifestyle changes that will keep your weight loss and new healthier lifestyle. The requirements of completing your journey to a healthy life may be rigorous and difficult to achieve. In my experience, many patients seem to fix blame for their obesity on other people and circumstances from their past and present. Some seem to expect that the staff and support system will fix them, when in reality the weight loss journey requires much work on the patient’s part. Developing a healthy, mature attitude while approaching the weight loss surgery (WLS) journey with personal responsibility, an adventurous heart, and team spirit will benefit you immensely when connecting to your medical caregivers.

BUILDING A PARTNERSHIP WITH YOUR SURGEON AND STAFF

First and foremost, I recommend that you approach the WLS journey simply as a person, rather than a medical disease defined as morbid obesity. Remember that members of the bariatric staff and even your surgeon are human and face their own daily stresses and pressures. During your initial consultation and throughout your WLS, you should aim to establish an egalitarian relationship among yourself, your surgeon, and his or her staff. The doctor and staff will have crucial demands you will have to follow, and in turn, they should be respectful of your fears and do their best to help you address them. It is also important that you expect to receive as well as to Copyright © 2012 MMC

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Body • Mind • Inspiration Challenges come with any of life’s journey involving drastic life style changes. Remember this is a journey, not a destination. Discipline will define and accomplish your goals, and a positive attitude and mindset will be crucial to your WLS journey success. give respect and common courtesy from and to everyone along your medical journey. Many patients with morbid obesity have experienced discrimination most of their lives and do not feel accepted for who they are. It is important to remember that on this journey you are part of a team whose members (medical personnel and peers) will likely accept you as you are and will work with you during the changes. Challenges come with any of life’s journey involving drastic lifestyle changes. Remember this is a journey, not a destination. Discipline will define and accomplish your goals, and a positive attitude and mindset will be crucial to your WLS journey success. At certain times, you may feel discouraged, in pain, or impatient. It is helpful to realize that on any given day circumstances may not fall in place as expected. Be patient and kind. This will always help you achieve your goals. An example of this can be seen in my own WLS experience. During one appointment, I came in to the office ready for my initial WLS to take place in two weeks. I had completed all of the required tests and preoperative appointments. My surgeon looked at my endoscopy report and found that the nurse had missed a short sentence indicating that there was a small amount of “unidentified fluid” in my stomach. The surgery was postponed until a biopsy was done. It took two more months to receive the results, and surgery was then rescheduled. I was furious inside, but I calmly said it was okay. Everybody on the team was doing his or her best and I understood that. I smiled and began to walk out the door with a whole new set of papers to complete. As I paused to look at a poster, I overheard the surgeon say that I was a “nice lady and will be good to work with.” I was so glad that I developed that first impression during a conflict. This became the basis of an eight-year relationship that still continues and that has endured many medical hardships. I believe that the strong trust and respect between my surgeon and the staff helped carry and me through every rough patch. It helped that I could be flexible and patient when situations did not turn out as well as I expected.

WORKING ON COMMUNICATION

It is crucial during all appointments that you express your concerns clearly. You might consider writing down

your questions and concerns to ensure you stay focused. It might also help to bring an advocate (family member or friend who knows you well) with you to the appointments. This person can fill in the gaps if the consultation liaison misses what you are trying to communicate. Many medical professionals depend on technology to keep your medical information timely and accurate. This may involve your doctor having an electronic device in the exam room with you. I remember the first time I experienced a “laptop surgeon.” Everything I was communicating to him was intense and from my heart. All I saw was the top of his head behind the screen of his device. I stopped talking, smiled, and made a funny comment on his hair. He got the point. I stopped reading my notes and he stopped typing. We made eye contact and I felt like he heard and acknowledged me as he asked probing questions. Then, during a brief pause he went back and recorded a summary of what was discussed. The important concept is to keep every clinical appointment focused on information, but express what you feel your surgeon or the bariatric staff member needs to hear. Like any new relationship, this will take time to develop, but this will be the foundation of success for all that comes ahead.

YOUR INITIAL CONSULTATION

Discussing your procedure. By the time you have your initial consultation, the different types of bariatric procedures for which you qualify will be the main topic of discussion. If the surgeon has an orientation information seminar, each procedure will be graphically explained, sometimes with accompanying handouts, with the pros and cons of each procedure. Hopefully you have also been researching each procedure on your own. Now is the time to discuss with your surgeon which procedure you both think will be best. Discussing your health history. At this point, you should have filled out a comprehensive form explaining your past health history, medications, family history, lifestyle and eating habits, past experiences with weight loss efforts, and whatever else your surgeon and staff need to know to apply for insurance coverage (if applicable) and keep you safe during your journey. It is critical that you are brutally honest with all your health issues involving other specialists and medications. BMI Body • Mind • Inspiration—Summer 2012

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Body • Mind • Inspiration Some patients may believe losing weight is

a silver bullet to solve all these emotional issues. Often times, it may be easy to place blame when your personal expectations are not met. This is where self advocacy and responsibility for your own feelings and behavior become paramount in developing emotional maturity and stability. You must advocate for yourself to make sure these specialists stay in contact during your WLS journey. Neurologists, cardiologists, endocrinologists, and any other specialist who treats you regularly, especially involving medication, must know what you are planning step by step. If you are part of a health maintenance organization (HMO), you likely have a primary care physician (PCP) who will pull together all of these authorizations. Consultations between your PCP and your bariatric surgeon may be necessary. Some WLS procedures, especially those involving malabsorption, will not be possible if you have medical conditions that require you to take medications. Complications from medical conditions, such as sleep apnea, heart conditions, and diabetes, just to mention a few, can be fatal to you during and immediately after surgery if not adequately planned for. Of crucial importance is reporting lifestyle habits that could hinder the surgical process and the rest of your WLS journey. Smoking and recreational drug and alcohol use fall into this category. If you engage in any of these habits, your surgeon will likely have guidelines for you to follow on limiting or probably totally ceasing these activities. Part of the preoperative process will be outlining a strategy of dealing with any habit that may sabotage your weight loss goals. Do not be afraid to tell the truth and ask for help in finally combatting these lifestyle habits. Your bariatric surgeon and/or insurance company have required tests and evaluations of you to qualify for surgery. Each medical clinic and test will have to report what happened during your appointment. It will be your responsibility to make sure these reports get to your bariatric surgeon’s office. Many times I gave up on faxing reports or sending x-rays between offices because there

