COSMETIC Outcomes Article
Body Contouring Surgery after Bariatric Surgery: A Study of Cost as a Barrier and Impact on Psychological Well-Being Arash Azin, H.B.Sc. Carrol Zhou, H.B.Sc. Timothy Jackson, M.D., M.P.H. Stephanie Cassin, Ph.D., C.Psych. Sanjeev Sockalingam, M.D. Raed Hawa, M.D., D.A.B.P.N. Toronto, Ontario, Canada
Background: Body-contouring surgery can be a solution to excess skin folds following bariatric surgery. Many patients desire body-contouring surgery, but the cost of the procedure may be a limiting factor. This study aims to examine barriers to access and to compare socioeconomic variables and psychological variables between bariatric surgery patients who have undergone body contouring and those who have not. Methods: In this cross-sectional study, a questionnaire packet was administered to (1) patients who underwent bariatric but not body-contouring surgery and (2) patients who underwent both. The questionnaire included perceived barriers to body-contouring surgery, socioeconomic barriers, measures of anxiety (Generalized Anxiety Disorder seven-item scale), depression (Patient Health Questionnaire nine-item scale), and quality of life (Short Form-36). Results: Among the 58 study participants, 93.1 percent reported having excess skin folds. Of this sample, 95.4 percent desired body-contouring surgery, and the majority (87.8 percent) of this subsample identified cost as the major barrier to access. Mean scores on the Generalized Anxiety Disorder scale (6.08 ± 5.97 versus 3.50 ± 3.10; p = 0.030) and the Patient Health Questionnaire (6.40 ± 6.77 versus 2.40 ± 2.37; p = 0.002) were significantly higher for the bariatric surgery group versus bariatric surgery plus body contouring group. Patients in the latter group had significantly higher Short Form-36 physical health component scores (56.80 ± 4.88 versus 49.57 ± 8.25; p = 0.010). Conclusions: Bariatric surgery patients who desire body-contouring surgery perceive cost as a major barrier. Patients undergoing body-contouring surgery may experience improved physical quality of life but not mental quality of life; however, body-contouring surgery may improve aspects of depression and anxiety. (Plast. Reconstr. Surg. 133: 776e, 2014.)
B
ariatric surgery is now considered the most effective long-term treatment for severe obesity, resulting in sustainable weight loss and improvements in obesity-related comorbidities and psychological distress.1–4 The impact of bariatric surgery on patient well-being, including improved quality-of-life and psychological distress, has been well established in the literature. Several studies using validated instruments From the Faculty of Medicine, Division of General Surgery, University Health Network, the Departments of Surgery and Psychiatry, University of Toronto; the Department of Psychology, Ryerson University; and the Toronto Western Hospital Bariatric Surgery Psychosocial Program. Received for publication October 8, 2013; accepted November 20, 2013. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000227
776e
to assess quality of life have established a clear improvement in this metric following bariatric surgery.5,6 In addition, aspects of psychological distress, including depression, have been shown to improve following bariatric surgery.7,8 However, after the initial rapid weight loss, up to 96 percent of bariatric surgery patients develop excess sagging skin folds,9 which can have dramatic mental and physical health effects, impacting both quality of life and psychological distress.10–12 For these reasons, many post–bariatric surgery patients desire corrective body-contouring surgery for their excess skin.
Disclosure: The authors have no financial interest to declare in relation to the content of this article. This work was not funded by any outside source.
www.PRSJournal.com
Volume 133, Number 6 • Post–Weight Loss Body-Contouring Surgery Access to body-contouring surgery is a major challenge for many patients after bariatric surgery. Past research has demonstrated that up to 74 percent of patients desire body-contouring surgery following bariatric surgery, yet only 21 percent undergo this procedure.13 The potential reasons for the large gap between the desire for body-contouring surgery and the actual decision to undergo the procedure have not yet been empirically examined. In several countries, bariatric surgery is covered by health insurance plans but body-contouring surgery remains an out-of-pocket expense for patients. Although socioeconomic status has been correlated with greater success following bariatric surgery, it remains unclear whether socioeconomic status alone is the primary barrier to body-contouring surgery access in most countries.14 Given that a high percentage of bariatric surgery patients do not access body-contouring surgery despite an expressed desire for this surgery, it is important to consider the psychological and quality-of-life implications of body-contouring surgery for patients who undergo this procedure. To date, the effects of body-contouring surgery on quality of life and psychological distress have also not been well established in the literature. Several groups have indicated improvement in quality of life following body-contouring surgery, whereas others have not replicated this finding.11,15–19 Given the high rates of psychiatric illness in bariatric surgery candidates,20 high rates of childhood trauma,21 and propensity for body image issues,22 it is possible that these historical factors may attenuate any quality-of-life differences (specifically, in mental domains) following body-contouring surgery. Measurement of psychological distress, such as depressive and anxiety symptoms, may provide additional insights into the psychological impact of excess skin folds on patients. Although bariatric surgery itself is initially associated with reductions in psychological distress, the magnitude of this relationship has been shown to decrease over time, with some studies showing an increase in depressive symptoms at approximately 2 years following bariatric surgery.7 It is unclear whether excess skin folds play a role in diminishing initial improvements in depressive symptoms following surgery. To our knowledge, no studies have assessed the impact of body-contouring surgery on anxiety symptoms, and only one study has assessed the impact of body-contouring surgery on depressive symptoms. In this study, Song et al. reported no change in depressive symptoms on the Beck
Depression Inventory following body-contouring surgery in a sample of 18 bariatric surgery patients.11 To extend the empirical literature on body-contouring surgery in bariatric surgery patients, we sought to conduct a cross-sectional study to examine barriers to accessing body-contouring surgery, and to compare socioeconomic variables (e.g., income, education, employment) and psychological variables (e.g., quality of life, psychological distress) between bariatric surgery patients who have undergone body-contouring surgery and those who have not. We hypothesized that cost would be the most commonly reported barrier to undergoing b ody-contouring surgery. Furthermore, we hypothesized that bariatric surgery patients who have undergone body-contouring surgery would report greater markers of socioeconomic status (e.g., higher income, higher education, more likely to be employed), and significantly higher quality of life and lower psychological distress (i.e., depression, anxiety) relative to patients not undergoing body-contouring surgery.
