BMJ 2014;349:g7637 doi: 10.1136/bmj.g7637 (Published 16 December 2014)
Page 1 of 1
Letters
LETTERS NICE ON OVERWEIGHT AND OBESITY
Need for guidelines on body recontouring after bariatric surgery 1
Alexandra Bucknor core surgical trainee , Chidi Ekwobi fellow in plastic surgery
2
Thoracic Surgery Department, Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK; 2Royal Marsden Hospital, London, UK 1
Stegenga and colleagues’ summary of the recently updated National Institute for Health and Care Excellence (NICE) guidance on management of overweight and obesity, including the role of bariatric surgery, proved an interesting read.1 However, there was little discussion of body recontouring after bariatric surgery.
The massive weight loss accompanying bariatric surgery can lead to the development of an abdominal “apron,” “bat wings,” and other large folds of redundant skin. Of 252 patients surveyed after bariatric surgery, 96% developed excess skin and three quarters desired body contouring surgery.2 Patients felt unattractive, experienced skin complications, and had difficulty finding well fitting clothes. Another study found that although 92% of responding surgeons acknowledged the functional problems arising from excessive amounts of skin, only 66% routinely counselled their patients about this preoperatively.3 Reconstructive surgeons have a variety of operative management strategies for this problem. Recent prospective randomised work found significant improvement in self esteem, sexual activity, work and social life, and physical ability in patients who underwent reconstructive surgery after bariatric surgery.4 However, there are no guidelines on how patients should access these services: no consensus on which patients warrant referral and certainly no referral pathways. Mention of the services in
the NICE guidance is disappointingly brief—that bariatric surgery should be offered only when the team can provide “information on, or access to, plastic surgery (such as apronectomy) when appropriate.”
Why the guidance ignores this crucial part of the weight loss journey is unclear. As clinicians, we must remain vigilant to the fact that these patients may benefit from early input from the plastic and reconstructive team and hope that the NICE guidance will follow suit. Competing interests: None declared. Full response at: www.bmj.com/content/349/bmj.g6608/rr/799945. 1 2 3 4
Stegenga H, Haines A, Jones K, Wilding J; on behalf of the Guideline Development Group. Identification, assessment, and management of overweight and obesity: summary of updated NICE guidance. BMJ 2014;349:g6608. (27 November.) Kitzinger HB, Abayev S, Pittermann A, Karle B, Bohdjalian A, Langer FB, et al. After massive weight loss: patients’ expectations of body contouring surgery. Obes Surg 2012;22:544-8. Highton L, Ekwobi C, Rose V. Post-bariatric surgery body contouring in the NHS: a survey of UK bariatric surgeons. J Plast Reconstr Aesthet Surg 2012;65:426-32. 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.
Cite this as: BMJ 2014;349:g7637 © BMJ Publishing Group Ltd 2014
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 1
Letters
LETTERS NICE ON OVERWEIGHT AND OBESITY
Need for guidelines on body recontouring after bariatric surgery 1
Alexandra Bucknor core surgical trainee , Chidi Ekwobi fellow in plastic surgery
2
Thoracic Surgery Department, Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK; 2Royal Marsden Hospital, London, UK 1
Stegenga and colleagues’ summary of the recently updated National Institute for Health and Care Excellence (NICE) guidance on management of overweight and obesity, including the role of bariatric surgery, proved an interesting read.1 However, there was little discussion of body recontouring after bariatric surgery.
The massive weight loss accompanying bariatric surgery can lead to the development of an abdominal “apron,” “bat wings,” and other large folds of redundant skin. Of 252 patients surveyed after bariatric surgery, 96% developed excess skin and three quarters desired body contouring surgery.2 Patients felt unattractive, experienced skin complications, and had difficulty finding well fitting clothes. Another study found that although 92% of responding surgeons acknowledged the functional problems arising from excessive amounts of skin, only 66% routinely counselled their patients about this preoperatively.3 Reconstructive surgeons have a variety of operative management strategies for this problem. Recent prospective randomised work found significant improvement in self esteem, sexual activity, work and social life, and physical ability in patients who underwent reconstructive surgery after bariatric surgery.4 However, there are no guidelines on how patients should access these services: no consensus on which patients warrant referral and certainly no referral pathways. Mention of the services in
the NICE guidance is disappointingly brief—that bariatric surgery should be offered only when the team can provide “information on, or access to, plastic surgery (such as apronectomy) when appropriate.”
Why the guidance ignores this crucial part of the weight loss journey is unclear. As clinicians, we must remain vigilant to the fact that these patients may benefit from early input from the plastic and reconstructive team and hope that the NICE guidance will follow suit. Competing interests: None declared. Full response at: www.bmj.com/content/349/bmj.g6608/rr/799945. 1 2 3 4
Stegenga H, Haines A, Jones K, Wilding J; on behalf of the Guideline Development Group. Identification, assessment, and management of overweight and obesity: summary of updated NICE guidance. BMJ 2014;349:g6608. (27 November.) Kitzinger HB, Abayev S, Pittermann A, Karle B, Bohdjalian A, Langer FB, et al. After massive weight loss: patients’ expectations of body contouring surgery. Obes Surg 2012;22:544-8. Highton L, Ekwobi C, Rose V. Post-bariatric surgery body contouring in the NHS: a survey of UK bariatric surgeons. J Plast Reconstr Aesthet Surg 2012;65:426-32. 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.
Cite this as: BMJ 2014;349:g7637 © BMJ Publishing Group Ltd 2014
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
