Commentary on: The Post-Adjustable Gastric Band Abdominoplasty

As a practicing bariatric surgeon, I appreciate the opportunity to comment on the article by Dr Wu et al entitled “The Post-Adjustable Gastric Band Abdominoplasty.” The information in this article should allow plastic surgeons who perform abdominoplasties in post-adjustable gastric band patients to maintain the integrity of the banding system while still obtaining acceptable cosmetic results. As noted by the author, obesity continues to be a major problem in the United States.1 An increasing fat mass can lead to a host of medical problems, including diabetes, hypertension, dyslipidemia, and obstructive sleep apnea.2 Significant obesity also shortens the life span of the individual and negatively affects his or her quality of life.3 Unfortunately for individuals suffering from the most extreme forms of obesity (a body mass index [BMI] of ≥35), current medical therapy has not proven very effective for achieving long-term weight loss success. For this group, weight loss surgery represents their best chance to achieve a healthier weight and achieve resolution of their weight-related comorbidities.4 For this reason, along with the improved safety of weight loss surgery, more and more severely obese individuals are turning to weight loss surgery to improve their health.5 Once patients have lost weight and have seen their medical problems improve, their attention often turns to a common side effect of their weight loss success—loose skin. In my experience, almost 100% of patients are interested in pursuing aesthetic surgery after they have lost weight, but for a variety of reasons, only 10% will actually move forward with it despite the benefits they experience with successful body contouring.6 As with most operations, appropriate preoperative planning will allow the plastic surgeon to avoid major issues at the time of surgery. Adjustable gastric band patients will generally lose 50% of their excess weight by 2 years postoperatively.7 I recommend that adjustable gastric band patients not seek aesthetic surgery until at least a year after surgery, when they have achieved their expected weight loss and have seen their weight plateau for a minimum of 3 months. As Dr Wu and his coauthors have suggested, I believe it is a good idea to involve the bariatric surgeon prior to abdominoplasty. The form the authors have developed (Appendix 1) is quite helpful, but I would encourage direct communication with the bariatric surgeon when feasible. If this is not possible, at a minimum, one should attempt to obtain the operative notes from the band surgery, as this should give all of the pertinent information needed about the band system that was implanted. There are currently only 2 bands approved for use in the United States: Realize Band (Ethicon Endosurgery; Ethicon, Inc., Somerville, New Jersey) and Lap-Band (Allergan, Inc., Irvine, California). These will be by far the most common types of bands the US-based aesthetic surgeon will encounter. I would strongly recommend that if a surgeon is going to be performing abdominoplasties on post-adjustable gastric band patients, he or she should call one of the manufacturer’s representatives prior to the first procedure, to familiarize himself or herself with the band, the port, and the tubing of each system, as they are very different from one another. If the patient has not seen a bariatric surgeon in the year prior to presenting for contouring surgery, I would strongly recommend that he or she be encouraged to see a surgeon prior to any cosmetic abdominoplasty procedure. Although vitamin and mineral deficiencies are less common in adjustable gastric band patients, they do still occur and, if present, can impair healing after aesthetic surgery.8 If a band patient is suffering from frequent emesis or active reflux, I think it is essential that he or she see a bariatric surgeon prior to aesthetic surgery, as these are signs that the band is too tight and needs to be evaluated. If the patient is tolerating foods well, I agree with the authors that fluid need not be removed from the band prior to abdominoplasty. If for any reason the port needs to be accessed intraoperatively or postoperatively, it is important that one uses a Huber needle, so as not to damage the septum of the port. The “capsule preservation” and “port swing” techniques described by the authors are interesting, appear to be safe, and provided excellent results in their hands. The authors report that preserving the capsule over the band decreased their seroma formation rate, but they provide no data to support this claim, and it likely would take a randomized trial to sort this out. The fact their patients had a pre-abdominoplasty BMI around 26 may be more important to their low rate of seroma formation than anything else. It is also worth noting that the Realize Band port has metal hooks that attach it to the abdominal fascia; these would make the “capsule preservation” technique presented in the article quite difficult to execute. The Lap-Band also has different port sizes, so some surgeons may find that they get a better cosmetic result by going to a smaller port, which is quite easy to accomplish but would require removing the capsule. I thoroughly support the notion that limited dissection of the port and tubing apparatus should decrease the chances of damage to either structure, but—and I’m sure the authors would agree—I would caution against compromising the cosmetic result to prevent relocating a port. From a bariatric surgery standpoint, it does not matter to me where the port is located as long as it is easily accessible and the banding system is intact. If the aesthetic surgeon has laparoscopic experience, the port can be easily moved to any location on the abdomen to give the patient the best cosmetic result. If the aesthetic surgeon is not comfortable performing basic laparoscopy, this is yet another reason to have a good working relationship with a bariatric surgeon in the community. I fully support the authors’ recommendations that if the tubing does not come out easily from the abdomen, then it should not be pulled aggressively. Although complications associated with band tubing are very unusual (I have seen 1 in 8 years of practice), they can be significant (as noted by the authors). I have reservations about the authors’ recommendation of 10 days of postoperative antibiotics (including 5 days of intravenous antibiotics) given the current data available. This is certainly an area where further study is needed to determine optimal care. I want to further emphasize the authors’ point that a patient presenting with a port infection remote to his or her abdominoplasty should be considered to have a gastric band erosion until proven otherwise. These patients need to be seen by their bariatric surgeon as quickly as possible. I congratulate the authors on a thoughtful paper that outlines a novel technique to achieve an optimal cosmetic result while maintaining the integrity of the adjustable gastric band system in post–weight loss surgery patients seeking abdominoplasty. Dr Stegemann is a paid consultant for Ethicon Endosurgery.