PATIENTS AND METHODS Study Sample Patients were recruited from the Toronto Western Hospital Bariatric Surgery Program, a Level 1A bariatric center accredited by the American College of Surgeons, during follow-up appointments between February 1, 2013, and August 1, 2013. All patients underwent a Roux-en-Y gastric bypass unless a sleeve gastrectomy was surgically indicated. Consent was obtained from patients for the study if they were between the ages of 18 and 65 years and had undergone bariatric surgery at least 1 year previously. Of the 71 patients who were approached for consent, 64 provided consent, and 58 completed the entire questionnaire, resulting in a response rate of 82 percent. This study was approved by the Institutional Research Ethics Board at the University Health Network in Toronto, Ontario, Canada. Study Measures Participants completed a survey consisting of demographic information and measures of psychological functioning. Demographic Survey The demographic data collected in the survey included age, sex, height, weight, relationship status, employment, level of education, and
777e
Plastic and Reconstructive Surgery • June 2014 household income. Income data were collected in the following increments: less than $10,000, $20,000 to $30,000, $30,000 to $40,000, $40,000 to $50,000, $50,000 to $75,000, $75,000 to $100,000, and greater than $100,000. Income was than dichotomized at $20,000, $40,000, and $75,000 based, respectively, on (1) the 2011 Canadian low-income cutoff for a large metropolitan area with a household size of two persons ($23,498), (2) the 2011 Canadian low-income cutoff for a large metropolitan area with a household size of four persons ($36,504), and (3) the 2010 average Canadian household income for two-parent families ($78,800).23 Surgical Information The questionnaire inquired about surgical information, presence of excess skin-folds, desire for body-contouring surgery, and barriers to body-contouring surgery. Presence of excess-skin folds and desire for body-contouring surgery were self-reported as either “yes” or “no.” Participants indicated the most pressing barrier to body-contouring surgery using the following options: cost, intent to lose more weight, risks of additional surgery, and other (with an option to write a response). Depression: Patient Health Questionnaire Nine-Item Scale Depressive symptoms were assessed using the Patient Health Questionnaire, a nine-item measure with each measure scored 0 to 3, yielding a total score between 0 and 27.24 The Patient Health Questionnaire has been validated in bariatric patient populations with good operating characteristics compared with a structured clinical interview for depression.25 Anxiety: Generalized Anxiety Disorder Seven-Item Scale Anxiety symptoms were assessed using the Generalized Anxiety Disorder seven-item scale, a validated anxiety screening measure consisting of seven items each scored between 0 and 3, yielding a total score between 0 and 21. The Generalized Anxiety Disorder seven-item scale has been shown to have good sensitivity and specificity for anxiety disorders.26,27 Quality-of-Life: Medical Outcomes Study Short-Form 36 Health Status Survey (Short Form-36) The Medical Outcomes Study Short-Form 36 Health Status Survey (Short Form-36) is a 36-item questionnaire that evaluates a patient’s quality of life by assessing the physical and mental components of health. The instrument measures eight
778e
domains of functioning. This instrument has been used extensively in bariatric surgery patients11,17 and is highly reliable for measuring healthrelated quality of life, with good construct validity, high internal consistency, and high test-retest reliability.28,29 Statistical Analysis Data were analyzed using IBM SPSS Version 21.0 (IBM Corp., Armonk, N.Y.). Participants were divided into two groups: (1) patients who underwent bariatric surgery but not body-contouring surgery and (2) patients who underwent both bariatric surgery and body-contouring surgery. The two groups were compared on demographic, socioeconomic, and psychological variables. Categorical data between the two aforementioned groups were compared using Fisher’s exact test with the exception of income category of $75,000, which was compared using the chi-square test. Continuous variables were represented as the mean ± SD unless otherwise mentioned. Comparison tests for continuous data were conducted using independent samples t test for variables meeting the assumptions of normality. The following variables met the requirements for normality based on the Shapiro-Wilk test (p values of the bariatric surgery plus body-contouring surgery group and the bariatric surgery–alone group are represented in parentheses in the mentioned order): age (p = 0.911 and p = 0.225), change in body mass index (p = 0.270 and p = 0.390), percentage body weight loss (p = 0.640 and p = 0.144), years of education (p = 0.385 and p = 0.100), Short Form-36 vitality score (p = 0.876 and p = 0.171), and Short F orm-36 physical health composite score (p = 0.119 and p = 0.260). All other continuous data were compared using the Mann-Whitney U test. A multivariate analysis between the bariatric surgery– alone and bariatric surgery plus body-contouring surgery group was conducted using a logistic regression model including all demographic variables as covariates to ascertain predictors of body-contouring surgery. A backward elimination of covariates with values of p > 0.2 was conducted as described by Vittinghof et al.,30 resulting in a model with the following variables: age, duration since bariatric surgery, employment status, and income greater than $75,000. Statistical significance level for all group comparisons was set at a value of p < 0.05.
RESULTS Of the 58 patients completing the survey, 48 underwent bariatric surgery alone and 10 patients underwent both bariatric surgery and
Volume 133, Number 6 • Post–Weight Loss Body-Contouring Surgery Table 1. Patient Demographics No. of participants Sex, no. female/male (% female) Mean age ± SD, yr No. married, common-law/single, divorced, separated (% married or common law) Years since bariatric surgery Weight loss operation, no. with RYGBP/gastric sleeve, (% RYGBP) Pre–bariatric surgery weight, kg Pre–bariatric surgery BMI, kg/m2 Post–bariatric surgery weight, kg Post–bariatric surgery BMI, kg/m2 Change in BMI, kg/m2 Percentage body weight loss, kg Income, no. of patients Median income category $20,000 (% >$20,000) $40,000 (% >$40,000) $75,000 (% >$75,000) Employed/unemployed, no. (% employed) ≤High school/>high school, no. (% >high school) Years of education
BS Only
BS/BCS
p
48 40/8 (83.33) 46.88 ± 10.33
10 9/1 (90.00) 40.00 ± 5.62
0.512 0.007*
29/19 (60.42) 2.14 ± 0.76
5/5 (50.00) 2.76 ± 0.78
0.726 0.022*
42/6 (87.50) 142.52 ± 30.57 51.01 ± 11.52 87.70 ± 24.84 31.41 ± 9.33 19.60 ± 7.34 38.42 ± 11.20
10/0 (100.00) 137.64 ± 39.00 50.50 ± 11.55 76.08 ± 24.87 27.96 ± 8.00 22.54 ± 5.97 44.78 ± 7.14
0.577 0.664 0.901 0.184 0.283 0.241 0.092
$50,000–$74,000 6/42 (87.50) 14/34 (70.83) 35/13 (27.08) 37/11 (77.10) 18/30 (62.50) 14.63 ± 2.54
$50,000–$74,000 0/10 (100.00) 2/8 (80.00) 5/5 (50.00) 9/1 (90.00) 3/7 (70.00) 15.30 ± 3.16
0.332 0.577 0.710 0.154 0.670 0.733 0.467
BS, bariatric surgery; BCS, body-contouring surgery; RYGBP, Roux-en-Y gastric bypass; BMI, body mass index. *Statistically significant (p < 0.05).
