Quality of Life Long-Term after Body
Contouring Surgery following Bariatric Surgery:
Sustained Improvement after 7 Years
Eva S. J. van der Beek, M.D.
Rinie Geenen, Ph.D.
Francine A. G. de Heer
Aebele B. Mink van der
Molen, M.D., Ph.D.
Bert van Ramshorst, M.D.,
Utrecht and Nieuwegein,
Background: Bariatric surgery for morbid obesity results in massive weight loss
and improvement of health and quality of life. A downside of the major weight
loss is the excess of overstretched skin, which may influence the patient’s quality
of life by causing functional and aesthetic problems. The purpose of the current
following bariatric surgery.
Methods: Quality of life was measured with the Obesity Psychosocial State
Questionnaire in 33 post–bariatric surgery patients 7.2 years (range, 3.2 to 13.3
years) after body contouring surgery. Data were compared with previous as-
sessments 4.1 years (range, 0.7 to 9.2 years) after body contouring surgery of the
quality of life at that time and before body contouring surgery.
Results: Compared with appraisals of quality of life before body contouring
surgery, a significant, mostly moderate to large, sustained improvement of
quality of life was observed in post–bariatric surgery patients 7.2 years after body
contouring surgery in six of the seven psychosocial domains. A small deterio-
except for the domain efficacy toward eating, which showed a significant im-
provement. At 7-year follow-up, 18 patients (55 percent) were satisfied with the
result of body contouring surgery.
Conclusions: This study indicates a sustained quality-of-life improvement in
post–bariatric surgery patients after body contouring surgery. This suggests the
importance of including reconstructive surgery as a component in the multi-
disciplinary approach in the surgical treatment of morbid obesity.
constr. Surg. 130: 1133, 2012.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
life.1–8The skin overhang after massive weight loss
causes feelings of unattractiveness and embarrass-
ment and gives rise to hygienic and physical prob-
lems. These new problems have a negative impact
on the quality of life of the post–bariatric surgery
ariatric surgery is the only effective treat-
ment of morbid obesity resulting in a long-
term sustained weight loss, a decrease in
More than two-thirds of the patients who have
a negative consequence of surgery.3Patient satis-
faction with the result of bariatric surgery may
decrease in the long term as a result of changes in
physical appearance because of substantial weight
loss.3,10,11Skin deformities after major weight loss
may result in psychological problems (e.g., re-
duced mental well-being and satisfaction with
physical appearance), social problems (e.g., re-
duced social acceptance, less intimacy, and a
smaller social network), and physical problems
From the Department of Plastic and Reconstructive Surgery,
University Medical Center Utrecht; the Department of Clin-
ical and Health Psychology, Utrecht University; and the
Departments of Plastic and Reconstructive Surgery and Sur-
gery, St. Antonius Hospital.
Received for publication January 23, 2012; accepted May
Disclosure: The authors received no financial sup-
port for the research, authorship, and/or publication
of this article. The authors declared no potential
conflicts of interest with respect to the research, au-
thorship, and/or publication.
(e.g., reduced physical functioning and skin
problems).3,9,12–14After body contouring surgery,
in patients who felt unattractive after bariatric sur-
gery and the quality of life improved.12,15–17
of functional and aesthetic surgery. It treats the
adverse consequences of, for instance, burns, traf-
fic accidents, or physical deformities after cancer
treatment.18Physical, mental, and social quality of
life have been indicated to improve after body
contouring.12,15,19There is an ongoing debate of
essential step after massive weight loss in the treat-
ment of morbid obesity. Whereas bariatric surgery
without body contouring has a beneficial influ-
ence on psychological functioning and quality of
life,3,10a stabilization or even decline of this effect
is seen from 2 years after surgery.20This could well
be attributable to changes in physical appearance
and the associated decline in satisfaction with
one’s body image. Body contouring surgery may
therefore play a beneficial role in the long-term
stabilization of the quality of life in patients with
massive weight loss following bariatric surgery.
The aim of this study was to evaluate the quality of
life at long-term follow-up after body contouring
procedures following bariatric surgery.
PATIENTS AND METHODS
A total of 465 patients underwent bariatric
surgery at the St. Antonius Hospital in Nieu-
had body contouring surgery in the same hospital
following massive weight loss and were invited to
participate in the study. On average 4 years later,
in 2007, 43 patients reported their quality of life
at a mean follow-up of 49 months after body con-
touring surgery and, retrospectively, their quality
these patients were invited to participate again in
the current study. If they gave informed consent,
a questionnaire was sent.