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were gaps with such reports being sent or received. Since these are required for surgery clearance and would delay the date, I made a special effort to hand deliver my paperwork to the appropriate bariatric office person as soon as they were available. These days, electronic transfers are common. Lab test and images may be recorded on compact disks. You may also want to get a hard copy of everything for your personal records.

PSYCHOLOGICAL EVALUATION

The psychological evaluation can help to access your mental and emotional health. Remembering what and how to eat, adjusting to constantly taking new medications while revising your old ones, and planning your daily meal intake are just a few of the changes you will have to make that will require you to be mentally healthy. These may seem simple, but as your body physically changes, it is important that you maintain your psychological wellbeing. Secondly, it is imperative that an individual be emotionally stable enough to handle the rigorous changes WLS will bring to your life. Patients may have developed obesity through a lifestyle of addiction, various abuse issues, failed relationships, depression, or other issues. None of these issues in themselves will disqualify a patient from WLS, but evaluation needs to be made on how stable he or she is to stand up to the challenges of a major surgery and possible complications during these drastic life changes. Such patients can benefit from a strong support system to help them improve upon these emotional challenges. If a patient’s emotional stability challenges are assessed as too great, he or she may be told to continue counseling for awhile longer until he or she can learn to accept and deal with the severe changes WLS will make on his or her life. Some patients may believe losing weight is a silver bullet to solve all these emotional issues. Often times, it may be easy to place blame when your personal expectations are not met. This is where self advocacy and responsibility for your own feelings and behavior become paramount in developing emotional maturity and stability. Emotional issues can improve with weight loss, but only as an individual grows stronger, address these issues, and realizes that a lot of other serious hurdles may lie ahead. Dealing with addictions that cause emotional eating and understanding changes in body image are just two of the possible major challenges ahead. Working with a qualified counselor and a bariatric support system is essential in WLS success. Being emotionally stable is paramount in achieving a new healthy lifestyle. Emotional instability can sabotage a patient’s success if it is not dealt with in a positive manner.

PREOPERATIVE PERIOD

After the initial consultation you will have many medical appointments and tests to complete that will be used to determine your qualifications for the bariatric procedure on which you have decided. In addition, it is common for most insurance companies and your surgeon to require a supervised fitness and weight loss requirement before surgery. This may require weeks or even months of adhering to a diet and exercise plan. In my program, the requirement was be lose 10 percent of your starting weight. You will be on a supervised diet, usually protein shakes with limited solid food, nutritional counseling, supplemental vitamins, which you might be required to take for life, and a modified exercise regimen. Patients may feel offended by this requirement and see it as just another weight loss program that they have failed many times before. However, this can be a wonderful opportunity to test your resolve and understand before you have your surgery what will be required post surgery and for years to come. Losing weight preoperatively (even a little) may make your procedure and recovery period easier. The simple exercises will help you get in shape to be more mobile and prevent postsurgical complications. Believe me, you will be grateful for completing your preoperative special nutrition and fitness plan when you first try to get out of your hospital bed and walk. You will also learn to appreciate this phase of your journey in the future.

GET TO KNOW THE OFFICE STAFF

There will be many questions and issues that come up during your life-long WLS journey. An established clinical bariatric practice will have staff members fulfilling certain roles. It is important that you become familiar with these people and know how to contact them, whether they are able to provide you with a phone number or e-mail address. Early on, you should also ask if there is a phone number to call in case of emergency. This is a standard of care that patients should expect. The following section lists different bariatric staff members you may encounter along with their roles. Administrative assistant. Get to know the surgeon’s administrative assistant, who may also fill the roles of office manager or personnel director. This person usually handles the surgeon’s schedule. You can contact this person with questions about your appointment and the doctor’s time agenda (e.g., time out of office). The administrative assistant can direct your questions and concerns to other departments as needed (e.g., hospital policy). Insurance coordinator. This person handles insurance authorizations and will know exactly what your policy will and will not cover. The insurance coordinator should be able to advise on any pre-requisite Copyright © 2012 MMC