ody-contouring surgery. The mean age of b respondents was 45.96 ± 10.00 years. The mean time since bariatric surgery was 2.25 ± 0.79 years. The mean change in body mass index was 20.10 ± 7.16 kg/m2, with a mean percentage total weight loss of 39.52 ± 10.83 percent. Participant characteristics of both the bariatric surgery–alone group and the bariatric surgery plus body-contouring surgery group are listed in Table 1. Compared with the bariatric surgery–alone group, the bariatric surgery plus body-contouring surgery group had a significantly lower mean age (p = 0.011) and reported longer time since surgery (p = 0.022). No significant differences between groups were reported in any other demographic variable collected. Barriers to Access to Body-Contouring Surgery In our total sample (n = 58), 93.1 percent of participants (n = 54) reported developing skin folds following bariatric surgery; however, only 17.2 percent (n = 10) underwent body-contouring surgery. Of the patients who did not undergo body-contouring surgery (n = 44), 95.4 per cent (n = 41) reported a desire to undergo body-contouring surgery. For the 41 patients desiring body-contouring surgery, cost was the most commonly reported barrier [87.8 percent (n = 36)], followed by a desire for more weight loss before considering body-contouring surgery [9.8 percent (n = 4)] and a fear of the operation [2.8 percent (n = 1)]. Despite cost being reported
as a major barrier to undergoing body-contouring surgery, the bariatric surgery–alone group and the bariatric surgery plus body-contouring surgery group did not significantly differ from each other with respect to any of the measured socioeconomic variables (income, education, and employment) as highlighted in Table 1. Multivariate Analysis To assess predictors of body-contouring surgery, a multivariate analysis using age, duration since bariatric surgery, employment status, and income was used. Age approached significance (OR, 0.932; 95 percent CI, 0.858 to 1.012; p = 0.094). Time elapsed since bariatric surgery was deemed an independent predictor, with an odds ratio of 4.078 (95 percent CI, 1.331 to 12.496). Neither being employed (OR, 3.287; 95 percent CI, 0.288 to 37.469; p = 0.338) nor having an income greater than $75,000 (OR, 4.180; 95 percent CI, 0.722 to 24.204; p = 0.110) independently predicted body-contouring surgery. Psychological Distress Psychological distress measures were compared between the bariatric surgery plus body-contouring surgery group and the bariatric surgery–alone group (Table 2). The bariatric surgery plus body-contouring surgery group had a mean Patient Health Questionnaire score of 2.40 ± 2.37 compared with 6.40 ± 6.77 for the bariatric surgery–alone group (p < 0.05). In terms of
779e
Plastic and Reconstructive Surgery • June 2014 Table 2. Psychological Distress and Quality of Life in Bariatric Surgery Patients Who Have Undergone Body Contouring Surgery and Those Who Have Not BS Only (mean ± SD) Depression scale PHQ-9 Anxiety scale GAD-7 Quality of life: SF-36 domains Physical functioning Role limitations due to physical activity Role limitation due to emotional problems Vitality Emotional well-being Social functioning Pain General health Quality of life: SF-36 global scores Physical health component score Mental health component score
BS/BCS (mean ± SD)
p
6.40 ± 6.77
2.40 ± 2.37
0.002*
6.08 ± 5.97
3.50 ± 3.10
0.030*
83.75 ± 15.59 76.56 ± 37.33 66.67 ± 42.94 57.50 ± 25.60 69.84 ± 24.40 69.01 ± 29.74 73.59 ± 25.35 70.93 ± 19.37
97.50 ± 3.54 100.00 ± 0.00 86.67 ± 32.20 53.50 ± 24.15 72.80 ± 16.74 83.75 ± 19.59 88.50 ± 11.97 85.50 ± 17.55
0.008* 0.022* 0.170 0.652 0.717 0.140 0.008* 0.032*
49.57 ± 8.25 45.61 ± 15.06
56.80 ± 4.88 46.97 ± 10.08
0.010* 0.786
BS, bariatric surgery; BCS, body-contouring surgery; PHQ-9, Patient Health Questionnaire nine-item scale; GAD-7, Generalized Anxiety Disorder seven-item scale; SF-36, Short Form-36. *Statistically significant (p < 0.05).
anxiety symptoms, patients’ mean Generalized Anxiety Disorder seven-item scale scores were significantly lower in the bariatric surgery plus body-contouring surgery group compared with the bariatric surgery–alone group (3.50 ± 3.10 versus 6.08 ± 5.97; p = 0.030). Quality of Life The bariatric surgery plus body-contouring surgery group had significantly higher scores in four of the eight subscales of the Short Form36 (Table 2), specifically, physical functioning (p = 0.008), role limitation due to physical activity (p = 0.022), pain (p = 0.008), and general health (p = 0.003). Two additional subscales had a trend for higher subscale scores: social functioning (p = 0.140) and role limitation due to emotional problems (p = 0.170). The bariatric surgery plus body-contouring surgery group had a significantly higher mean physical health component score on the Short Form-36 compared with the bariatric surgery–alone group (p = 0.010). The mean mental health component score was not significantly different between the bariatric surgery plus body-contouring surgery group and the bariatric surgery–alone group.
DISCUSSION Many bariatric surgery patients perceive the excess skin folds following surgery as another obstacle in their weight loss journey. The results of our study confirm the high patient-reported rates of excess skin folds after weight loss surgery
780e
(93.1 percent), corroborating the recent findings by Kitzinger et al.13 In addition, nearly all patients in our sample (95.4 percent) who did not undergo body-contouring surgery desired body-contouring surgery, whereas only a fraction of patients in our sample (17.2 percent) actually underwent body-contouring surgery. Our exploration of potential barriers to accessing body-contouring surgery suggests that, as hypothesized, cost was reported as the most common barrier in accessing body-contouring surgery for this patient population. However, participants who pursued body-contouring surgery did not report higher income or education, and were not more likely to be employed. A study conducted in the United States reported that the likelihood of undergoing bodycontouring surgery was associated with an income greater than $20,00031; however, over 50 percent of those who underwent body-contouring surgery had partial insurance coverage, a scenario not possible in our study setting. In addition, our study identified a relationship between lower age and body-contouring surgery in univariate analysis and a trend toward significance in multivariate analysis. Although this has not been previously identified in the literature, it is possible that patients who are younger are more invested in their appearance and may pursue unconventional methods of paying for body-contouring surgery (e.g., loans, borrowing from family). Additional research is needed to further explore this study finding. Our study findings also contribute to our evolving understanding of the psychosocial trajectory of patients following bariatric
Volume 133, Number 6 • Post–Weight Loss Body-Contouring Surgery surgery—specifically, patients who undergo bodycontouring surgery. There is a paucity of literature comparing anxiety and depressive symptoms using specific symptom measures in bariatric surgery patients with excess skin folds and those who underwent b ody-contouring surgery. Although our study did not longitudinally assess changes in depression and anxiety from before to after body-contouring surgery, our results indicate that patients who underwent body-contouring surgery had significantly lower anxiety (as measured by the Generalized Anxiety Disorder seven-item scale) and depression (as measured by the Patient Health Questionnaire nine-item scale) relative to patients who did not undergo body-contouring surgery. Although there are no studies to our knowledge comparing anxiety before and after body-contouring surgery, our finding related to depressive symptoms builds on a prior study by Song et al., which reported that mood remained stable before body-contouring surgery and at 3 and 6 months after b ody-contouring surgery.11 It is notable that none of the participants in the study by Song et al. scored higher than 10 on the Beck Depression Inventory at any of the aforementioned time points, suggesting minimal depression even before body-contouring surgery and little room for improvement. In contrast, the current study used the Patient Health Questionnaire and found that the mean score in bariatric patients who did not undergo body-contouring surgery fell within the mild range, whereas the mean score for those who underwent body-contouring surgery fell within the minimal depression range. The benefits of weight-loss surgery on quality of life have been well documented in the empirical literature.5,6 In this study, we found significantly higher quality of life scores in b ody-contouring surgery patients on all four of the Short Form-36 subscales that mainly predict physical health (i.e., physical functioning, role limitation due to physical activity, bodily pain, and general health). This is in keeping with research suggesting that excess skin folds result in complications such as rashes, ulcers, impaired ambulation, and poor body image, all of which can impair physical functioning.10,12 Furthermore, a recent study also noted reduced ability to exercise secondary to excess skin folds following bariatric surgery.32 The lack of significant group differences in the mental quality of life domains of the Short Form-36 is in concordance with a study by Singh et al., which used the Short Form-36 in 30 post–bariatric surgery–alone and 16 post–bariatric surgery plus body-contouring surgery patients and reported
significantly lower scores (i.e., worse) in social functioning and role limitations due to emotional problems and no change in emotional well-being in the bariatric surgery and b ody-contouring surgery group.17 It is also possible that our sample size did not provide sufficient power to detect a difference in mental quality-of-life domains. However, we observed a nonsignificant trend toward higher scores in the three subdomains that contribute the most to mental quality of life (social functioning, role limitation due to emotional problems, and emotional well-being), which is congruent with the significant findings on our depressive (Patient Health Questionnaire nine-item scale) and anxiety (Generalized Anxiety Disorder seven-item scale) measures. Our study findings should be interpreted in the context of the following limitations. First, our study may not have been adequately powered to detect significant differences in all study measures. Second, although our Bariatric Surgery Program is an assessment center for three hospitals at the University of Toronto, it represents a single Canadian context; thus, the findings may not be generalizable to other bariatric surgery populations. Third, we used a cross-sectional study design and were unable to assess longitudinal changes in quality of life and psychological distress from before to after body-contouring surgery. Finally, given the differences in health care systems in the United States and Canada, additional research is needed to explore potential barriers to body-contouring surgery in a U.S. health care setting.
