Background

Plastic surgery after massive weight loss remains a fast growing subspecialty. Massive weight loss achieved through bariatric surgery and/or lifestyle changes causes both functional and aesthetic problems. Patients suffer from deformities caused by ptotic skin envelopes that lead to difficulties in daily life. Especially the lower trunk is a region that is highly affected after massive weight loss. Problems in hygiene may cause skin infections. Limited mobility and personal distress regarding appearance can lead to deficiency in social life [1].

All these factors should have an impact on quality of life and body image that may improve with circumferential body lifting of the lower trunk. However, very few studies exist that investigate the quality of life and psychological outcome after body lift surgery [2–6]. Hence, the aim of the present study was to examine the mentioned aspects of psychological well-being before and after lower body lift in a prospective repeated measures design. As previous studies revealed, weight loss—either by bariatric surgery or non-surgical methods—has beneficial influences on body image. Furthermore, it was of interest for the clinical trial to study to which extent plastic surgery leads to an improvement of quality of life and body image in comparison to the positive impact of weight loss alone. Therefore, the longitudinal study was combined with a randomised cross-sectional research design. The aim was to compare the period before massive weight loss to the situation before body lifting surgery regarding the satisfaction with life and the subjective body image.

Patients and Methods

Patients

Twenty-seven patients (25 females and 2 males) who had undergone bariatric surgery after psychological counselling (gastric banding, n = 11; gastric bypass, n = 16) in two different hospitals of the region of upper Austria were scheduled for circumferential body lifting of the lower trunk. They had lost 61 kg on average through bariatric surgery. Their mean weight was 71 kg with a mean height of 168 cm. The patients, aged 21–58 years (mean = 39.9, SD = 10.9), underwent body lift surgery in our department of plastic and reconstructive surgery between 2008 and 2010. All participants took part in two psychological examinations on a voluntary basis and completed the prospective pre–post study. Follow-up was 6 months.

Measures

For psychological examination, two specific questionnaires were administered. The World Health Organization Quality of Life (WHOQOL)-BREF survey is an international cross-culturally comparable quality of life assessment instrument. The WHOQOL-BREF is a shorter version of the original inventory containing 100 items and is therefore especially suitable for clinical trials. The questionnaire was used to assess global quality of life, physical health, psychological health, social relationships and environment with 26 items.

The subjective body experience, body image and satisfaction were assessed using the Body Appraisal Inventory (FBeK) that included the following scales: insecurity and uneasiness (19 items), attractiveness and self-confidence (13 items) and accentuation of the own body and sensibility (20 items) (Figs. 1, 2, and 3).

Fig. 1
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Descriptive results (means) regarding quality of life. Descriptive results (means) regarding quality of life. Pre 1 and Post 1 refer to the pre- and postoperative measurements in group 1. Pre 2 and Post 2 describe the pre- and postoperative scores in group 2

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Fig. 2
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Descriptive results (means) regarding body experience. Descriptive results (means) regarding body experience. Pre 1 and Post 1 refer to the pre- and postoperative measurements in group 1. Pre 2 and Post 2 describe the pre- and postoperative scores in group 2

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Fig. 3
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Improvement in mobility

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Procedure

The WHOQOL-BREF and the Body Appraisal Inventory were administered by a psychologist during a 45-min lasting interview at two points of measurement. Consequently, each patient completed the described questionnaires twice—the preoperative assessment took place 2 weeks before the body lift operation of the lower trunk and the postoperative follow-up assessment 6 months after the surgery.

Body Lift Procedure

We start the operation under general anaesthesia in prone position (Fig. 9). According to the preoperative drawings, we incise the superior resection line down to the level of superficial. We form the gluteal region based on each patient's individual clinical findings. Symmetry is important to reduce irregularities seen in the upright position postoperatively. After skin resection, we perform the multilayer wound closure (Fig. 10). We close the dog ears temporarily with clamps and turn the patient in supine position.