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Body • Mind • Inspiration requirements for surgery, such as nutritional and excersise classes. You will probably be anxious to keep in touch and see how your insurance coverage is handled. Your surgeon will write a comprehensive insurance request with medical terms explaining how you qualify for the procedure you have chosen. You may be able to start your preoperative appointments with other medical specialists during the approval process if your insurance authorizes you to do so. It is important that you do not jump ahead of your medical plan because you may be liable for medical bills if not granted insurance approval. Ask the insurance coordinator if there is an estimated time line you can follow. Believe that the insurance coordinator is working as fast as the system will allow. Insurance is very complex. For those who have limited insurance, large copays, or are in between insurance coverage or have no insurance at all, some offices have finance plans available for which you may qualify. Ask your practice if they offer such assistance and, if so, ask to meet with someone to discuss your financing and payment options. There is also, of course, the option to pay out of your own pocket. You will find out that when you calculate the past expenses caused by obesity, the investment you make for your surgery will be paid back many times over as obesity issues are resolved over time. Just the medications and food savings are substantial. Nursing staff. The nursing staff will be your main contacts for any medical issues or questions you have. You may be given a manuel for reference on your specific surgery that might include certain complications and their symptoms. The nursing staff will likely be responsible for arranging your preoperative classes. During these preoperative classes, you learn important details about your surgery, including the following: 1. How to prepare for surgery 2. What the hospital will and will not provide 3. Your diet immediately before and after your surgery 4. Addressing any concerns with your anesthesiologit prior to your surgery 5. How to exercise after surgery 6. How to prepare for recovery 7. Your surgeon’s specific requirements before, during, and after surgery. It is usually the nursing staff’s primary responsibility to relay information on your medical issues directly to your surgeon. Any issue you have should be directed to the appropriate person. Support group leader and members. Immediately after your interest in WLS and when you are fairly certain of your surgeon, start attending support groups if your program offers them. Preoperative patients are always BMI Body • Mind • Inspiration—Summer 2012

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During my WLS journey as a high-risk patient, I found that displaying a sense of humor once in a while helped myself, the staff members, and my surgeons through serious and scary times. This cartoon demonstrates my personal sense of humor about the WLS journey. Illustration by James W. Elston James Elston Studio http://www.jameselston.com

welcomed, and you will get a firsthand idea of what to expect on your WLS journey. Many bariatric centers of excellence (now accredited jointly by the American Society for Metabolic and Bariatric Surgery [ASMBS] and American College of Surgeons [ACS] under the new Metabolic and Bariatric Surgery Accredititation and Quality Improvement Program [MBSIQP]) have a mentor program where the long-term patients of your chosen procedure will walk with you on your journey. They can help answer the majority of your questions as they know your surgeon’s procedures and preferences. If this mentor does not know the answers, he or she can help point you to the right source. The support group leader(s) can be a valuable resource for you through the whole hospital experience, from the preoperative period and complications to future plastic surgery, providing resources along the way. A support group leader will provide both pre and post operative advice on any subject. Medical, physical, nutritional, psychological, and social concerns related to

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WLS will be addressed. If you are curious about resources available to you, it is import that you just ask. Some examples of resources and programs include exercise classes; social events like the Walk For Obesity, parties, and clothing exchanges; counseling on self image issues, emotional eating, and nutrition. Even surgeons come to events periodically. With so many people and resources, rest assured that you are part of a caring family. Just one month after my surgery, I connected with WLS people in my area, the Central Coast Redwoods of California, via social networking websites. The patients covered about nine different surgeons and all the procedures. Not a weekend went by where we weren’t offered an activity to do that we all shared in planning and implementing. We walked the Redwoods and the beaches; trained for short races; had monthly social gettogethers (sometimes with clothing and recipe exchanges); and went scuba diving, horseback riding, and took belly-dancing lessons together. We were exploring together all the activities we were never able to do because of our obesity. In my case, it had been 20 years since I was able to attempt such activities. We had fun and helped to keep each other accountable for the WLS journey with support.

CONCLUSION

As your WLS journey begins, it is imperative you establish solid relationships based on trust and respect with your surgeon, the bariatric staff, and support system. Without this, you may become fragmented and confused learning all the procedures and behavioral changes for a healthier lifestyle. It is also imperative to begin your journey with maturity and a positive attitude. Try your best to adhere to all of the plans and processes, and be sure to educate yourself as much as possible. Most important of all, however, is to realize that you are a person, not a disease, and this is your journey, meaning you will likely will get out what you put into it. I have (for the most part) enjoyed my WLS journey and the wonderful results of having more energy, better relationships, and an opportunity to better fulfill my life goals. I believe I would have never succeeded without a strong support system in place to help me understand each step of the way. Now, I am engaging in the process that is most exciting of all—paying it forward.

RESOURCES 1.

Cook, Coleen. Success Habits of Weight Loss Surgery Patients. Salt Lake City, Utah: Bariatric Support Centers International; 2012.

Bariatric University. http://www.bariatricu.com

Founded in 2005 by Susan Lassetter and Dana Schroeder from the Silicon Valley Bay Area of California, Bariatric University was created at the beginning of my WLS journey. Bariatric University is an excellent educational resource for understanding the life coaching model in comparison to the direct lecturing method in achieving long-term goals in you WLS journey. Bariatric University was the main place for my initial training and support. Dr. Sharma’s Obesity Notes http://www.drsharma.ca

Available at: http://bsciresourcecenter.com/proddetail.php? prod=3.SHBook A primary resource for patients on the dynamics and life long issues of WLS. An educational resource for support for patients covering comprehensive subjects throughout the WLS journey. Many international seminars and training opportunities for support groups. 2.

Dr. Groopman writes clear and concise books for patients who want to learn how the majority of doctors will interact with them. Patients who want to learn how to communicate their needs and expectations effectively to medical medical professionals should read How Doctors Think. The Anatomy of Hope: How People Prevail in the Face of Illness is excellent for teaching both doctors and patients how to keep hope and support alive during difficult health issues 3.

Dr. Arya Sharma is the Chair of Obesity Research and Management at the University of Alberta, Canada. He sends out a daily e-mail blog, which is open to anybody, on various issues related to obesity both from the physicians’ and patients’ perspective.

Groopman, Jeromne. How Doctors Think. 1st Edition. New York, New York: Houghton Mifflin Company; 2007. Groopman, Jeromne. The Anatomy of Hope: How People Prevail in the Face of Illness. New York, New York: Random House Trade Paperbacks; 2005.