SUMMARY Our study confirms that, according to patients, cost remains a major barrier to accessing b ody-contouring surgery. Despite cost being a barrier to body-contouring surgery access, other socioeconomic factors, including income, may not significantly differ in patients who undergo body-contouring surgery relative to those who do not undergo the procedure. In addition, our study provides some preliminary evidence that patients who undergo body-contouring surgery report less anxiety and depression relative to bariatric surgery patients experiencing excess skin folds. Longitudinal studies are needed to compare the long-term physical and psychological adjustment in bariatric surgery patients who undergo body-contouring surgery following surgery and those who do not. If our findings are replicated in longitudinal studies, funding for body-contouring surgery may need to be reevaluated if the goal of
781e
Plastic and Reconstructive Surgery • June 2014 bariatric surgery is to enhance the physical and mental well-being of patients. Raed Hawa, M.D., D.A.B.P.N. Department of Psychiatry Toronto Western Hospital 7 Main Pavillion, Room 401 Toronto, Ontario M5T 2S8, Canada [email protected]
ACKNOWLEDGMENTS
The authors thank the Toronto Western Hospital Bariatric Surgery Program interprofessional team and the patients in the program for participating in the study. REFERENCES 1. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA 2004;292:1724–1737. 2. Bult MJ, van Dalen T, Muller AF. Surgical treatment of obesity. Eur J Endocrinol. 2008;158:135–145. 3. Dixon JB, Dixon ME, O’Brien PE. Depression in association with severe obesity: Changes with weight loss. Arch Intern Med. 2003;163:2058–2065. 4. Kennel KA. Review: Sparse high-quality evidence supports surgery for obesity. ACP J Club 2005;143:51. 5. de Zwaan M, Lancaster KL, Mitchell JE, et al. Health-related quality of life in morbidly obese patients: Effect of gastric bypass surgery. Obes Surg. 2002;12:773–780. 6. Schok M, Geenen R, van Antwerpen T, de Wit P, Brand N, van Ramshorst B. Quality of life after laparoscopic adjustable gastric banding for severe obesity: Postoperative and retrospective preoperative evaluations. Obes Surg. 2000;10:502–508. 7. de Zwaan M, Enderle J, Wagner S, et al. Anxiety and depression in bariatric surgery patients: A prospective, follow-up study using structured clinical interviews. J Affect Disord. 2011;133:61–68. 8. Dymek MP, le Grange D, Neven K, Alverdy J. Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: A brief report. Obes Surg. 2001;11:32–39. 9. Kitzinger HB, Abayev S, Pittermann A, et al. After massive weight loss: Patients’ expectations of body contouring surgery. Obes Surg. 2012;22:544–548. 10. Zuelzer HB, Baugh NG. Bariatric and body-contouring surgery: A continuum of care for excess and lax skin. Plast Surg Nurs. 2007;27:3–13; quiz 14. 11. Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH. Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring) 2006;14:1626–1636. 12. Sarwer DB, Thompson JK, Mitchell JE, Rubin JP. Psychological considerations of the bariatric surgery patient undergoing body contouring surgery. Plast Reconstr Surg. 2008;121:423e–434e. 13. Kitzinger HB, Abayev S, Pittermann A, et al. The prevalence of body contouring surgery after gastric bypass surgery. Obes Surg. 2012;22:8–12. 14. van Hout GC, Verschure SK, van Heck GL. Psychosocial predictors of success following bariatric surgery. Obes Surg. 2005;15:552–560.
782e
15. van der Beek ES, Te Riele W, Specken TF, Boerma D, van Ramshorst B. The impact of reconstructive procedures following bariatric surgery on patient well-being and quality of life. Obes Surg. 2010;20:36–41. 16. Lazar CC, Clerc I, Deneuve S, Auquit-Auckbur I, Milliez PY. Abdominoplasty after major weight loss: Improvement of quality of life and psychological status. Obes Surg. 2009;19:1170–1175. 17. Singh D, Zahiri HR, Janes LE, et al. Mental and physical impact of body contouring procedures on post-bariatric surgery patients. Eplasty 2012;12:e47. 18. Coriddi MR, Koltz PF, Chen R, Gusenoff JA. Changes in quality of life and functional status following abdominal contouring in the massive weight loss population. Plast Reconstr Surg. 2011;128:520–526. 19. Modarressi A, Balagué N, Huber O, Chilcott M, Pittet-Cuénod B. Plastic surgery after gastric bypass improves long-term quality of life. Obes Surg. 2013;23:24–30. 20. Mitchell JE, Selzer F, Kalarchian MA, et al. Psychopathology before surgery in the longitudinal assessment of bariatric surgery-3 (LABS-3) psychosocial study. Surg Obes Relat Dis. 2012;8:533–541. 21. Sansone RA, Schumacher D, Wiederman MW, Routsong-Weichers L. The prevalence of childhood trauma and parental caretaking quality among gastric surgery candidates. Eat Disord. 2008;16:117–127. 22. Sarwer DB, Thompson JK, Cash TF. Body image and obesity in adulthood. Psychiatr Clin North Am. 2005;28:69–87, viii. 23. Statistics Canada. Low income lines, 2010–2011. Available at: http://www.statcan.gc.ca/pub/75f0002m/2012002/lico-sfreng.htm. Accessed September 9, 2013. 24. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study: Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 1999;282:1737–1744. 25. Cassin S, Sockalingam S, Hawa R, et al. Psychometric properties of the Patient Health Questionnaire (PHQ-9) as a depression screening tool for bariatric surgery candidates. Psychosomatics 2013;54:352–358. 26. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317–325. 27. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med. 2006;166:1092–1097. 28. Brazier JE, Harper R, Jones NM, et al. Validating the SF-36 health survey questionnaire: New outcome measure for primary care. BMJ 1992;305:160–164. 29. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care 1992;30:473–483. 30. Vittinghof E, Glidden DV, Shiboski SC, McCulloch CE. Regression Methods in Biostatistics: Linear, Logistic, Survival, and Repeated Measures Models. New York: Springer; 2005. 31. Gusenoff JA, Messing S, O’Malley W, Langstein HN. Patterns of plastic surgical use after gastric bypass: Who can afford it and who will return for more. Plast Reconstr Surg. 2008;122:951–958. 32. Baillot A, Asselin M, Comeau E, Méziat-Burdin A, Langlois MF. Impact of excess skin from massive weight loss on the practice of physical activity in women. Obes Surg. 2013;23:1826–1834.
