Plastic Surgery After WLS: What Order Should Procedures Be Done?

August 14, 2019

Bariatric surgery leads to a significant amount of loose skin and deflation referred to in Plastic Surgery as lipodystrophy. A person’s age and their genetics will often result in varying degrees of loose skin in different parts of the body. In my practice, having done reconstructive surgery for massive weight loss for over 20 years, there is still no magical formula on what order procedures should be performed.

Plastic Surgery After WLS: Surgical Priorities

Most commonly male and female patients differ in what bothers them the most. For most of my female patients, the areas of the abdominal wall and breasts tend to be the ones that are prioritized.

I have an algorithm that I attempt to utilize for patients called the GBRX method.

First Stage

During the first stage, we tend to do the abdomen, the breasts, and sometimes the arm lifts. During this stage, we may do the abdominoplasty or a body lift. The pubic area, which often sags, is also elevated. The abdominal muscles are tightened to create a flat abdomen (see pic).

The breast typically requires a lift with an augmentation. We preferentially utilize silicone implants under the muscle to get soft natural results. Depending on the body habitats of the patient, an arm lift can often be done at stage 1. If all three procedures are done we keep the patient in our surgical center for 23-hour observation. We encourage walking and deep breathing to minimize post-operative complications. I have personally done over 700 of these combined procedures and have only transfused one patient for a post-operation hematoma.

Second Stage

At the second stage, the goal is to do the back lift, the buttock lift, and contouring, and incorporate the vertical thigh lift in this stage. The recovery for stage 2 is generally dependent on the thigh lift. Drains can stay in up to three weeks. The thigh lift is possibly the most difficult post-op recovery procedure.

Typically a vertical scar is utilized in patients with significant weight loss to get the best outcome.

I often get asked about buttock augmentation procedures and these are generally very unsatisfying procedures in the post-bariatric patient, especially if the patient has limited fat to transfer. I don’t use buttock implants due to their associated complications. (pic 2 thigh lift)

The fold in the upper back can also be addressed at the stage.

Third Stage

The third stage tends to be the facial rejuvenation and it usually combines a brow lift with upper and lower lid blepharoplasty, a facelift and neck lift. The facial rejuvenation procedures give an amazing result if done well. 10-15 years of aging can be erased and a natural outcome is obtained enhancing the patient’s self-assurance. Their procedures are not very painful and by two weeks most patients are doing well and can socialize. Overall, the recovery of their procedures is much less than stage 1 and 2.

While these are not set in stone, (and sometimes I have a patient who wants the facelift done first as that area is more visible or some patients have the arms that bother them the most), we try and modify the algorithm based on what the patient desires.  We tend to space the procedures eight weeks apart to allow the body to rebuild its normal hemoglobin content. Most patients who have had bariatric surgery will have problems with anemia if they have a Roux-en-Y gastric bypass and we want to make sure their blood counts are stable before we undertake the next procedure.

In Summary

In general, while there is no set algorithm on which procedures are done in what order, most people tend to do their abdominal and chest wall work prior to the other procedures. Ultimately, it is the patient's decision on what they like to do in what order that ultimately dictates what order we do the procedures.

ABOUT THE AUTHOR Dr. Munish K. Batra has over 20 years of experience and known for taking on complex surgical cases. The San Diego County Medical Society awarded him twice with the honor of Top Plastic Surgeon in San Diego. He has been featured in the LA Times, People Magazine, and the Oprah Winfrey Show for his outstanding work. Recognized for his bedside manner, humanitarian work, honesty & superb technical skills, Dr. Batra has built a world-renown cosmetic surgery practice called Coastal Plastic Surgeons in San Diego, CA.

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