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Publications by Abraham Vergheses. http://www.abrahamverghese.com/ Dr. Vergheses’ deep interest in bedside medicine and his reputation as a clinician, teacher, and writer led to his being recruited to Stanford University in 2007 as a tenured professor. His books and resources explain how imperative it is for patients and doctors to have close relationships for the purpose of healing. He spent many years being close to human immunodeficiency virus (HIV) patients and their families and writes about his experiences in relationships made during that time. BMI

Obesity Help. http://www.obesityhelp.com/ A network for bariatric doctors and patients, ObesityHelp is a comprehensive interactive website with forums on any WLS you can imagine. Each doctor has his or her own forum.

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OBESITY AND THE BRAIN by Kimberley E. Steele, MD, FACS; Thomas H. Magnuson, MD, FACS; Anne O. Lidor MD, MPH, FACS; Dean F. Wong, MD; and Michael A. Schweitzer, MD, FACS

ach year, the number of patients with morbid obesity in the United States increases alarmingly. When traditional weight loss methods fail, the only successful alternative is bariatric surgery. However, despite the indisputable effectiveness of bariatric surgery, there remain those who have less successful weight loss than others. This cannot be attributed entirely to the type of procedure itself but may in fact be more complicated and involve genetics and neurochemical factors. In this article, we review the work that has been done on the neurotransmitter dopamine and how it may relate to the population with obesity.

INTRODUCTION

The number of individuals with morbid obesity in the United States is increasing at an alarming rate. When traditional weight loss methods fail, the best alternative is usually bariatric surgery. But why do some bariatric patients have more successful weight loss than others? Despite the indisputable effectiveness of bariatric surgery in the aggregate, there remains significant interindividual variability in the treatment response.1 This difference cannot be attributed entirely to the type of procedure (i.e. restrictive vs. malabsorptive) that the patient undergoes. Something much more complicated, involving both genetics and environment and mediated through neurochemical factors, is at play. It is well known that caloric intake is regulated by the brain, notably the hypothalamus. Our subconscious mind, as it were, informs us of when and how much to eat. For

If an individual carries a genetically reduced sensitivity to dopamine, he or she may require excessive reward stimulation—in effect, a “fix”— just to feel normal. For certain individuals, this may take the form of overeating, resulting in obesity, while others may manifest a tendency toward compulsive gambling, shopping, or other behaviors. millennia, these brain mechanisms have prevented starvation and ensured the continuance of our species. Unfortunately, what was adaptive in the relatively calorie-restricted environment of the past has become a liability in our current obesogenic environment, with its abundance of inexpensive, highly caloric, and generously portioned foods. In this environment, it is difficult at times for almost all of us to resist the urge to overeat. But for the individual with a genetic predisposition to obesity, this abundance of food can fuel an addiction that is potentially as harmful as cigarettes, alcohol, or cocaine.

Drs. Steele, Magnuson, Lidor, and Schweitzer are all from the Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland. Dr. Wong is from the Department of Neuroradiology, The Johns Hopkins University School of Medicine. 12

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NEUROCHEMICAL MECHANISMS IN THE BARIATRIC PATIENT

Research in neuroscience has revealed that a common mediator of many addictive behaviors is the neurotransmitter dopamine, which some have termed the pleasure molecule. Dopamine is the primary regulator of eating behavior2 and is released in response to both appropriate and excessive eating.3 Abnormal regulation of this molecule may explain why individuals with obesity tend to eat more carbohydrate and energy-dense foods than their nonobese counterparts. If an individual carries a genetically reduced sensitivity to dopamine, he or she may require excessive reward stimulation—in effect, a “fix”—just to feel normal. For certain individuals, this may take the form of overeating, resulting in obesity, while others may manifest a tendency toward compulsive gambling, shopping, or other behaviors. The relevance for the bariatric surgeon is that understanding of these neurochemical mechanisms may shed light on why some patients fail weight loss surgery. A diagnostic test, if it can be found, that would predict which patients were predisposed to fail would be an important tool for the bariatric surgeon, enabling customized pre-operative planning and postoperative care. Recent efforts at understanding the brain mechanisms of reward behavior have made use of positron-emission computed tomography (PET). PET is a nuclear medicine imaging technique that can display dynamic neurochemical changes in the brain. As such, it is considered a “functional” imaging modality, offering information beyond what can be gathered by strictly anatomic imaging, such as a computed tomography (CT) scan. In the clinical setting, PET imaging is well known for its role in differentiating actively metabolizing metastatic disease from other tissues. But in research centers, PET imaging has also been instrumental in the elucidation of central dopaminergic pathways and their relation to reward-based behaviors.4

OBESITY AND DOPAMINE

In 2001, Dr. Gene-Jack Wang used PET imaging to demonstrate that patients with obesity had reduced dopamine receptor availability when compared to controls, and that there was an inverse linear relationship between dopamine receptor availability and body mass index (BMI); that is, the higher the BMI, the lower the dopaminergic activity.5 Two hypotheses have been proposed to explain this relationship. The first is that individuals with obesity are born with a primary deficiency in dopamine receptors, with an associated under stimulation of dopaminergic reward circuits. This is thought to result in overeating as a compensatory mechanism. The second explanation is that dopaminergic receptor activity is initially normal, but becomes downCopyright © 2012 MMC

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Body • Mind • Inspiration regulated as a result of chronic over stimulation of dopaminergic pathways in individuals with obesity, in a manner analogous to the insulin insensitivity seen in such patients. Bariatric surgical patients present us with a uniquely valuable resource to determine which of these hypotheses is correct. If obesity is characterized by a primary dopamine receptor deficiency, one would expect that this deficiency would not improve substantially following gastric bypass surgery. On the other hand, if decreased receptor density is due to receptor down regulation, the marked weight loss produced by gastric bypass surgery could be expected to result in increased receptor availability, as food intake is decreased and the attendant chronic dopaminergic overstimulation is alleviated.