Body Contouring Surgery after Bariatric Surgery: A Study of Cost as a Barrier and Impact on Psychological Well-Being Arash Azin, H.B.Sc. Carrol Zhou, H.B.Sc. Timothy Jackson, M.D., M.P.H. Stephanie Cassin, Ph.D., C.Psych. Sanjeev Sockalingam, M.D. Raed Hawa, M.D., D.A.B.P.N. Toronto, Ontario, Canada
Background: Body-contouring surgery can be a solution to excess skin folds following bariatric surgery. Many patients desire body-contouring surgery, but the cost of the procedure may be a limiting factor. This study aims to examine barriers to access and to compare socioeconomic variables and psychological variables between bariatric surgery patients who have undergone body contouring and those who have not. Methods: In this cross-sectional study, a questionnaire packet was administered to (1) patients who underwent bariatric but not body-contouring surgery and (2) patients who underwent both. The questionnaire included perceived barriers to body-contouring surgery, socioeconomic barriers, measures of anxiety (Generalized Anxiety Disorder seven-item scale), depression (Patient Health Questionnaire nine-item scale), and quality of life (Short Form-36). Results: Among the 58 study participants, 93.1 percent reported having excess skin folds. Of this sample, 95.4 percent desired body-contouring surgery, and the majority (87.8 percent) of this subsample identified cost as the major barrier to access. Mean scores on the Generalized Anxiety Disorder scale (6.08 ± 5.97 versus 3.50 ± 3.10; p = 0.030) and the Patient Health Questionnaire (6.40 ± 6.77 versus 2.40 ± 2.37; p = 0.002) were significantly higher for the bariatric surgery group versus bariatric surgery plus body contouring group. Patients in the latter group had significantly higher Short Form-36 physical health component scores (56.80 ± 4.88 versus 49.57 ± 8.25; p = 0.010). Conclusions: Bariatric surgery patients who desire body-contouring surgery perceive cost as a major barrier. Patients undergoing body-contouring surgery may experience improved physical quality of life but not mental quality of life; however, body-contouring surgery may improve aspects of depression and anxiety. (Plast. Reconstr. Surg. 133: 776e, 2014.)
B
ariatric surgery is now considered the most effective long-term treatment for severe obesity, resulting in sustainable weight loss and improvements in obesity-related comorbidities and psychological distress.1–4 The impact of bariatric surgery on patient well-being, including improved quality-of-life and psychological distress, has been well established in the literature. Several studies using validated instruments From the Faculty of Medicine, Division of General Surgery, University Health Network, the Departments of Surgery and Psychiatry, University of Toronto; the Department of Psychology, Ryerson University; and the Toronto Western Hospital Bariatric Surgery Psychosocial Program. Received for publication October 8, 2013; accepted November 20, 2013. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000227
776e
to assess quality of life have established a clear improvement in this metric following bariatric surgery.5,6 In addition, aspects of psychological distress, including depression, have been shown to improve following bariatric surgery.7,8 However, after the initial rapid weight loss, up to 96 percent of bariatric surgery patients develop excess sagging skin folds,9 which can have dramatic mental and physical health effects, impacting both quality of life and psychological distress.10–12 For these reasons, many post–bariatric surgery patients desire corrective body-contouring surgery for their excess skin.
Disclosure: The authors have no financial interest to declare in relation to the content of this article. This work was not funded by any outside source.
www.PRSJournal.com
Volume 133, Number 6 • Post–Weight Loss Body-Contouring Surgery Access to body-contouring surgery is a major challenge for many patients after bariatric surgery. Past research has demonstrated that up to 74 percent of patients desire body-contouring surgery following bariatric surgery, yet only 21 percent undergo this procedure.13 The potential reasons for the large gap between the desire for body-contouring surgery and the actual decision to undergo the procedure have not yet been empirically examined. In several countries, bariatric surgery is covered by health insurance plans but body-contouring surgery remains an out-of-pocket expense for patients. Although socioeconomic status has been correlated with greater success following bariatric surgery, it remains unclear whether socioeconomic status alone is the primary barrier to body-contouring surgery access in most countries.14 Given that a high percentage of bariatric surgery patients do not access body-contouring surgery despite an expressed desire for this surgery, it is important to consider the psychological and quality-of-life implications of body-contouring surgery for patients who undergo this procedure. To date, the effects of body-contouring surgery on quality of life and psychological distress have also not been well established in the literature. Several groups have indicated improvement in quality of life following body-contouring surgery, whereas others have not replicated this finding.11,15–19 Given the high rates of psychiatric illness in bariatric surgery candidates,20 high rates of childhood trauma,21 and propensity for body image issues,22 it is possible that these historical factors may attenuate any quality-of-life differences (specifically, in mental domains) following body-contouring surgery. Measurement of psychological distress, such as depressive and anxiety symptoms, may provide additional insights into the psychological impact of excess skin folds on patients. Although bariatric surgery itself is initially associated with reductions in psychological distress, the magnitude of this relationship has been shown to decrease over time, with some studies showing an increase in depressive symptoms at approximately 2 years following bariatric surgery.7 It is unclear whether excess skin folds play a role in diminishing initial improvements in depressive symptoms following surgery. To our knowledge, no studies have assessed the impact of body-contouring surgery on anxiety symptoms, and only one study has assessed the impact of body-contouring surgery on depressive symptoms. In this study, Song et al. reported no change in depressive symptoms on the Beck
Depression Inventory following body-contouring surgery in a sample of 18 bariatric surgery patients.11 To extend the empirical literature on body-contouring surgery in bariatric surgery patients, we sought to conduct a cross-sectional study to examine barriers to accessing body-contouring surgery, and to compare socioeconomic variables (e.g., income, education, employment) and psychological variables (e.g., quality of life, psychological distress) between bariatric surgery patients who have undergone body-contouring surgery and those who have not. We hypothesized that cost would be the most commonly reported barrier to undergoing b ody-contouring surgery. Furthermore, we hypothesized that bariatric surgery patients who have undergone body-contouring surgery would report greater markers of socioeconomic status (e.g., higher income, higher education, more likely to be employed), and significantly higher quality of life and lower psychological distress (i.e., depression, anxiety) relative to patients not undergoing body-contouring surgery.
