Weight loss drugs pose challenges for plastic surgeons

The popularity of GLP-1 drugs has created a new generation of body contouring patients and a new set of challenges for plastic surgeons, according to a study from Duke University School of Medicine, which suggests that how much weight patients lose - and how fast - could affect surgical results to tighten or remove excess skin after massive weight loss.

The study found that massive or rapid weight loss prior to abdominal body contouring surgery is predictive of postoperative complications. Patients with combined bariatric surgery and GLP-1RA use have the highest degree and rate of weight loss and subsequently experience higher complication rates.

Duke researchers analysed more than a decade of abdominal body contouring procedures, such as tummy tucks, and found that patients who lost large amounts of weight quickly faced higher risks of surgical complications.

The more than 500 patients studied were grouped based on how they lost weight: through bariatric surgery alone, GLP-1 medications such as semaglutide and tirzepatide alone, or a combination of both. Patients using combined bariatric surgery/GLP-1RAs (28.6%) and bariatric surgery alone (24.1%) had the highest total body weight loss percentages (TBWL%). Patients with combined bariatric surgery/GLP-1RA use had the highest rate of weight loss at 0.95% TBWL per month.

Irrespective of weight loss modality, a higher magnitude of weight loss was predictive of seroma (OR 1.05 [1.02-1.08], p=0.004) and composite complications (OR 1.03 [1.01-1.05], p=0.017) on multivariable regression. Higher weight loss rate was also predictive of postoperative seroma (OR 2.64 [1.26-5.60], p=0.010). Combined bariatric surgery/GLP-1RA use was predictive of seroma (OR 3.05 [1.02-8.08], p=0.032), hematoma (OR 3.74 [1.02-13.76], p=0.047), and unplanned return to the operating room (OR 6.78 [2.42-17.99], p<0.001).

The highest complication rates were seen among patients who combined surgery with GLP-1 drugs that reduce appetite. These patients not only lost the most weight overall, about 29% of their body weight (compared with 10% among GLP-1 users), but did so at the fastest rate. But those rapid changes may come with trade-offs, said senior study author and professor of surgery, Dr Ash Patel, a plastic and reconstructive surgeon at Duke Health.

"These are highly effective weight-loss tools, and they are changing the patient population we see in body contouring," Patel said. "We're operating on people whose bodies have undergone rapid, profound changes, and that affects healing."

Compared with other groups, patients who used both treatments were significantly more likely to develop seromas - pockets of fluid that can form under the skin during surgery - as well as haematomas that require medical attention. They were also far more likely to need another surgery.

Patients who had both bariatric surgery and GLP-1 therapy returned to the operating room at a rate of 29.6% compared with 5.1% among patients without medical weight loss.

Body contouring procedures, which can include tummy tucks, breast lifts and procedures to tighten sagging skin on arms and thighs, are often perceived as minor or purely cosmetic. In reality, surgeons say, they are major operations that require large incisions and substantial healing demands.

"We're seeing an explosion of patients coming in and asking, 'What can you do for this extra skin?'" Patel said.

At the same time, expectations have evolved. Greater openness about weight-loss treatments, along with social media and celebrity influence, has made people more aware of their appearance and more likely to pursue the procedures.

The study suggests that the body's response to rapid weight loss may help explain the higher complication rates.

Patients who lose weight through slower, sustained lifestyle changes may experience fewer issues because their bodies - and their skin - have more time to adapt. In contrast, rapid weight loss can weaken tissue quality and affect healing.

"The amount of weight loss and the speed of weight loss are both important," Patel said.

Among those studied, most weight-loss surgery patients sought body contouring about two years later, while those in the GLP-1 group had stopped taking the medications just ten weeks before plastic surgery after taking the medication for 103 weeks.

Patients considering body contouring after significant weight loss should have detailed discussions with their care teams about timing, expectations and potential risks, particularly if they have used or are using multiple weight-loss strategies at once.

Doctors are focusing on ways to lower surgical risks where possible, including optimising nutrition, ensuring adequate protein intake and addressing other factors such as diabetes and smoking.

After massive weight loss, patients commonly develop deficiencies in vitamins A, D, E, K and B12, as well as folate, copper and iron. Many of these nutrients play essential roles in wound healing.

"We do everything we can to minimise risks," Patel said. "But we also need patients to understand their role by following instructions, wearing compression garments and allowing their bodies time to heal."

As weight-loss treatments continue to evolve, researchers say understanding their downstream effects will be essential, not just for plastic surgeons, but for the broader medical community.

At the microscopic level, the body changes in different ways depending on how weight is lost. Bariatric surgery alters how the body absorbs nutrients, while GLP-1 drugs work differently.

Researchers are trying to understand how these differences affect complication rates, especially compared with weight loss from diet and exercise.

No matter how it's achieved, whether through surgery, medication or lifestyle changes, sustained weight loss is an effective way to lower the risk of diabetes, heart disease and high blood pressure and improve long-term health.

"This is not about discouraging weight loss, far from it," Patel said. "It's about optimising outcomes. We want patients to look and feel better and to get through surgery safely."

The findings were reported in the paper, ‘Massive Weight Loss with Bariatric Surgery and GLP-1RA Therapy Predicts Postoperative Complications Following Abdominal Body Contouring’, published in the journal Plastic & Reconstructive Surgery, To access this paper, please click here (log-in maybe required)