Quality of life was measured with the Obesity
Psychosocial State Questionnaire (Table 1), an
obesity-specific quality-of-life questionnaire.8For
the purpose of this study, we used 31 items of the
Obesity Psychosocial State Questionnaire, which
measures seven domains (Table 1): physical func-
tioning (six items), mental well-being (four items),
physical appearance (11 items), social acceptance
(three items), self-efficacy toward eating and weight
network (two items). Six of the seven scales have a
moderate (Cronbach ? between 0.50 and 0.80) to
high (Cronbach ? ?0.80) reliability after modifi-
cation, and one scale consisted of only one item.
The questionnaire has a rating scale ranging from
1 (almost never) to 5 (almost always). A lower
score reflects few problems on the domain and
acteristics of the Obesity Psychosocial State Ques-
tionnaire, established in a sample of 287 patients
(severe) obesity, are satisfactory.21
Patients were asked to answer 12 additional
questions about their weight, actual health sta-
tus, whether they had or would undergo plastic
surgery again, whether body contouring surgery
was an inevitable step to improve daily quality of
life, and satisfaction with the final result and
with the scar on a scale from 1 (very satisfied) to
4 (dissatisfied). To examine the association be-
tween weight status and quality of life, the pa-
tients were categorized into a group of patients
with a stable weight or weight loss and a group
of patients with weight gain after body contour-
ing surgery and after 4 years’ follow-up. A stable
weight was defined as a weight with a maximum
measured at the time of reconstructive surgery
and in 2007, on average 4 years after reconstruc-
Table 1. Example Items of the Obesity Psychosocial
To kneel or to
duck easily (reversed score)
To feel depressed
To feel fatty when someone takes
To be discriminated against
because of my weight
To feel helpless toward my eating
To have sexual problems because
of my weight
To visit friends and acquaintances
*Respondents answer to the extent to which they agree with the
proposition on a five-point rating format ranging from 1 (almost
never) to 5 (almost always). A higher score reflects worse psycho-
social well-being and functioning.
Plastic and Reconstructive Surgery • November 2012
All statistical analyses were performed using
SPSS for Windows version 17.0 (SPSS, Inc., Chi-
cago, Ill.). Paired t tests were used to compare the
scores on the seven Obesity Psychosocial State
Questionnaire domains before and after body
follow-up scores. These differences were ex-
pressed by way of Cohen effect sizes. Effect sizes of
0.2, 0.5, and 0.8 are considered to reflect differ-
ences of small, medium, and large magnitude,
respectively.22Repeated measures analysis of
variance with weight change as a covariate was
used to examine whether quality-of-life changes
between 4 and 7 years after body contouring
surgery were explained by weight change. Chi-
square tests and independent t test were used to
examine possible determinants of satisfaction
with body contouring surgery.
Forty-one patients were invited to participate
again in this study. Two patients of the original sam-
and phone number. Thirty-three patients (80 per-
cent) returned the questionnaire, 32 women and
follow-up interval was 7.2 years (86 months; range,
38 to 159 months) since body contouring surgery
since bariatric surgery.
Table 2 lists the characteristics of the patients.
Thirty-one patients (94 percent) underwent laparo-
scopic gastric banding and two patients underwent
gastric bypass surgery as a primary procedure. Be-
cause of unsatisfactory results or band-related prob-
lems, eight of the 31 laparoscopic gastric banding
patients underwent gastric bypass surgery as a re-
operation. Four patients had diabetes at the time
of body contouring surgery, and 21 patients had
hypertension. A total of 57 body contouring pro-
cedures were performed (Table 3). Sixteen pa-
cedure. No differences were seen in weight status
and quality-of-life scores on the Obesity Psychos-
after body contouring (p ? 0.10 for all).
Since the previous study 3 years earlier, at a
mean follow-up of 49 months (range, 8 to 110
months) after body contouring surgery, 15 patients
(45 percent) regained weight and nine patients (27
percent) lost further weight. Eight patients (24 per-
cent) had another body contouring surgery proce-
dure after the previous study, 4 years after the first
body contouring. Another 30 percent would have
wanted another procedure but they did not choose
Quality of Life
As compared with their perception of the sit-
uation before body contouring surgery, at a mean
follow-up of 7.2 years after body contouring sur-
gery, patients significantly improved on six of the
seven psychosocial domains of the Obesity Psy-
chosocial State Questionnaire. Table 4 shows the
effect sizes of the seven domains for the patients
before body contouring surgery and at the 4-year
and 7-year follow-up after body contouring sur-
gery. At 4-year follow-up after body contouring
surgery, patients perceived a large improvement
functioning (t ? 5.95, p ? 0.000), mental well-
being (t ? 5.09, p ? 0.000), physical appearance
(t ? 7.71, p ? 0.000), and social acceptance (t ?
