Does Body Contouring After Bariatric Weight Loss Enhance Quality of Life? A Systematic Review of QOL Studies

Bariatric and metabolic surgery (BS) achieves significant improvements in the multiple comorbidities associated with obesity such as diabetes mellitus, hypertension, hyperlipidaemia, obstructive sleep apnoea and cardiovascular disease [1‐4] that in turn result in improvements to quality of life (QOL) [5]. However, these beneficial outcomes in QOL are not always observed. In approximately one third of patients undergoing BS, the adipocutaneous tissue following massive weight loss (MWL) fails to contract, resulting in loose, hanging excess skin [6]. These cutaneous deformities manifest as significant cosmetic and functional impairments that interfere with mobility and activities of daily living. In addition, patients are predisposed to skin infection, skin rashes and dependent lymphoedema [7]. The literature demonstrates that these complications following MWL negatively impact upon QOL and other markers of psychosocial distress, including social isolation, self-esteem and perceptions of body image [8‐11].

Unfortunately, these skin deformities following MWL cannot be resolved by modifications in lifestyle, diet and exercise. Post-bariatric body contouring surgery (BCS) offers a solution by surgically removing excess adipose tissue [6]. However, BCS is not routinely offered and there is ongoing debate as to whether BCS is an essential procedure following BS [12]. Much of this debate stems from whether BCS contributes to more than purely cosmetic outcomes. Evidence in the literature to suggest BCS following BS may improve QOL is currently mixed. Early studies reveal that BCS in post-bariatric patients does not result in significant improvements in QOL compared to patients without BCS [13]. However, more recent work suggests that reconstructive surgery following MWL leads to demonstrable improvements in both functional and psychosocial markers of QOL such as ambulation, self-esteem, sexual function and body image [14‐18]. The objective of this study was therefore to identify the importance of BCS following BS, through a systematic review and meta-analysis of studies assessing the use of BCS in post-bariatric patients to improve physical, mental and social QOL.

Thirteen studies fulfilled our inclusion criteria and were included in subsequent analysis. This produced a pooled dataset of 796 patients undergoing BCS following bariatric surgery. Characteristics of included studies are in shown in Table 1. Eight of these were prospective observational studies, four were cross-sectional studies and one was a retrospective cohort study. BCS procedures performed included dog-ear correction, abdominoplasty, panniculectomy, dermolipectomy, liposuction, brachioplasty, mammoplasty, breast reduction and thigh lift. The scores used to assess QOL in each study are outlined in Table 1. The length of follow-up ranged from 2 to 42 months.

This systematic review and meta-analysis included 13 studies evaluating the effect of BCS on QOL in post-bariatric patients. Overall, our pooled analyses demonstrate that BCS in post-bariatric patients results in statistically significant improvements in numerous indicators of QOL, specifically physical functioning (28.5% increase), psychological wellbeing (45.7% increase) and social functioning (24% increase). These improvements in QOL were also associated with statistically significant, though modest weight loss following BCS. The benefit of BCS on sustaining weight loss was also observed by Froylich [32], who demonstrated post-bariatric patients who had undergone BCS maintained weight loss for a significantly longer period than a matched cohort who did not have BCS.

We also demonstrated improvements in body image, sexual functioning, pain, workability and self-esteem, although these were not significant. The lack of significant effect size in body image has previously been explained [33] where patients tend to demonstrate a discrepancy between their expectations from BCS and the ideal body type they desire. When choosing their ideal body type, participants selected a silhouette one size smaller than the body shape they believed to be attainable from BCS. As a result of this phenomenon, patients would remain dissatisfied with their body image despite the significant weight loss achieved from BCS. This is a common finding in patients with body dysmorphic disorder who present with an extreme preoccupation with an imagined or mild defect in appearance, resulting in significant social, psychological and occupational impairment [34]. As a result, many of these patients seek cosmetic surgery; however, evidence suggests that this cohort still reports a high rate of dissatisfaction with treatment outcomes [35]. Additionally, results revealed that although psychological wellbeing significantly increased, improvements in self-esteem were not significant. It would seem plausible that improvements in mood would be accompanied by similar effects in self-esteem; however, it has been observed that self-esteem and psychological wellbeing acted independently to each other [13].

Although the pooled analysis of global QOL scores revealed an improvement following BCS, this was not a significant result. This is surprising given that individual domains of QOL such as physical, social and psychological functioning demonstrated such significantly positive effects. This finding may be attributable to the wide variation in global scores used among included studies to assess overall QOL. For example, SF-36, HRQOL, WHOQOL and IWQOL were included in the range of global scores used by different studies to quantify the overall changes in QOL following BCS.