RESEARCH TO PRACTICE

Our group studied five female subjects ranging in age from 20 to 38 years old, all of whom underwent laparoscopic Roux-en Y gastric bypass (RYGB).6 The mean BMI was 45kg/m2. These subjects underwent preoperative brain magnetic resonance imaging (MRI), as well as PET imaging with the injection of [11C] raclopride, a radioligand for D2/D3 receptors. Five regions of interest were studied, including the ventral striatum, anterior putamen, posterior putamen, anterior caudate nucleus, and posterior caudate nucleus. Six weeks after undergoing standard RYGB, each subject was weighed. The average weight loss six weeks following surgery was 25.4lbs. The five patients then underwent postoperative PET imaging with [11C] raclopride. We found that dopamine D2 receptor availability, measured as [11C] raclopride binding, increased in female patients who lost weight following RYGB. These findings were consistent with Wang et al5 in showing an inverse relationship between BMI and dopamine receptor availability. Since previous work had been limited to comparisons of obese subjects with matched controls, the question of whether decreased dopamine D2 receptor availability was a cause or effect of increased BMI remained unclear. Our data, though limited to only five subjects, did suggest that dopamine receptor binding potential increases in response to weight loss, implying that decreased receptor density is a consequence and not a cause of obesity, and thus, arguing against the concept that obesity is caused by a primary deficiency of dopamine receptors. One year following our study, Dunn et al7 published the only other study reporting dopamine receptor availability after RYGB. Five female subjects, age 41 to 52 years old with a mean BMI of 43kg/m2, were enrolled in the study. Four subjects underwent RYGB and one subject underwent laparoscopic sleeve gastrectomy BMI Body • Mind • Inspiration—Summer 2012

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(LSG). A very similar PET protocol was utilized, except that the radioligand [18 f] fallypride was used instead of [11C] raclopride. To our surprise, they obtained the opposite of our results: dopamine D2 receptor availability decreased following bariatric surgery. While both protocols were very similar, there were some differences that may have accounted for discrepant findings. The most likely contributing factor was a difference in age. The mean age in Dunn’s study was 14 years greater than ours. Age is known to affect the dopaminergic response. As middle age approaches, estrogen and progesterone levels decrease, and this is associated with less D2 receptor expression and function.8 Furthermore, both our study and Dunn’s study were limited by small sample size, so larger studies are needed.

CONCLUSION

Indeed, it may turn out that both of the hypotheses regarding dopamine could be correct. Some individuals might carry a genetic deficiency in dopamine receptors, while others might develop down regulation of receptors due to overstimulation. A further understanding of these neurochemical mechanisms may have important implications for both surgical and nonsurgical management of obesity, including the selection of patients for different surgical procedures and the prediction of long-term outcomes following bariatric surgery. Ultimately, we hope that PET imaging of the brain will one day serve as a useful guide in the management of the bariatric surgical patient.

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REFERENCES 1.

5. 6.

Melton-Meaux GB, Steele KE, Schweitzer MA, et al. Suboptimal weight loss after gastric bypass surgery: correlation of demographics, co-morbidities, and insurance status with outcomes. J Gastrointest Surg. 2008;12(2):250–255. Chau DT, Roth RM, Green AI. The neural circuitry of reward and its relevance to psychiatric disorders. Curr Psychiatry Rep. 2004;6:391–99. Comings DE, Blum K. Reward deficiency syndrome: genetic aspects of behavioral disorders. Prog Brain Res. 2000;126:325–341. Volkow ND, Fowler JS, Wang GJ, Telang BF. Imaging dopamine’s role in drug abuse and addiction. Neuropharmacology. 2009;56 (Suppl 1):3–8. Epub 2008 Jun 3. Wang GJ, Volkow ND, Logan J, et al. Brain dopamine and obesity. Lancet. 2001;3:354–357. Steele KE, Prokopowicz GP, Schweitzer MA, et al. Alterartions of central dopamine receptors before and after gastric bypass surgery. Obes Surg. 2010;20:369–374. Dunn JP, Cowan RL, Volkow ND, et al. Decreased dopamine type 2 receptor availability after bariatric surgery: preliminary findings. Brain Research. 2010;123–130. Bazzett TJ, Becker JB. Sex differences in the rapid and acute effects of estrogen on striatal D2 dopamine receptor binding. Brain Res. 1994;637:163–172. BMI

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Going Under: Anesthesia in the Individual with Obesity by Vipul Shah, MD, and Stephanie B. Jones, MD

Many individuals with overweight and obesity undergo anesthesia for both major and minor procedures. While advances in anesthesia have made "going under" much safer, there are certain specific considerations for overweight individuals. Individuals should bear these considerations in mind in order to help reduce their risk of complications.

hether this is your first or your fifth operation, going under anesthesia can be an anxiety provoking experience. As anesthesiologists, patients often ask us: “How will you know if I am getting enough anesthesia?” or “Will I feel pain?” While nothing in life is completely free of risk, advances in technology and monitoring have made “going under” much safer than it was in the past. Your anesthesiologist is trained to look for signs that you are adequately anesthetized during surgery, and we have many medications to help alleviate pain.