PATIENTS AND METHODS Study Sample Patients were recruited from the Toronto Western Hospital Bariatric Surgery Program, a Level 1A bariatric center accredited by the American College of Surgeons, during follow-up appointments between February 1, 2013, and August 1, 2013. All patients underwent a Roux-en-Y gastric bypass unless a sleeve gastrectomy was surgically indicated. Consent was obtained from patients for the study if they were between the ages of 18 and 65 years and had undergone bariatric surgery at least 1 year previously. Of the 71 patients who were approached for consent, 64 provided consent, and 58 completed the entire questionnaire, resulting in a response rate of 82 percent. This study was approved by the Institutional Research Ethics Board at the University Health Network in Toronto, Ontario, Canada. Study Measures Participants completed a survey consisting of demographic information and measures of psychological functioning. Demographic Survey The demographic data collected in the survey included age, sex, height, weight, relationship status, employment, level of education, and
777e
Plastic and Reconstructive Surgery • June 2014 household income. Income data were collected in the following increments: less than $10,000, $20,000 to $30,000, $30,000 to $40,000, $40,000 to $50,000, $50,000 to $75,000, $75,000 to $100,000, and greater than $100,000. Income was than dichotomized at $20,000, $40,000, and $75,000 based, respectively, on (1) the 2011 Canadian low-income cutoff for a large metropolitan area with a household size of two persons ($23,498), (2) the 2011 Canadian low-income cutoff for a large metropolitan area with a household size of four persons ($36,504), and (3) the 2010 average Canadian household income for two-parent families ($78,800).23 Surgical Information The questionnaire inquired about surgical information, presence of excess skin-folds, desire for body-contouring surgery, and barriers to body-contouring surgery. Presence of excess-skin folds and desire for body-contouring surgery were self-reported as either “yes” or “no.” Participants indicated the most pressing barrier to body-contouring surgery using the following options: cost, intent to lose more weight, risks of additional surgery, and other (with an option to write a response). Depression: Patient Health Questionnaire Nine-Item Scale Depressive symptoms were assessed using the Patient Health Questionnaire, a nine-item measure with each measure scored 0 to 3, yielding a total score between 0 and 27.24 The Patient Health Questionnaire has been validated in bariatric patient populations with good operating characteristics compared with a structured clinical interview for depression.25 Anxiety: Generalized Anxiety Disorder Seven-Item Scale Anxiety symptoms were assessed using the Generalized Anxiety Disorder seven-item scale, a validated anxiety screening measure consisting of seven items each scored between 0 and 3, yielding a total score between 0 and 21. The Generalized Anxiety Disorder seven-item scale has been shown to have good sensitivity and specificity for anxiety disorders.26,27 Quality-of-Life: Medical Outcomes Study Short-Form 36 Health Status Survey (Short Form-36) The Medical Outcomes Study Short-Form 36 Health Status Survey (Short Form-36) is a 36-item questionnaire that evaluates a patient’s quality of life by assessing the physical and mental components of health. The instrument measures eight
778e
domains of functioning. This instrument has been used extensively in bariatric surgery patients11,17 and is highly reliable for measuring healthrelated quality of life, with good construct validity, high internal consistency, and high test-retest reliability.28,29 Statistical Analysis Data were analyzed using IBM SPSS Version 21.0 (IBM Corp., Armonk, N.Y.). Participants were divided into two groups: (1) patients who underwent bariatric surgery but not body-contouring surgery and (2) patients who underwent both bariatric surgery and body-contouring surgery. The two groups were compared on demographic, socioeconomic, and psychological variables. Categorical data between the two aforementioned groups were compared using Fisher’s exact test with the exception of income category of $75,000, which was compared using the chi-square test. Continuous variables were represented as the mean ± SD unless otherwise mentioned. Comparison tests for continuous data were conducted using independent samples t test for variables meeting the assumptions of normality. The following variables met the requirements for normality based on the Shapiro-Wilk test (p values of the bariatric surgery plus body-contouring surgery group and the bariatric surgery–alone group are represented in parentheses in the mentioned order): age (p = 0.911 and p = 0.225), change in body mass index (p = 0.270 and p = 0.390), percentage body weight loss (p = 0.640 and p = 0.144), years of education (p = 0.385 and p = 0.100), Short Form-36 vitality score (p = 0.876 and p = 0.171), and Short F orm-36 physical health composite score (p = 0.119 and p = 0.260). All other continuous data were compared using the Mann-Whitney U test. A multivariate analysis between the bariatric surgery– alone and bariatric surgery plus body-contouring surgery group was conducted using a logistic regression model including all demographic variables as covariates to ascertain predictors of body-contouring surgery. A backward elimination of covariates with values of p > 0.2 was conducted as described by Vittinghof et al.,30 resulting in a model with the following variables: age, duration since bariatric surgery, employment status, and income greater than $75,000. Statistical significance level for all group comparisons was set at a value of p < 0.05.
RESULTS Of the 58 patients completing the survey, 48 underwent bariatric surgery alone and 10 patients underwent both bariatric surgery and
Volume 133, Number 6 • Post–Weight Loss Body-Contouring Surgery Table 1. Patient Demographics No. of participants Sex, no. female/male (% female) Mean age ± SD, yr No. married, common-law/single, divorced, separated (% married or common law) Years since bariatric surgery Weight loss operation, no. with RYGBP/gastric sleeve, (% RYGBP) Pre–bariatric surgery weight, kg Pre–bariatric surgery BMI, kg/m2 Post–bariatric surgery weight, kg Post–bariatric surgery BMI, kg/m2 Change in BMI, kg/m2 Percentage body weight loss, kg Income, no. of patients Median income category $20,000 (% >$20,000) $40,000 (% >$40,000) $75,000 (% >$75,000) Employed/unemployed, no. (% employed) ≤High school/>high school, no. (% >high school) Years of education
BS Only
BS/BCS
p
48 40/8 (83.33) 46.88 ± 10.33
10 9/1 (90.00) 40.00 ± 5.62
0.512 0.007*
29/19 (60.42) 2.14 ± 0.76
5/5 (50.00) 2.76 ± 0.78
0.726 0.022*
42/6 (87.50) 142.52 ± 30.57 51.01 ± 11.52 87.70 ± 24.84 31.41 ± 9.33 19.60 ± 7.34 38.42 ± 11.20
10/0 (100.00) 137.64 ± 39.00 50.50 ± 11.55 76.08 ± 24.87 27.96 ± 8.00 22.54 ± 5.97 44.78 ± 7.14
0.577 0.664 0.901 0.184 0.283 0.241 0.092
$50,000–$74,000 6/42 (87.50) 14/34 (70.83) 35/13 (27.08) 37/11 (77.10) 18/30 (62.50) 14.63 ± 2.54
$50,000–$74,000 0/10 (100.00) 2/8 (80.00) 5/5 (50.00) 9/1 (90.00) 3/7 (70.00) 15.30 ± 3.16
0.332 0.577 0.710 0.154 0.670 0.733 0.467
BS, bariatric surgery; BCS, body-contouring surgery; RYGBP, Roux-en-Y gastric bypass; BMI, body mass index. *Statistically significant (p < 0.05).