We preserve the Scarpa's fascia during abdominal flap elevation (Fig. 8). The technique is equal to the one we use for abdominoplasty procedures. One can lift the superior aspect of the anterior thighs, the sagging skin of the mons pubis and the lateral gluteal region when pulling the Scarpa's fascia upwards after abdominal flap resection. Beginning with preparation from the suprapubic incision, we leave the Scarpa's fascia about 3 cm beneath the umbilicus and use the rectus fascia for further preparation. After tissue resection, the Scarpa's fascia is suspended onto the rectus fascia with absorbable sutures. In case of rectus diastasis, we excise the Scarpa's fascia in the area of plication. After umbilicus reinsertion, wound closure is performed again in a multilayer fashion (Figs. 4, 5, 6, and 7).

Fig. 4
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Female patient undergoing central body lifting, preoperative

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Fig. 5
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Female patient undergoing central body lifting, postoperative

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Fig. 6
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Male patient undergoing central body lifting, preoperative

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Fig. 7
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Male patient undergoing central body lifting, postoperative

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Patients were randomised in group 1 (n 1 = 12) and group 2 (n 2 = 15). During the first interview, participants of group 1 had to answer the same questions as patients in group 2, but were asked to consider the pre-weight loss period. Patients in group 2 had to answer the questions referring to their current life. For the second interview, 6 months after the body lift procedure, no differences were made between the two groups (Figs. 8, 9, and 10).

Fig. 8
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Scarpa's fascia preserving preparation on the abdominal wall

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Fig. 9
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Patient in prone position before body lifting procedure

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Fig. 10
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Patient in prone position after body lifting procedure

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The method of retrospective survey in group 1 at the first measurement point has to be applied due to the lack of opportunity to collect historical or longitudinal data during the life period before weight loss. However, it is known that former life events and life periods are reliably remembered if they have shown saliency. Since obesity is an emotionally intense phase of life for the persons concerned and bariatric surgeries are in many cases significant biographical turning points, it is assumed that reliable and valid data can be collected in a retrospective survey.

Statistical Analysis

A series of independent-samples t tests were performed to investigate mean differences between groups 1 and 2 at both measurement points. As a result of the repeated measures design, paired t tests were performed to evaluate the impact of body lifting surgery on psychological well-being in both groups. A two-tailed significance testing was used throughout—a p value less than 0.05 was considered to be statistically significant.

Results

The findings of the study will be described in detail below and are summarised in Figs. 1 and 2 in graphic and tabular form by showing the means of each scale.

Results of the Cross-sectional Design

The two groups were compared measuring the quality of life (WHOQOL-BREF) and body experience (FBeK) at the first measurement point (see Figs. 1 and 2: Pre 1, Pre 2).

Group 1 reporting quality of life during pre-weight loss period of time scored significantly lower on physical health (p = 0.014) and on global quality of life (p = 0.03) in comparison to patients who reported their quality of life before body lifting operation. Group differences in psychological health and environment were found to be non-significant in preoperative measurements, whereas the lower mean in group 1 concerning social relationships nearly reached significance (p = 0.07).

The two groups were also compared in regard to their body experience before weight loss (group 1) and before body lifting surgery (group 2). Unexpectedly, statistical analysis revealed no significant differences between the groups in their physical insecurity, attractiveness and accentuation of their own body at the first measurement point.

To control the randomised assignment to the different groups, the WHOQOL-BREF scores and the FBeK scores of the second psychological assessment after plastic surgery were compared between group 1 and group 2 (see Figs. 1 and 2: Post 1, Post 2). According to expectations—due to the equal instruction to complete the questionnaires—no significant differences were found in any scales.

Results of the Prospective Repeated Measures Design

The pre–post comparison in group 1 showed a highly significant increase in global quality of life, physical and psychological health, social relationships and environment in consequence of weight loss and plastic surgery (in all scales: p < 0.01, see Fig. 1: Pre 1, Post 1).

