Introduction

Obesity in the USA remains a vital concern for healthcare practitioners, with rates continuing to increase at an alarming rate [1,2,3]. Specifically, the state of morbid obesity (body mass index [BMI] > 40 km/m2) is known to significantly impact several aspects of both health and psychosocial well-being [4,5,6]. Bariatric surgery is often relied upon to stimulate weight loss and improve the wide range of obesity-related health problems, where weight loss following bariatric surgery is shown to improve health-related quality of life (HR-QOL), as well as decrease prevalence of medical comorbidities [7]. High rates of obesity, coupled with advancement in bariatric surgical techniques, have led to an increasing number of bariatric procedures performed worldwide [8, 9]. However, massive weight loss is commonly associated with excess skin and soft tissue, which can also cause dermatitis, cellulitis, and skin ulcerations, in addition to a negative influence on quality of life [10,11,12]. As a result, body contouring procedures, such as panniculectomy, mastopexy, lower body lift, thigh lift, and brachioplasty, are requested to enhance psychosocial well-being, as well as minimize associated conditions that complicate daily living [13].

Patient-reported outcome (PRO) measures have been used successfully throughout plastic surgery as a means of quantifying patient perspectives and overall satisfaction following an operation. The BODY-Q© is a validated PRO instrument that evaluates the patients weight-loss experience, physical function and the HR-QOL of body contouring treatments [14,15,16]. Overall, the BODY-Q measures three domains: appearance, HR-QOL, and the patients’ healthcare experience, through 18 independently functioning scales, including obesity-specific physical symptoms. Advantages of the BODY-Q, as a qualitative assessment tool for patients undergoing body contouring, have been well-described throughout the literature, and can provide critical information for plastic surgeons, regarding patient quality of life [17].

Various studies, both in the USA and globally, have utilized the BODY-Q to assess HR-QOL following body contouring surgery, with positive results highlighting the efficacy of these procedures [13, 18, 19]. However, in obese patients specifically, HR-QOL is significantly impaired, and even lower in those patients seeking treatment for obesity. Current analyses examining the impact of morbid obesity on HR-QOL following post-bariatric body contouring surgery are lacking. Additional evidence-based studies utilizing both clinical and qualitative analyses are needed to further delineate the impacts of obesity on body contouring surgery outcomes, and to improve results and enhance pre-operative counseling for body contouring patients. The purpose of this study was to evaluate the association of morbid obesity (BMI > 40 kg/m2) with both clinical and HR-QOL, through conducting a comparative analysis of morbidly obese and non-morbidly obese patients, utilizing the BODY-Q.

Methods

Design and Study Population

We performed a retrospective cohort study approved by the University of Pennsylvania Institutional Review Board. Inclusion criteria were comprised of adult men and women (≥ 18 years old) seeking consultation for truncal body contouring procedures by a single plastic surgeon (JPF) who administer patient-reported outcomes (PRO) surveys as standard of care in a large academic center between September 2016 and March 2020. Exclusion criteria included body contouring procedures in which the primary procedure was not truncal in nature. We additionally excluded those with incomplete QOL data. Patients were subsequently stratified into two cohorts (morbidly obese [MO] vs. non-morbidly obese [NMO]) as classified by the World Health Organization (WHO) class III or BMI greater than or equal to 40 [20].

Data Source and Covariates

Demographic, clinical, and operative variables were extracted through review of the electronic medical record (EMR). Variables extracted included age, race (African-American, Caucasian, Other), ethnicity (Non-Latino or Non-Hispanic, Latino or Hispanic, Unknown), private insurance, BMI, smoking status (non-smoker, active, former), diabetes mellitus, hypertension (HTN), chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), immunosuppression, and history of weight loss surgery.

BODY-Q© Questionnaire and QOL Data Collection

The BODY-Q© is a validated PRO survey composed of 25 functional scales spanning across three domains: appearance, quality of life, and experience with care encompassing both pre- and post-operative settings [21]. Scoring ranges from 0 (worst) to 100 (best), except for physical function, which is inversed. As standard of care in our practice and to limit patient survey burden, we administer a tailored BODY-Q© instrument containing 14 (post-operative) and 11 (pre-operative) of the functional scales [22]. To ensure comparability in this study, functional scales not present in both the pre- and post-operative BODY-Q©, such as those related to the appearance (appraisal of body contouring scar) and the experience of care domains, were excluded. Of the 11 resultant scales present in both the pre- and post-operative instruments, three were within the appearance domain and eight were health-related quality of life domain. Table 1 summarizes the individual components of the BODY-Q© used in the study, with sample questions included within each functional scale. BODY-Q© surveys were prospectively maintained in a REDCap database (REDCap, Vanderbilt University, Tennessee).

Table 1. BODY-Q domains included in the study
Full size table

Outcomes

The primary outcomes were QOL and satisfaction as measured by each of the BODY-Q© domains. These outcomes data were collected during preoperative (baseline) and postoperative encounters. Secondary outcomes included postoperative complications such as cellulitis, surgical site infection (SSI), seroma, hematoma, delayed healing, wound dehiscence, readmissions and emergency department (ED) visits related to the index procedure, and reoperations (due to a complication).