ody-contouring surgery. The mean age of b respondents was 45.96 ± 10.00 years. The mean time since bariatric surgery was 2.25 ± 0.79 years. The mean change in body mass index was 20.10 ± 7.16 kg/m2, with a mean percentage total weight loss of 39.52 ± 10.83 percent. Participant characteristics of both the bariatric surgery–alone group and the bariatric surgery plus body-contouring surgery group are listed in Table 1. Compared with the bariatric surgery–alone group, the bariatric surgery plus body-contouring surgery group had a significantly lower mean age (p = 0.011) and reported longer time since surgery (p = 0.022). No significant differences between groups were reported in any other demographic variable collected. Barriers to Access to Body-Contouring Surgery In our total sample (n = 58), 93.1 percent of participants (n = 54) reported developing skin folds following bariatric surgery; however, only 17.2 percent (n = 10) underwent body-contouring surgery. Of the patients who did not undergo body-contouring surgery (n = 44), 95.4 per cent (n = 41) reported a desire to undergo body-contouring surgery. For the 41 patients desiring body-contouring surgery, cost was the most commonly reported barrier [87.8 percent (n = 36)], followed by a desire for more weight loss before considering body-contouring surgery [9.8 percent (n = 4)] and a fear of the operation [2.8 percent (n = 1)]. Despite cost being reported
as a major barrier to undergoing body-contouring surgery, the bariatric surgery–alone group and the bariatric surgery plus body-contouring surgery group did not significantly differ from each other with respect to any of the measured socioeconomic variables (income, education, and employment) as highlighted in Table 1. Multivariate Analysis To assess predictors of body-contouring surgery, a multivariate analysis using age, duration since bariatric surgery, employment status, and income was used. Age approached significance (OR, 0.932; 95 percent CI, 0.858 to 1.012; p = 0.094). Time elapsed since bariatric surgery was deemed an independent predictor, with an odds ratio of 4.078 (95 percent CI, 1.331 to 12.496). Neither being employed (OR, 3.287; 95 percent CI, 0.288 to 37.469; p = 0.338) nor having an income greater than $75,000 (OR, 4.180; 95 percent CI, 0.722 to 24.204; p = 0.110) independently predicted body-contouring surgery. Psychological Distress Psychological distress measures were compared between the bariatric surgery plus body-contouring surgery group and the bariatric surgery–alone group (Table 2). The bariatric surgery plus body-contouring surgery group had a mean Patient Health Questionnaire score of 2.40 ± 2.37 compared with 6.40 ± 6.77 for the bariatric surgery–alone group (p < 0.05). In terms of
779e
Plastic and Reconstructive Surgery • June 2014 Table 2. Psychological Distress and Quality of Life in Bariatric Surgery Patients Who Have Undergone Body Contouring Surgery and Those Who Have Not BS Only (mean ± SD) Depression scale PHQ-9 Anxiety scale GAD-7 Quality of life: SF-36 domains Physical functioning Role limitations due to physical activity Role limitation due to emotional problems Vitality Emotional well-being Social functioning Pain General health Quality of life: SF-36 global scores Physical health component score Mental health component score
BS/BCS (mean ± SD)
p
6.40 ± 6.77
2.40 ± 2.37
0.002*
6.08 ± 5.97
3.50 ± 3.10
0.030*
83.75 ± 15.59 76.56 ± 37.33 66.67 ± 42.94 57.50 ± 25.60 69.84 ± 24.40 69.01 ± 29.74 73.59 ± 25.35 70.93 ± 19.37
97.50 ± 3.54 100.00 ± 0.00 86.67 ± 32.20 53.50 ± 24.15 72.80 ± 16.74 83.75 ± 19.59 88.50 ± 11.97 85.50 ± 17.55
0.008* 0.022* 0.170 0.652 0.717 0.140 0.008* 0.032*
49.57 ± 8.25 45.61 ± 15.06
56.80 ± 4.88 46.97 ± 10.08
0.010* 0.786
BS, bariatric surgery; BCS, body-contouring surgery; PHQ-9, Patient Health Questionnaire nine-item scale; GAD-7, Generalized Anxiety Disorder seven-item scale; SF-36, Short Form-36. *Statistically significant (p < 0.05).
anxiety symptoms, patients’ mean Generalized Anxiety Disorder seven-item scale scores were significantly lower in the bariatric surgery plus body-contouring surgery group compared with the bariatric surgery–alone group (3.50 ± 3.10 versus 6.08 ± 5.97; p = 0.030). Quality of Life The bariatric surgery plus body-contouring surgery group had significantly higher scores in four of the eight subscales of the Short Form36 (Table 2), specifically, physical functioning (p = 0.008), role limitation due to physical activity (p = 0.022), pain (p = 0.008), and general health (p = 0.003). Two additional subscales had a trend for higher subscale scores: social functioning (p = 0.140) and role limitation due to emotional problems (p = 0.170). The bariatric surgery plus body-contouring surgery group had a significantly higher mean physical health component score on the Short Form-36 compared with the bariatric surgery–alone group (p = 0.010). The mean mental health component score was not significantly different between the bariatric surgery plus body-contouring surgery group and the bariatric surgery–alone group.
DISCUSSION Many bariatric surgery patients perceive the excess skin folds following surgery as another obstacle in their weight loss journey. The results of our study confirm the high patient-reported rates of excess skin folds after weight loss surgery
780e
(93.1 percent), corroborating the recent findings by Kitzinger et al.13 In addition, nearly all patients in our sample (95.4 percent) who did not undergo body-contouring surgery desired body-contouring surgery, whereas only a fraction of patients in our sample (17.2 percent) actually underwent body-contouring surgery. Our exploration of potential barriers to accessing body-contouring surgery suggests that, as hypothesized, cost was reported as the most common barrier in accessing body-contouring surgery for this patient population. However, participants who pursued body-contouring surgery did not report higher income or education, and were not more likely to be employed. A study conducted in the United States reported that the likelihood of undergoing bodycontouring surgery was associated with an income greater than $20,00031; however, over 50 percent of those who underwent body-contouring surgery had partial insurance coverage, a scenario not possible in our study setting. In addition, our study identified a relationship between lower age and body-contouring surgery in univariate analysis and a trend toward significance in multivariate analysis. Although this has not been previously identified in the literature, it is possible that patients who are younger are more invested in their appearance and may pursue unconventional methods of paying for body-contouring surgery (e.g., loans, borrowing from family). Additional research is needed to further explore this study finding. Our study findings also contribute to our evolving understanding of the psychosocial trajectory of patients following bariatric
Volume 133, Number 6 • Post–Weight Loss Body-Contouring Surgery surgery—specifically, patients who undergo bodycontouring surgery. There is a paucity of literature comparing anxiety and depressive symptoms using specific symptom measures in bariatric surgery patients with excess skin folds and those who underwent b ody-contouring surgery. Although our study did not longitudinally assess changes in depression and anxiety from before to after body-contouring surgery, our results indicate that patients who underwent body-contouring surgery had significantly lower anxiety (as measured by the Generalized Anxiety Disorder seven-item scale) and depression (as measured by the Patient Health Questionnaire nine-item scale) relative to patients who did not undergo body-contouring surgery. Although there are no studies to our knowledge comparing anxiety before and after body-contouring surgery, our finding related to depressive symptoms builds on a prior study by Song et al., which reported that mood remained stable before body-contouring surgery and at 3 and 6 months after b ody-contouring surgery.11 It is notable that none of the participants in the study by Song et al. scored higher than 10 on the Beck Depression Inventory at any of the aforementioned time points, suggesting minimal depression even before body-contouring surgery and little room for improvement. In contrast, the current study used the Patient Health Questionnaire and found that the mean score in bariatric patients who did not undergo body-contouring surgery fell within the mild range, whereas the mean score for those who underwent body-contouring surgery fell within the minimal depression range. The benefits of weight-loss surgery on quality of life have been well documented in the empirical literature.5,6 In this study, we found significantly higher quality of life scores in b ody-contouring surgery patients on all four of the Short Form-36 subscales that mainly predict physical health (i.e., physical functioning, role limitation due to physical activity, bodily pain, and general health). This is in keeping with research suggesting that excess skin folds result in complications such as rashes, ulcers, impaired ambulation, and poor body image, all of which can impair physical functioning.10,12 Furthermore, a recent study also noted reduced ability to exercise secondary to excess skin folds following bariatric surgery.32 The lack of significant group differences in the mental quality of life domains of the Short Form-36 is in concordance with a study by Singh et al., which used the Short Form-36 in 30 post–bariatric surgery–alone and 16 post–bariatric surgery plus body-contouring surgery patients and reported
significantly lower scores (i.e., worse) in social functioning and role limitations due to emotional problems and no change in emotional well-being in the bariatric surgery and b ody-contouring surgery group.17 It is also possible that our sample size did not provide sufficient power to detect a difference in mental quality-of-life domains. However, we observed a nonsignificant trend toward higher scores in the three subdomains that contribute the most to mental quality of life (social functioning, role limitation due to emotional problems, and emotional well-being), which is congruent with the significant findings on our depressive (Patient Health Questionnaire nine-item scale) and anxiety (Generalized Anxiety Disorder seven-item scale) measures. Our study findings should be interpreted in the context of the following limitations. First, our study may not have been adequately powered to detect significant differences in all study measures. Second, although our Bariatric Surgery Program is an assessment center for three hospitals at the University of Toronto, it represents a single Canadian context; thus, the findings may not be generalizable to other bariatric surgery populations. Third, we used a cross-sectional study design and were unable to assess longitudinal changes in quality of life and psychological distress from before to after body-contouring surgery. Finally, given the differences in health care systems in the United States and Canada, additional research is needed to explore potential barriers to body-contouring surgery in a U.S. health care setting.