It is now established that massive weight loss following bariatric surgery leads to both physical and psychological impairments due to development of loose and ptotic skin, with areas of redundant adipose tissue interfering with activities of daily living [36]. The resulting impact on mobility, body image perceptions and mood prevent post-bariatric patients from fully re-integrating themselves into society [13, 37]. Therefore, weight loss alone may not result in sustained improvements in QOL [23] and further surgical intervention through BCS may offer one route to achieve enhanced lifestyle and psychological goals. Currently, many healthcare providers consider BCS procedures to be predominately cosmetic and merely an adjunct to bariatric surgery [15] and therefore, these are not associated as part of a multimodal treatment to enhance patient quality of life for obesity.

In the UK, current NICE guidance on the management of obesity simply encourages increased information on and access to reconstructive surgery where appropriate. Consequently, the criteria determining eligibility for BCS have traditionally been locally determined and therefore received criticisms of precipitating a postcode lottery [38]. The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) have offered more specific guidance on the inclusion criteria for BCS with clearer referral pathways [36]. These include (i) age over 16 years and (ii.a) starting BMI above 40 kg/m² or above 35 kg/m² with comorbidities and (ii.b) current BMI of less than or equal to 28.0 kg/m2, (ii.c) weight stability of 12 months and (ii.d) significant functional disturbance (both physical and psychological). Furthermore, they have recommended the use of central funding and national registry of outcomes and the use of a national referral document [36].

However, the literature demonstrates that in single-payer health systems such as the UK’s National Health Service, there is a low national uptake of these guidelines with only 7% of Clinical Commissioning Groups implementing the guidance, resulting in continued regional variation of BCS rates [39], despite 70% of patients seeking BCS following massive weight loss even when qualifying for surgery. This could be due to (i) the lack of pooled QOL data and an evidence-based consensus regarding BCS outcomes and indications based on QOL and patient-reported outcome measures (PROMS), (ii) the operative risks of BCS surgery following bariatric surgery and (iii) the financial restraints of some health systems. These factors may contribute to the limited drive for healthcare payers to integrate BCS into the routine bariatric surgical pathway.

This study is the first to quantitatively meta-analyse improvements in QOL after BCS in patients who have undergone bariatric surgery. Although previous studies have reviewed the existing literature, they have not extracted QOL data and quantitatively synthesised various QOL scores to produce an overall effect [40, 41]. Additionally, our analyses revealed a low degree of heterogeneity in improvements in physical and social functioning, adding robustness to our results. However, the results presented here should be interpreted in the context of a number of limitations.

Firstly, most studies were inherently limited due to their study design, with no randomised controlled trials being eligible for inclusion in our analysis. Secondly, we did observe a significant degree of heterogeneity in other measures of QOL, particularly psychological wellbeing, body image, sexual function and pain. This may be attributable to the wide variation in scoring systems used across studies to measure each indicator of QOL. Other confounding factors contributing to this heterogeneity include variations in methodology, study designs, sample sizes and follow-up periods.

Thirdly, we classified the various indicators of QOL across all studies into defined groups, including physical functioning, social functioning, psychological wellbeing, body image, pain, self-esteem and global QOL. The integration varying through these combined classifications may be a source or bias in our results.

In summary, we demonstrate that BCS may improve QOL in patients who have previously undergone bariatric surgery. Statistically significant improvements in physical, social and psychological functioning, as well as benefits in body image, sexual functioning and self-esteem suggest that BCS should not be merely a cosmetic adjunct to bariatric surgery, but has a role in reversing the functional and psychological abnormalities that result from the accumulation of excess skin after massive weight loss. Although there is persistent debate on whether BCS should be an optional or essential addition to bariatric surgery, this study provides further evidence that BCS should be considered as an integral part of the bariatric surgical pathway. The evidence presented in this review acts as further encouragement to increase the uptake of post-bariatric BCS guidelines and therefore increase consistency in the regional provision of BCS across the UK and worldwide. Furthermore, these results could be employed in the routine counseling of patients prior to bariatric surgery as evidence-based information regarding the benefits of BCS. Ultimately however, larger prospective and randomised controlled trials, in addition to cost-effectiveness studies of BCS, are needed within the context of centralised databases and increased multidisciplinary practitioner consensus. Together, these can further our understanding of the effects of BCS on QOL and its role in supporting the multitude of current and future weight loss modalities in the management of obesity and its comorbidities.