Statistical Analysis

Descriptive statistics were used to report counts and frequencies for categorical data, and medians and interquartile range (IQR) for non-normally distributed continuous data. Pearson’s Chi-square and Kruskal–Wallis tests were used to compare categorical and continuous data, respectively. Paired Wilcoxon signed-rank test was used to compare improvement of BODY-Q© for each group. The improvement in QOL difference between postoperative and preoperative BODY-Q© scores was compared between groups.

BODY-Q© functional scales with at least half of the items completed were scored (the mean was utilized for the missing data). For each functional scale, the raw score was computed and converted to a Rasch transformed score (0–100) as per the developer [23]. Values of p <0.05 were considered statistically significant. Data analysis was formed using MATLAB version R2017b (The MathWorks, Inc., Natick, Massachusetts, USA) and STATA version 12 (StataCorp, College Station, TX, USA).

Results

A total of 82 patients were considered for eligibility. Of these, 59 patients met the inclusion criteria (55% response rate): 43 (72.4%) in the non-morbidly obese cohort and 16 (27.6%) in the morbidly obese cohort (Figure 1). Overall, enrolled patients had a median age of 50 years (IQR ± 17); were majority female (88.1%), African-American (61.1%), non-Hispanic (89.9%), and had a median BMI of 32.3 kg/m2 (IQR ± 12.6). Common comorbidities present in the study population included diabetes mellitus (18.6%), peripheral vascular disease (3.4%), immunosuppressed status (3.4%), and COPD (1.7%). Patients in the cohort included 23.7% that were former smokers, while 6.8% identified as current smokers at the time of the procedure. Bariatric procedures performed included gastric bypass (51.3%), gastric sleeve (44.3%), and laparoscopic band (4.4%).

Fig. 1
figure 1

Flow diagram depicting patient eligibility and final cohort selection process

Full size image

For the majority (94.8%) of patients, this was their first experience with body contouring surgery. The median number of procedures was 2( ± 1), with a single truncal procedure performed 75.9% (panniculectomy [n = 41] vs. abdominoplasty [n = 3]). The remaining 24.1% of cases involved multiple concurrent procedures. This included truncal BCP plus either an additional body contouring procedures or a concomitant procedure(s). Additional body contouring procedures included thighplasty (6.78%), mastopexy (3.39%), and brachioplasty (8.47%). Other concomitant procedures included primary suture repaired umbilical/ventral herniorrhaphy (6.78%), liposuction (3.39%), and breast augmentation (1.69%). Regarding weight changes, the median pre-operative weight for this group was 189 pounds (lbs), while the median post-operative weight at most recent follow-up was 201 lbs. These were similar between groups (p > 0.05).

Insurance payers included private (NMO 72.1% vs. MO 62.5%), public (NMO 18.6% vs. MO 31.3%), and HMO (NMO 2.3% vs. MO 0%). The mean length of stay was 1.77 days (± 2.2). The most common complication was delayed wound healing (21.6%), followed by superficial SSI (13.1%), dehiscence (4.9%), hematoma (2.8%), seroma (1.6%), deep SSI (2.9%), venous thromboembolism (1.5%), and fat necrosis (4.4%). There was no difference in the complication rate between cohorts (p = 0.264). Patients in the NMO cohort were more likely to be females (NMO 91.1% vs. MO 68.8%; p <0.01); otherwise, no other differences were noted across study groups (Table 2).

Table 2. Patient demographics and comorbidities
Full size table

QOL and Satisfaction

Table 3 reports BODY-Q© net scores between preoperative and postoperative domains shared between cohorts. The median time to postoperative BODY-Q© was 5 months (IQR ± 4), which was not significantly different between cohorts (p > 0.05). In a univariate analyses, net BODY-Q© scores were lower in the following three domains: satisfaction with body (median 30 [IQR ± 53] vs. 65 [IQR ± 54]; p = 0.036), body image (39 [IQR ± 55] vs. 52 [IQR ± 44]; p = 0.025), and social function (12 [IQR ± 18] vs. 19 [IQR ± 35]; p = 0.015) but were comparable for the other eight domains assessed (p > 0.05).

Table 3. Effect of body contouring on health-related quality of life
Full size table

Discussion

Obesity has represented a growing pandemic and truncal BCP have become one of a multitude of approaches to address some of the debilitating aspects of this pathology. BCP have been shown to result in increased QOL and improvements regarding body self-satisfaction through varying grades and stages of obesity, though variations in these improvements amongst subgroups of obese patients are unexplored. This study showed that while morbidly obese patients gain self-satisfaction, they do not enjoy the same improvements through certain domains compared to their obese counterparts.