5.63, p ? 0.000). For intimacy, a medium differ-
ence was seen (t ? 4.29, p ? 0.000); for social
network, a small difference was seen (t ? 2.29,
p ? 0.029). A large deterioration was seen for
Table 2. Characteristics of the 33 Participants*
Weight before bariatric
BMI before bariatric
Weight before reconstructive
BMI before reconstructive
Current weight, kg
Current BMI, kg/m2
BMI, body mass index.
*Thirty-two women and one man.
Table 3. Type of Body Contouring Surgery
Type of Body Contouring Surgery
No. of Procedures
Volume 130, Number 5 • Body Contouring after Bariatric Surgery
self-efficacy at 4-year follow-up (t ? –4.46, p ?
At 7-year follow-up, a large improvement as
compared with the appraisal of the situation be-
fore body contouring surgery was seen in the do-
mains physical functioning (t ? 4.47, p ? 0.001),
physical appearance (t ? 4.50, p ? 0.001), and
well-being, a medium difference was seen (t ?
3.55, p ? 0.001). A small difference was seen for
intimacy (t ? 2.25, p ? 0.03), self-efficacy (t ?
–1.29, p ? 0.21), and social network (t ? 2.64,
p ? 0.013).
Between 4-year follow-up and 7-year follow-up,
a medium improvement was seen for the domain
self-efficacy (t ? 3.40, p ? 0.002). This improve-
ment was independent of weight change; that is,
the difference between the two follow-up mea-
surements of self-efficacy remained significant
after controlling for weight change (F ? 6.30, p ?
0.02). A small deterioration was seen in the do-
mains physical functioning (t ? –2.16, p ? 0.04),
mental well-being (t ? –1.48, p ? 0.15), and phys-
ical appearance (t ? –2.27, p ? 0.03). This dete-
for weight change: physical functioning (F ? 0.22,
p ? 0.65), mental well-being (F ? 0.59, p ? 0.45),
reflects that weight regain explained the deterio-
ration in these quality-of-life domains. For social
acceptance (t ? 0.14, p ? 0.89), intimacy (t ?
–0.80, p ? 0.43), and social network (t ? –0.09,
p ? 0.93), trivial differences were seen between
4-year and 7-year follow-up.
Weight Status and Quality of Life
Table 5 shows the results of the Obesity Psy-
chosocial State Questionnaire for patients with a
stable weight or weight loss after body-contouring
surgery and patients with weight regain. At 7-year
follow-up, as compared with patients with a stable
weight or with weight loss, a significantly worse
score was seen in patients who had gained weight
since body contouring on the domains mental
well-being (p ? 0.009), social acceptance (p ?
0.03). On the domains physical functioning, phys-
ical appearance, and social network, patients with
weight regain had worse scores, but the differ-
ences were not significant (p ? 0.05).
At 7-year follow-up after body contouring sur-
gery 18 patients (55 percent) were (very) satisfied
with the result of body contouring surgery, four
patients (12 percent) had a neutral opinion, and
Table 4. Mean Scores of 33 Patients on Seven Domains of the Obesity Psychosocial State Questionnaire before
and Short- and Long-Term after Body Contouring Surgery*
1. Before Body
3.48 ? 0.82
3.34 ? 0.93
3.95 ? 0.66
3.29 ? 1.25
2.92 ? 1.41
3.17 ? 1.27
2.70 ? 0.91
After Body Contouring Surgery
d, Cohen effect; NS, not significant (paired t tests).
*A higher score on the Obesity Psychosocial State Questionnaire reflects a worse psychosocial state.
†p ? 0.05.
‡p ? 0.01.
§p ? 0.001.
2. 4-Yr Follow-Up
2.38 ? 0.76
2.52 ? 0.91
2.73 ? 0.76
2.23 ? 0.61
3.95 ? 0.75
2.46 ? 1.06
2.31 ? 0.83
3. 7-Yr Follow-Up
2.72 ? 0.96
2.77 ? 1.07
3.12 ? 0.91
2.21 ? 0.85
3.27 ? 1.04
2.64 ? 1.04
2.33 ? 0.92
Table 5. Mean Scores on Seven Domains of the
Obesity Psychosocial State Questionnaire for 18
Patients with Weight Loss or a Stable Weight and 15
Patients with Weight Regain at 7-Year Follow-Up
after Body Contouring Surgery
NS, not significant.