The corresponding statistical analysis to evaluate mean differences in group 2 revealed that the body lift operation alone leads to a significant improvement in the psychological, social and environmental domain and in global quality of life (in all the mentioned scales: p < 0.05), whereas there was no significant impact on the physical health in general (see Fig. 1: Pre 2, Post 2). However, descriptive statistics showed an improvement in mobility as part of physical health—results are presented in Fig. 3. Positive descriptive changes were also found in further items of the physical health domain: The necessity of medical treatment as well as feelings of physical pain and discomfort decreased due to lower body lifting in group 2.

Since groups 1 and 2 did not differ significantly in the subjective body experience at both measurement points, equal results were found in the groups regarding changes in body image. The scale “insecurity and uneasiness” scored significantly lower after the body lifting of the lower trunk (p < 0.01)—the mean scores fell at least by half in both groups. In contrast, the patients reported a significantly higher attractiveness and self-confidence after the surgery (p < 0.001). The mean scores in this scale even increased almost threefold in both groups. Statistical analysis of the third scale showed that the accentuation and sensibility of the own body remained unchanged between the two measurement points. The reported changes in body experience due to plastic surgery are also illustrated in Fig. 2.

Discussion

There is a massive increase in post-massive weight loss surgery worldwide. However, studies that investigate the positive impact of the circumferential body lift procedure are rare. In the past, several studies have shown the improvement in quality of life and body image in plastic surgery in general [7, 8]. Some studies investigated post-weight loss surgery in particular. But mostly, several body contouring procedures, such as liposuction or abdominoplasties, were included [2–6].

Referring to the pioneer work of Ted Lockwood, the evolution of the circumferential body lift procedure of the lower trunk has reached the plastic surgery departments worldwide [9]. Nowadays, the circumferential body lift has become the gold standard to treat the massive weight loss patient's lower trunk [10]. With one single operation, it has become possible to treat the abdomen, lateral thighs and buttock region. It might be obvious that this single procedure improves quality of life and body image. But this question has seldom been investigated objectively in a prospective manner. On the basis of this prospective longitudinal study, we have demonstrated that circumferential body lifting of the lower trunk significantly improves quality of life in general as well as the psychological health and social relationships. Besides, the study revealed that plastic surgery has a particularly significant impact on aspects of body image. Attractiveness and self-confidence greatly improved, whereas feelings of physical insecurity and uneasiness decreased significantly.

It may also be of concern how patients after weight loss differ from those before weight loss regarding quality of life and body image again. Studies on postbariatric patients have shown an improvement on both [11, 12]. However, those results did not always match with the clinical experiences we have made throughout the last years. Patients very often faced low self-esteem after weight loss and all of them complained about their new body which revealed a body image comparable to the one they had before bariatric surgery. Therefore, we designed a cross-sectional design with one group reconsidering the pre-weight loss period during the first interview. The other group was asked to refer to the present situation when answering the questions. With this design, it became possible to compare the period before weight loss to the situation before plastic surgery regarding the patient's body image and quality of life.

The study results revealed that weight loss alone does not lead to a long-term improvement in the body image of our patients. On the contrary, patients who were scheduled for a body lift operation reported a comparably high physical insecurity and comparably low attractiveness like patients before weight loss. But body image improved significantly with plastic surgery. Taking into account previous studies, bariatric surgery or dietetic weight loss alone may indeed have a beneficial effect on body image. However, our empirical results and clinical experiences suggest that this effect is only immediate or short term at least for a part of the patients. This result does not narrow the importance of bariatric surgery or dietetic weight loss, but underscores the importance of interdisciplinary work. The process of becoming thinner is not terminated with massive weight loss alone [13]. Patients do need further surgical treatment in their post-weight loss period to achieve the goals that were causal for their lifestyle changes: improving health, quality of life and self-confidence.

Conclusion

Post-weight loss surgery improves quality of life and body image. It is therefore an important part in the interdisciplinary treatment of the massive weight loss patient.