Various outcome measures have indicated QOL improvement following BCP for post-bariatric and post-obese patients, particularly in the setting of excessive weight loss [24]. Less known is the particular QOL changes in obese and morbidly obese patients, and if this has an effect on satisfaction. Part of the difficulty in capturing the effects of BCP in obese patients was the lack of standardized and comprehensive measures. The recently developed and validated BODY-Q captures multiple aspects of self-reflection on a variety of image domains [13]. While most outcome measures were equivalent across both sets of patients, the morbidly obese cohort gained a significantly lower overall mean difference of improvement for satisfaction with body. Although BCP can mitigate the physical appearance of obesity and dramatically reduce weight, it does not necessarily serve as a complete substitute for other approaches to weight loss, particularly in the setting of excessive underlying fat and adipose tissue. For this reason, many providers advise weight loss prior to the pursuit of BCP [25]. Secondarily, it may be that morbidly obese patients have extensive adiposity that truncal BCP can help address, but does not otherwise produce the same dramatic effects post-operatively as it would with obese or healthy weight patients. We hypothesize that morbidly obese patients are inherently not satisfied due to the self-reflective presumption of being further off from their “ideal self”, whereas obese patients, by nature of their lesser baseline fat, exude greater self-satisfaction.

Similarly, obese patients were significantly more satisfied with the “body image” domain, compared to morbidly obese patients who displayed more modest gains in satisfaction. A study by Pecori et al. showed that weight loss in morbidly obese patients without subsequent cosmetic procedures resulted in low self-satisfaction scores, while those with complete weight loss and subsequent cosmetic procedures showed similar scores to a healthy, “lean” control group [26]. This indicates that weight loss alone may not be enough to achieving ideal satisfaction. However, our study shows that BCP may also not be enough when isolated as a factor for self-perception, and that starting, baseline weight also likely plays an influential role. Despite this, there is evidence that BCP in obese patients can result in sustained and stable weight loss and QOL [27, 28]. Additionally, multiple previous studies examining body contouring in the morbidly obese population have shown significant improvements in QOL scores which are achieved by several metrics, similar to our own results [26, 29, 30]. Unfortunately, these studies did not investigate the dichotomy between obese and morbidly obese patients, making their exact impacts unknown. Regardless, it is likely that a combination of both approaches is necessary to optimize results of body image and enhance chances of achieving results that are more in line with self-perceived “ideal self”.

The psychological and psychosocial implications of obesity are well documented. Obesity confers fear of self-doubt and psychiatric barriers to adequate socialization. While the results of this study indicated that both obese and morbidly obese patients enjoy similar improvements in psychosocial distress and psychological function, morbidly obese patients did not see the same degree of improvement within “social function”. This is likely related to body satisfaction and body image, where this cohort does not see their own bodies as “ideal”, and may presume comparable perceptions from others, compromising their social functioning abilities [12]. There also may be secondary anxieties owning to fears of inadequate hygiene and adequate ambulation even after BCP if obesity remains [31]. Similarly, it may simply be that a lack of self-confidence precludes optimal functioning and enjoyment in social settings, resulting in a decreased perception of social functioning abilities [12, 32]. However, it is important to note that some studies have suggested that psychosocial characteristics in these patients go beyond physical changes, and may have more innate components than once realized [32,33,34]. Even still, there is a clear benefit in being a less severely obese patient prior to BCP as it relates to social functioning.

Surgical risk is an important and critical discussion when operating on obese patients, particularly in the setting of procedures that may be seen as “cosmetic” and elective in nature. The largest encountered post-operative complication in this study was delayed wound healing, though this was similar across groups. Indeed, obesity confers increased morbidity following BCP, as well as lends the potential for increased costs [35, 36]. However, most previous literature has shown that this increased morbidity may largely be minor in nature, in line with our own results [37,38,39,40]. This highlights the importance of proper pre-operative counseling for patients in understanding the risks involved with pursuing BCP while categorically obese, though it appears that these procedures can be safely preformed based upon individualized risk-assessment in light of important QOL improvements.

The authors acknowledge limitations to this study. There are inherent limitations with the survey study designs, as patient response bias during the data collection process may be implicated. There is a relatively small sample size in the morbidly obese cohort, and sub-group analyses were not performed. Patient motivation for initially pursuing BCP was not evaluated, which can have important effects on ultimate satisfaction. Additionally, a lack of complete medical records did not allow for analysis of the overall amount of team between bariatric procedures and body contouring procedures, a potentially critical variable in analysis. Further, the BODY-Q was truncated in our study in order to limit patient survey burden, and we used questions from the BODY-Q to specifically identify quality of life changes. However, in doing so we lost some of metrics measuring appearance and experience of care. Finally, our results were an intermediate term following BCP, and long-term results may present different conclusions. Despite these, we believe this study shows the importance of obesity grade in ultimate satisfaction outcome and highlights the important of pre-operative expectations.

Conclusion

Both obese and morbidly obese patients enjoy several QOL improvements following truncal BCP. However, morbidly obese patients see significantly less QOL improvements as it pertains to specific QOL domains: satisfaction with body, body image and social function. Additionally, post-bariatric BCP can be safely performed in the obese and morbidly obese patient without increased risk of major complications.