PLASTIC SURGERY AT ITS WORST

On March 22nd 2009 on Discovery “Health” Channel I watched an episode of ‘Plastic Surgery Before and After’ which truly nauseated me and upset me as a health care professional.

First of all simply presenting the surgery in isolation without detailed background including any prior attempts at non surgical weight loss etc could lead the viewer to believe that this is an acceptable or recommended form of weight loss. If they were showing it for shock value - it kind of did the trick for me. I was shocked.

I realize that many plastic surgeons do charity work in foreign countries for conditions like cleft palate and disfigurement. But.. if they get the money to do that from their elective esthetic plastic surgery practice, particularly from outrageous procedures performed on obese people, then their ethics should be called into question.

Sure the patient has to be provided with ‘informed consent’ but.. does the patient truly know the harm they are causing and the huge risk they are undertaking as well as all the healthier options?

The case in question?
A woman noticed after seeing her son’s graduation videos that she was very obese. She admitted to being 335 lb but to me looked much heavier. She had a gastric bypass to lose weight.

Patients undergoing severe weight loss surgery are supposed to have proven attempts at medically supervised weight loss. There are supposed to be criteria prior to any consideration of the surgery. I understand that in the U.S. failure of medically supervised weight loss is indicated at 6 months if there has not been a 5% to 10% weight loss. Good grief if you are 200 lb overweight that is hardly a very good attempt – and sorry but I would doubt that the person is following the plan if they have not lost at least 5-10% of their weight even in 6 months. It is a very very weak guideline. From what I have seen, and read, I doubt very much that the criteria is rigidly enforced.

Mistake # 1
OK gastric bypass a treatment in bariatrics is not 'plastic surgery' but after gastric bypass the rapid and unhealthy loss likely make her proceed to mistake # 2.

Look at some of the complications involved in gastric bypass:

The functional size of the stomach is reduced and complications are not few. Some studies report that the 30 day mortality (death rate) is 7% for the laparascopic procedure and can be as much as 14.5 % for the incisional procedure.

The obese generally have poor wound healing. Fat doesn’t heal well and is prone to infection. Incisions are at risk of dehiscence – splitting open. I have actually seen several abdomens split open and the bowel come out in my surgical nursing career. It is not a very nice experience - (and I mean for the patient) gently holding the bowel in place with saline dressings until the surgeon arrives and hoping they don’t develop massive infection from the exposure of the bowel to the atmosphere. And hopefully they do not go into shock.

Other potential complications of the surgical weight loss procedures: infection, hemorrhage, blood clots, leakage of the anastomosis (joined part) from the bowel into the sterile abdominal cavity causing infection possible peritonitis; abcess; hernia; would infection, ulcers, stricture (blockage) dumping syndrome – when the client eats a sugary food it bypasses rapidly to the bowel causing symptoms of rapid heart beat, cold sweats and diarrhea; nutritional deficiencies such as hyperparathyroidism, iron deficiency, Vitamin B12 deficiency, malabsorption syndrome, anemia, protein malabsorption, as well as pulmonary embolism and respiratory failure; nausea and vomiting, gallstones, malnutrition. I haven’t even started on the anesthetic risks.

Histological and liver function tests are generally abnormal in the morbidly obese including fatty changes in the liver. There is no clear understanding regarding these changes and the ability to metabolize anesthetic agents which are mostly detoxified in the liver. The obese used to be at risk of “halothane hepatitis” but I believe they do not use that agent anymore. Even if the metabolism of anesthetics is not a risk there are dozens of others that the anesthesiologist has to worry about and which I won’t go into detail here.

I knew that often they have to use two operating tables to accommodate the patient but I was blown away at an anesthetic journal article that reported how common it is that these people can flip off the table during positional changes thus making it advisable to strap them down well. Due to their body habitus (size) they are also at great risk of pressure sores and neural (nerve) injuries during surgery.
Sound good so far?

On Oprah recently she featured some morbidly obese people. One was a woman 29-years-old and 900 lb - she decided on a gastric bypass. It took 8 firemen and a great deal of embarrassment for her to be transported to hospital. 12 different hospitals had turned her down for the surgery. She made a video plea for someone to help her. A hospital and physician stepped up to the plate. Tragically she died 12 days after surgery from a massive heart attack.

The other key person in the story was a 20-year-old 800 lb male who also underwent gastric bypass. He so far has lived and is down to around 500 lb.

The really horrible thing is, in the first case the woman was bed ridden and could not properly feed herself - so someone had to enable her eating habits - similarly the boy's mother had to bring him all his meals - he could get up to the bathroom but it was too painfull to do anything else for himself.

This procedure does nothing to change the eating pattern and lifestyle habits of the individual and bodes poorly for long term health.

The weight loss is very rapid along with ongoing lack of exericse it does nothing to allow your body, particularly your tissues and skin time to adjust and adapt leaving huge hanging folds of skin making it very difficult to maintain hygiene. I don't know how it affects the metabolism but I would doubt it would be a positive effect.

Perhaps the extreme weight of the 900 and 800 lb persons were considered a medical emergency - but who really knows if the woman would have fared better by some intense medically supervised hospital controlled non surgical weight loss plan.

The woman in the program I mentioned earlier (who was 335 lb) lost 100 lb and looked dreadful to me – she was smaller but still very fat with huge bulky bumps of cellulite. She was pleased with her weight loss.

She had the goal of wearing a bathing suit and hated that her legs rubbed together so what did she do next?

Mistake # 2 excessive plastic surgery.

Now remember - she is still at least 225 lb.

She underwent plastic surgery. The surgeon made a two foot incision at the back of her thighs across her buttocks trying to hide the gigantic incision in the butt crease. He cut enormous amounts of skin and removed fat and lipo-sucked out more fat. Then he made a one foot incision on the inside of each leg trying to tighten the legs and sucked out and removed more fat again. Cripes, it might as well have been a butcher shop.

The result? Very slightly smaller ugly legs now with huge ugly scars.

Yep. She wore a bathing suit bless her heart.

The woman is still obese. Although she ‘feels healthier’ probably because she is lighter overall but I do not see how two extreme surgeries would make her healthier. She still has the body, and organs and likely the habits of a morbidly obese individual. Organ fat and the health of the blood vessels are not altered with lipo suction procedures.

I could say she took the easy way out but I can't say that because it is so severe that she must have suffered terribly with both surgeries.

With a nutrition and exercise plan, she may not have ended up looking like Gwyneth Paltrow (thankfully perhaps) but she would have stood a chance of having a scar free pleasing appearance and she certainly would have greater health if she had proper support for nutritional counseling and exercise.

No surgeon should touch a patient until the patient has lost a significant amount of weight with proper nutrition and exercise. This is just wrong. They need better controls to protect patients from themselves but most of all from surgeons who perform surgery just because they can and just because someone asks for it. Look at Micheal Jackson. Need I say more. Even the rich are not immune from plastic surgery nightmares.

Which brings me to the point that we need more non invasive obesity support centers. There is paucity of bariatric centres. Given the obesity in well fed countries, and the risks of increased mortality and morbidity, this is unbelievable.

We need more health care money spent on prevention and helping the morbidly obese to downsize in a healthy non-surgical way. Too bad the woman had not spent the $20,000+ for the plastic surgery on healthy alternatives.