PREOPERATIVE CONSIDERATIONS

If you are an individual with obesity, you may have heard rumors that can make you even more apprehensive about anesthesia. The good news is that anesthesia is still safe for people with obesity, although there are special considerations that are specific to this population. Along with all the standard preparations, such as determining which medications to stop and which to continue to take up to the day of surgery, individuals with obesity often have other health conditions that can play an important part in how well they do during and after the operation.

Individuals with obesity are at a higher risk for diabetes.1 If you have diabetes, it is important to continue to be vigilant about blood sugar control as uncontrolled diabetes can complicate surgery and recovery. Even if your diabetes is well controlled, your drug regimen may need to be adjusted prior to going to the operating room. If you are taking insulin, a general rule is to take half your normal dose of long-acting insulin the night before surgery because you will not be eating after midnight the day of your operation. The exact details are tailored to each individual and you should discuss your diabetic management with your primary care physician (PCP) prior to surgery. Individual with obesity also have a higher risk of obstructive sleep apnea (OSA). If you have OSA, it is important to use your continuous positive airway pressure (CPAP) machine as prescribed. If you think you may have OSA but have not been diagnosed, discuss your options with your PCP.

OPERATIVE CONSIDERATIONS

Now comes the big day. The anesthesiologist will tailor the type of anesthetic to best suit the needs of you and your surgeon. The anesthesiologist may offer deep

Dr. Shah was a Resident in the Department of Anesthesia, Critical Care and Pain Management, Beth Israel Deaconess Medical Center, Clinical Fellow in Anaesthesia, Harvard Medical School, Boston, Massachusetts at the time this paper was written. Dr. Jones is Vice Chair for Education, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts 16

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sedation, general anesthesia, and/or a nerve block. He or she may also recommend different monitoring devices to help keep you safe during the procedure. Regardless of the type of anesthesia, there are specific challenges for you and your anesthesiologist if you have obesity. Procedures such as intravenous (IV) placement, nerve blocks, and epidurals may be more difficult because in individuals with obesity it can be difficult to locate the anatomical structures (e.g., veins) needed to complete the task. The best advice for you is to be patient, and if you are getting uncomfortable, ask for a break. Your anesthesiologist wants to make sure you are at ease before surgery, so he or she will usually be willing to give you time to catch your breath if a procedure is difficult. If you are going to be under general anesthesia, there is an increased risk of difficulty with placement of a breathing tube. Most hospitals have several different devices that can help with the placement of breathing tubes, but if you have ever been told that you are a “difficult intubation,” it is extremely important to tell your anesthesiologist and surgeon prior to the surgery. You may be asked to take an antacid prior to surgery. Since individuals with obesity may have a higher risk of aspiration (inhalation of stomach contents) during intubation, this will neutralize stomach acid. Another good practice is to bring your CPAP machine with you when you come to the hospital. If you are going to be under sedation, your anesthesiologist may have you use it during the operation, and it is important to use it after surgery when you are waking up from anesthesia.

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Once the operation is over, there are still some important considerations. Your anesthesiologist and surgeon will want to maximize your breathing capacity because during the time spent under anesthesia, the lungs can become compressed. In order to do this, you may use a device called an incentive spirometer to help expand your lungs. If you are still in significant pain, your anesthesiologist may recommend other techniques to combat your pain, such as nerve blocks or epidurals, in order to decrease the need for sedating pain medications. Finally, there is an increased risk of developing a blood clot, so you will likely receive bloodthinning shots and be encouraged to get out of bed as soon as possible.

FINAL THOUGHTS

As you can see, going under anesthesia can be safe, as long as you are aware of the risks and work with your doctors to try to minimize risk impact. If you have any specific questions or concerns, you should contact your anesthesiologist before the day of surgery to address them so you can be confident and feel safe on the day of surgery. REFERENCES

Kahn SE, Hull RL, Utzschneider KM. Mechanisms linking obesity to insulin resistance and type 2 diabetes. Nature. 2006;444:840–846. BMI

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FIGHTING OBESITY ONE CALORIE AT A TIME

An Interview with NFL Veteran Jamie D. Dukes by Terrence M. Fullum, MD, FACS

About JAMIE D. DUKES Jamie is a 10-year NFL Veteran and current host on NFL Network. Jamie and his wife, Angela, are the founders of the “Put Up Your Dukes Foundation,” whose mission is to fight the deadly links to the diseases of excess weight. In June 2010, the Put Up Your Dukes Foundation launched the Billion Pound Blitz (BPB), a program that challenges individuals to be accountable for their physical and fiscal health needs.The BPB provides access to celebrities and professional Athletes for individuals who achieve success. To accomplish this goal, tools like “Chachersize” and “Ask The Fat Doctors” were created as a fun way to engage participants. Dukes, along with Falcons owner Arthur Blank and other current NFL players, partnered with United States Senate representatives to reintroduce the Fitness Integrated with Teaching (FIT) Kids Act. The FIT Kids Act works to combat childhood obesity by strengthening physical education programs throughout the country. Dr. Fullum: Jamie, congratulations on the early success of your Billion Pound Blitz Campaign and the Put Up Your Dukes Foundation. What made you decide to become a gladiator against obesity and obesity-related diseases? Jamie: There’s an old saying that is absolutely true: “Your pain is your passion.” That is truly the case for me. Despite at one time being one of the top athletes in the world, I struggled all my life with excess weight. Watching seven former teammates