SUMMARY Our study confirms that, according to patients, cost remains a major barrier to accessing b ody-contouring surgery. Despite cost being a barrier to body-contouring surgery access, other socioeconomic factors, including income, may not significantly differ in patients who undergo body-contouring surgery relative to those who do not undergo the procedure. In addition, our study provides some preliminary evidence that patients who undergo body-contouring surgery report less anxiety and depression relative to bariatric surgery patients experiencing excess skin folds. Longitudinal studies are needed to compare the long-term physical and psychological adjustment in bariatric surgery patients who undergo body-contouring surgery following surgery and those who do not. If our findings are replicated in longitudinal studies, funding for body-contouring surgery may need to be reevaluated if the goal of
781e
Plastic and Reconstructive Surgery • June 2014 bariatric surgery is to enhance the physical and mental well-being of patients. Raed Hawa, M.D., D.A.B.P.N. Department of Psychiatry Toronto Western Hospital 7 Main Pavillion, Room 401 Toronto, Ontario M5T 2S8, Canada [email protected]
ACKNOWLEDGMENTS
The authors thank the Toronto Western Hospital Bariatric Surgery Program interprofessional team and the patients in the program for participating in the study. REFERENCES 1. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA 2004;292:1724–1737. 2. Bult MJ, van Dalen T, Muller AF. Surgical treatment of obesity. Eur J Endocrinol. 2008;158:135–145. 3. Dixon JB, Dixon ME, O’Brien PE. Depression in association with severe obesity: Changes with weight loss. Arch Intern Med. 2003;163:2058–2065. 4. Kennel KA. Review: Sparse high-quality evidence supports surgery for obesity. ACP J Club 2005;143:51. 5. de Zwaan M, Lancaster KL, Mitchell JE, et al. Health-related quality of life in morbidly obese patients: Effect of gastric bypass surgery. Obes Surg. 2002;12:773–780. 6. Schok M, Geenen R, van Antwerpen T, de Wit P, Brand N, van Ramshorst B. Quality of life after laparoscopic adjustable gastric banding for severe obesity: Postoperative and retrospective preoperative evaluations. Obes Surg. 2000;10:502–508. 7. de Zwaan M, Enderle J, Wagner S, et al. Anxiety and depression in bariatric surgery patients: A prospective, follow-up study using structured clinical interviews. J Affect Disord. 2011;133:61–68. 8. Dymek MP, le Grange D, Neven K, Alverdy J. Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: A brief report. Obes Surg. 2001;11:32–39. 9. Kitzinger HB, Abayev S, Pittermann A, et al. After massive weight loss: Patients’ expectations of body contouring surgery. Obes Surg. 2012;22:544–548. 10. Zuelzer HB, Baugh NG. Bariatric and body-contouring surgery: A continuum of care for excess and lax skin. Plast Surg Nurs. 2007;27:3–13; quiz 14. 11. Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH. Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring) 2006;14:1626–1636. 12. Sarwer DB, Thompson JK, Mitchell JE, Rubin JP. Psychological considerations of the bariatric surgery patient undergoing body contouring surgery. Plast Reconstr Surg. 2008;121:423e–434e. 13. Kitzinger HB, Abayev S, Pittermann A, et al. The prevalence of body contouring surgery after gastric bypass surgery. Obes Surg. 2012;22:8–12. 14. van Hout GC, Verschure SK, van Heck GL. Psychosocial predictors of success following bariatric surgery. Obes Surg. 2005;15:552–560.
782e
15. van der Beek ES, Te Riele W, Specken TF, Boerma D, van Ramshorst B. The impact of reconstructive procedures following bariatric surgery on patient well-being and quality of life. Obes Surg. 2010;20:36–41. 16. Lazar CC, Clerc I, Deneuve S, Auquit-Auckbur I, Milliez PY. Abdominoplasty after major weight loss: Improvement of quality of life and psychological status. Obes Surg. 2009;19:1170–1175. 17. Singh D, Zahiri HR, Janes LE, et al. Mental and physical impact of body contouring procedures on post-bariatric surgery patients. Eplasty 2012;12:e47. 18. Coriddi MR, Koltz PF, Chen R, Gusenoff JA. Changes in quality of life and functional status following abdominal contouring in the massive weight loss population. Plast Reconstr Surg. 2011;128:520–526. 19. Modarressi A, Balagué N, Huber O, Chilcott M, Pittet-Cuénod B. Plastic surgery after gastric bypass improves long-term quality of life. Obes Surg. 2013;23:24–30. 20. Mitchell JE, Selzer F, Kalarchian MA, et al. Psychopathology before surgery in the longitudinal assessment of bariatric surgery-3 (LABS-3) psychosocial study. Surg Obes Relat Dis. 2012;8:533–541. 21. Sansone RA, Schumacher D, Wiederman MW, Routsong-Weichers L. The prevalence of childhood trauma and parental caretaking quality among gastric surgery candidates. Eat Disord. 2008;16:117–127. 22. Sarwer DB, Thompson JK, Cash TF. Body image and obesity in adulthood. Psychiatr Clin North Am. 2005;28:69–87, viii. 23. Statistics Canada. Low income lines, 2010–2011. Available at: http://www.statcan.gc.ca/pub/75f0002m/2012002/lico-sfreng.htm. Accessed September 9, 2013. 24. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study: Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 1999;282:1737–1744. 25. Cassin S, Sockalingam S, Hawa R, et al. Psychometric properties of the Patient Health Questionnaire (PHQ-9) as a depression screening tool for bariatric surgery candidates. Psychosomatics 2013;54:352–358. 26. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317–325. 27. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med. 2006;166:1092–1097. 28. Brazier JE, Harper R, Jones NM, et al. Validating the SF-36 health survey questionnaire: New outcome measure for primary care. BMJ 1992;305:160–164. 29. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care 1992;30:473–483. 30. Vittinghof E, Glidden DV, Shiboski SC, McCulloch CE. Regression Methods in Biostatistics: Linear, Logistic, Survival, and Repeated Measures Models. New York: Springer; 2005. 31. Gusenoff JA, Messing S, O’Malley W, Langstein HN. Patterns of plastic surgical use after gastric bypass: Who can afford it and who will return for more. Plast Reconstr Surg. 2008;122:951–958. 32. Baillot A, Asselin M, Comeau E, Méziat-Burdin A, Langlois MF. Impact of excess skin from massive weight loss on the practice of physical activity in women. Obes Surg. 2013;23:1826–1834.