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to date die from the diseases of excess weight was the catalyst for establishing the Put Up Your Dukes Foundation whose sole charge is to fight against the diseases of excess weight. Dr. Fullum: Your personal story is inspiring. If you don’t mind, please share a little more about your own battle with obesity. Jamie: I played 10 years in the NFL and in my retirement, my weight incrementally went up to the point that I was a happy meal over 400 pounds. Watching other teammates die contributed to my angst as I realized that it was only a matter of time before I would encounter an adverse event. Dr. Fullum: As a professional athlete and sports celebrity, you are in a unique position to reach millions who suffer from obesity. How do you plan to make a difference? Jamie: While there is much work to do, the Put Up Your Dukes Foundation was successful in the inclusion of bariatric solutions in the menu of services for former NFL players. We have also created the following solutions: • Chachersize—an exercise program based on Line Dancing. Learn more at www.chachersize.com • Chachersize ABC (Academic Burst Curriculum)— improves student focus while increasing physical fitness. Learn more at www.chachersizeabc.com • Ask The Fat Doctors—The Fat Doctors online webcast, of which you, Dr. Fullum, are an invaluable part, shines a clinical spotlight on the diseases of excess weight in a multifaceted and entertaining way. Learn more at www.askthefatdoctors.com • Billion Pound Blitz—a solution that utilizes incentive with high-profile celebrity brands. Lern more at www.billionpoundblitz.com Copyright © 2012 MMC

“I played 10 years in the NFL and in my retirement, my weight incrementally went up to the point that I was a Happy Meal over 400 pounds. Watching other teammates die contributed to my angst as I realized that it was only a matter of time before I would encounter an obesity-related event.”

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Jamie Dukes and his team leading an exercise class

Dr. Fullum: I recently had the incredible opportunity to work with you on the “Ask the Fat Doctor” podcast and the City of Atlanta’s Seniors “Healthier You” campaign. These are grass roots movements that you have initiated. What is your strategy and what are your goals? Jamie: The “Healthier You” is a national seniors strategy designed to improve the quality of life for seniors, not only physically with our Boomers Chachersize, but also educationally as we provide them with relevant information that is germane to their wellbeing. Atlanta was the kick off and the goal is to expand to the following areas in the next 18 months: New York/New Jersey; Washington, DC/Baltimore; Raleigh/Duham; South Florida; Dallas; and Los Angeles. Dr. Fullum: If someone reading this article wants to get involved, how can he or she do it? Jamie: Contact us at www.puydf.org. Dr. Fullum: Although there are successful long-term surgical treatments for obesity, the demand far out numbers the supply. According to the Center for Disease Control (CDC), there are over 20 million people in the United States who qualify for weight loss surgery, but we are only performing approximately 115,000 surgeries yearly. It is obvious that the only viable cure for obesity is prevention. If you were the surgeon general, how would you attack the obesity epidemic?

The Dukes family (left to right: Joi, Jamie Jr., Jamie Sr., Angela)

Jamie: Create3, a national marketing effort with the fast food industry extols the healthier choices on their menus. The reality is Americans eat an average of 3.5 times per week at fast food establishments, not only for taste, but for economics. Fast food restaurants have healthy choices and we need to redirect consumers to the healthy part of the menu. Dr. Fullum: America needs to change as a society if we are going to cure obesity and continue to live longer and healthier lives. How will your grass roots campaign affect such a change? Jamie: One calorie at a time… BMI

Dr. Terrence M. Fullum is Associate Professor of Surgery at Howard University College of Medicine, Chief, Division of General Surgery and Chief, Division of Minimally Invasive and Bariatric Surgery at Howard University Hospital in Washington, DC. In addition, Dr Fullum is Medical Director of the Howard University Center for Wellness and Weight Loss Surgery. Copyright © 2012 MMC

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VOLUMETRY:

A New Dimension in Contouring the Massive Weight Loss Individual by Michele A. Shermak, MD, FACS

Individuals who undergo massive weight loss may become volumetrically challenged. In a landscape of skin excess and overhang, significant tissue deflation may develop, particularly in the face, breast, and buttock area. Strategies for volumetric reconstruction and enhancement depend on the use of commercial injectible fillers, fat grafting, flap rotation, and shifting of tissue from a site of excess to one of deficiency.

INTRODUCTION

Adding volume is one of the last things one would think a patient who has undergone massive weight loss would desire; however, massive weight loss actually leads to significant deflation of the skin from head to toe, and this deflation is most apparent in the face, neck, breasts, and buttock. Following massive loss of volume (fat), these parts of the body can take on an appearance best described as a deflated balloon—not the fit, attractive physique one would hope to achieve following significant weight loss. Volume lost in specific body regions may be restored, however, in the massive weight loss patient through the use of fillers, tissue grafting, local tissue rearrangement, and prosthetics to achieve fullness, shape, and a positive body image.

THE FACE

Changes in facial skin due to massive weight loss may mimic the aging process, which visually can add years to a face, even in the most youthful individual. As the volume of the face decreases, the skin becomes more lax and the facial folds more pronounced, the skin of the brows may descend into the eyes causing fullness and skin excess of the upper lids, cheeks may descend

causing an elongation of the lower eyelids, the jawline may appear more blunted and jowled, and most notably, the neck may appears more full with lack of definition between the neck and the jaw. Cosmetic treatment includes injection of fillers, fat grafting, lifting of tissues with suspension in face, and necklifting.1 These treatments may be performed as isolated procedures or may be used together to complement each other in achieving more comprehensive correction. Fillers. Most fillers are off-the-shelf products and include those made with hyaluronic acid (e.g., Juvederm® [Allergan, Irvine, California], Perlane® [Medicis Aesthetics, Scottsdale, Arizona], and Restylane® [Medicis Aesthetics, Scottsdale, Arizona]) or poly-L-lactic acid (e.g., Sculptra®, Sanofi-Aventis, Bridgewater, New Jersey). Hyaluronic acid products are indicated for correction of moderate-to-severe facial wrinkles and folds and can be used to blunt pronounced folds between the nose and lip (nasolabial folds) and to plump thinned lips that have frowning corners of the mouth due to loss of volume (Figure 1). The poly-L-lactic acid products are used to plump up

Dr. Shermak is Associate Professor of Plastic Surgery, Johns Hopkins School of Medicine in Baltimore, Maryland.

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flattened, descended cheeks and the areas around the eyes, and treating these areas subsequently can lift the lower part of the face, which improves the overall appearance. Fat grafting. An individual’s own fat may also serve as the filler, and this fat in volumes of approximately 10 to 30cc can be used to fill the nasolabial folds and lips, either as a stand-alone procedure or in combination with facelifting (Figure 2). Fat grafting is a small operative procedure that can be combined into larger body contouring procedures. Fat is harvested from the abdomen or thigh, concentrated with removal of fluid components of the aspirate, and transferred into the face. The grafted fat will incorporate almost completely into the recipient site. When there is an extreme degree of volume loss and surgical facelifting is required, fat grafting can easily be incorporated into the procedure.

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FIGURE 1. This individual sustained massive weight loss. She was unhappy with the appearance of her face after weight loss (A). She underwent a facelift with plication of the muscles and skin tightening. After surgery, she achieved greater fulness of the lips and nasolabial folds with Restylane injection (B).

THE BREAST

The breast of a woman who has undergone massive weight loss may incur significant deflation with ptosis, medial displacement of the nipple, areolar complexes, and sliding down of the inframammary folds (IMFs). As the fatty component of the breast tissue decreases, the overall volume of the breast decreases. Corrective options for the breast include breastlift (mastopexy), augmentation with fat grafting, augmentation with breast implants, and combinations of these procedures (Figure 3). Most women pursue a breastlift, with removal and tightening of the skin around the existing breast tissue. The underlying breast tissue may be rearranged to transfer redundant tissue from under the arm to the central breast area as an autoaugmentation, and the tissue is stabilized to avoid displacement and descent2 (Figure 4). Fat grafting is a new addition to the breast augmentation armamentarium, and hundreds of milliliters of purified fat can be transferred into the breast tissue, subcutaneous tissue, and pectoralis muscles. This is a new technique, and there is not much data yet available on it. In 2010, Parrish and Metzinger3 stated that the available literature on this procedure consists primarily of case reports and case series, with no controlled trials. Therefore, outcomes thus far have not been measured in a standardized way. Concerns have been raised that the placement of mature adipocytes and adipocyte-derived stem cells into the hormonally active environment of the breast may potentiate breast cancer, but there have been no clinical trials yet that investigate this possibility, and a consensus regarding the basic science is still developing.

FIGURE 2. A woman before (A) and after (B) fat grafting og the nasolabial folds and mouth in conjunction with a facelift.

FIGURE 2. This is a woman in her 30s who lost greater than 50-percent excess body weight, leading to significant volume loss and sagging of her breasts (A). She had a mastopexy combined with augmentation with breast implants to correct her presentation (B). She is three years out from her surgery.

THE BUTTOCK

An individual who has undergone massive weight loss has increased vertical length between the upper back and the buttock, an area of tissue that was previously expanded with subcutaneous fat. This span of back tissue following weight loss becomes deflated, and redundant tissue buries the buttocks below it. Many weight loss individuals pursue belt lipectomies with abdominal panniculectomy or abdominoplasty to treat the abdomen, continuous with a backlift to raise the BMI Body • Mind • Inspiration—Summer 2012

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Body • Mind • Inspiration buttock and the outer thigh. In some cases, there is so much redundant back tissue, that it can be recycled to create an autogenous implant for the buttock (Figure 5). Provided circulation by the superior and inferior gluteal arteries, autologous gluteal augmentation with an individual’s own tissue provides a solution to the deflation of the buttock.4 While gluteal implants can be used to treat deflation of the buttocks, in this author’s opinion, harvesting the material for augmentation directly from the individual’s own body and injecting it into the gluteal muscles and subcutaneous fat should be considered as an option before synthetic implants.

CONCLUSION

Individuals who have sustained massive weight loss may seek corrective surgery for excess or hanging skin due to volume loss. The face and neck, breast, and buttock areas are particularly susceptible to volume deficiency after massive weight loss. Options include use of fillers; autogenous tissue, including grafts and flaps; and implants in order to add volume necessary to achieve a youthful, shapely body. FIGURE 4. This woman in her 40s lost greater than 50 percent excess body weight, leading to significant volume loss and sagging of her breasts (A,B). She did not desire implants. She had a mastopexy with augmentation of the breast tissue rotated in from the axillary fullness (C,D).

REFERENCES

2. 3.

Bucky LP, Kanchwala SK. The role of autologous fat and alternative fillers in the aging face. Plast Reconstr Surg. 2007;120(6 Suppl):89S–97S. Shermak MA, ed. Breast and Body Contouring Surgery Atlas, First Edition. New York: McGraw Hill, 2011. Parrish JN, Metzinger SE. Autogenous fat grafting and breast augmentation: a review of the literature. Aesthet Surg J. 2010;30(4):549–556. Centeno RF, Mendieta CG, Young VL. Gluteal contouring surgery in the massive weight loss patient. Clin Plast Surg. 2008;35(1):73–91; discussion 93. BMI

FIGURE 5. This woman lost greater than 50-percent excess body weight, leading to significant volume loss and sagging in her buttock region. The lower back is excessive and buries her buttock under it (A). She had autologous gluteal augmentation designed from the lower back tissues that would otherwise be discarded. The buttock is far more full and visible (B). Functionally, the patient is more comfortable sitting as well.

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