Loss after Body
2.48 ? 0.94 2.95 ? 0.96 NS
2.27 ? 0.933.22 ? 1.00
2.78 ? 0.823.36 ? 0.93NS
1.82 ? 0.60
3.75 ? 0.77
2.30 ? 0.98
2.09 ? 0.74
2.41 ? 0.95
2.82 ? 1.07
3.13 ? 1.303
2.59 ? 1.02
Plastic and Reconstructive Surgery • November 2012
result. At 4-year follow-up, 29 patients (67 per-
cent) were (very) satisfied, six patients (14 per-
cent) had a neutral opinion, and eight patients
(19 percent) were not satisfied with the result. All
but one patient (97 percent) would undergo body
contouring surgery again and considered body
contouring surgery after massive weight loss an
inevitable step to improve daily quality of life. Nei-
change before body contouring (t ? 0.81, p ?
0.43) nor weight change after body contouring
surgery (t ? 0.05, p ? 0.97) or between 4-year
follow-up and 7-year follow-up (t ? –0.25, p ?
0.81) differed between patients who were satisfied
and patients who were not satisfied with body con-
touring surgery. Satisfaction did also not differ for
patients who underwent laparoscopic gastric
banding or gastric bypass surgery (chi-square ?
0.48, p ? 0.67). Finally, satisfaction did not differ
between patients who did or did not have abdomi-
noplasty (chi-square ? 1.24, p ? 0.42), patients
who did or did not have reduction mammaplasty
(chi-square ? 2.20, p ? 0.27), or patients who did
or did not have other types of body contouring
In this study of 33 post–bariatric surgery pa-
tients, with a mean follow-up of more than 7 years
after body contouring surgery, a trivial to small
after reconstructive surgery. However, patient
quality of life was still significantly better on six of
the seven quality-of-life domains than the percep-
tion of quality of life before body contouring.
Enhancement of psychosocial functioning is
dissatisfaction is a frequent phenomenon in obe-
sity and is correlated to low quality of life.23An
improvement of quality of life and body image
a decline may occur after the first postoperative
years.25,26Some bariatric patients report body im-
age dissatisfaction caused by the loose, hanging
skin after massive weight loss.9For these patients,
body contouring surgery could be a means of im-
proving quality of life. The results of the current
study with long-term evaluations suggest that body
contouring surgery causes a sustained improve-
ment of quality of life.
Our study showed that quality of life deterio-
rated somewhat with increasing time after body
contouring surgery. This could reflect that pa-
tients get used to the improvement after resection
of skin surplus. Directly after body contouring sur-
gery, patients likely experience benefit because of
a reduction of physical and hygienic problems.27
realistic or critical of these results and focus more
on the aesthetic result. Most patients have high
expectations about the aesthetic results of body
contouring surgery. The reality after corrective
surgery can be disappointing.13Surgery to one
part of the body can lead to an imbalance of body
contours and sometimes results in extensive scars.
This implies that it is important to offer realistic
and extensive preoperative information about
both the possibilities and limits of body contour-
ing surgery to prevent unrealistic expectations
ity of life could be weight regain. Obesity, negative
body image, and quality of life are inextricably
linked.28In the current study, 20 of the 33 patients
had weight regain (mean, 13.2 kg) between 2007
and 2010. Our analysis showed that weight regain
explained most of the deterioration of quality of
life long term after body contouring surgery.
the result, all but one patient would choose to
undergo body contouring surgery again, in accor-
dance with the literature.27,29Patients reported
that body contouring surgery was an inevitable
step in the process of losing weight by bariatric
surgery. Several possible determinants of satisfac-
but body mass index, weight change before and
after body contouring surgery, the occurrence of
complications, type of bariatric surgery, and type
of body contouring surgery were not associated
with satisfaction. Body contouring after bariatric
outcomes and an increase in physical activity as has
been observed after reduction mammaplasty.27,30
Physical activity after bariatric surgery is associated
with sustained weight loss and improved quality of
life.31Thus, body contouring surgery may have sev-
eral additional benefits in the treatment of morbid
Our study is unique in analyzing a relatively
large cohort of post–bariatric surgery patients
long term after body contouring surgery. As yet,
no study followed patients for more than 2 years
after body contouring.9,15This study also has some
limitations. Retrospective appraisals of how pa-
tients perceived their quality of life before body
contouring surgery were used. Furthermore, the
psychometric characteristics of the Obesity Psy-
chosocial State Questionnaire were only estab-
Volume 130, Number 5 • Body Contouring after Bariatric Surgery
lished preliminarily8but were found to be satis-
factory. Finally, this study had an observational
design in which only patients who had body con-
touring surgery were included. We had no control
group. To be able to conclude that changes in
quality of life are caused by body contouring (in-
stead of being attributable to time or aging ef-
fects), an experimental design should be used in-
cluding patients who have not undergone body
contouring surgery after massive weight loss.
A trivial to small decrease in quality of life was
seen from 4 to 7 years after body contouring sur-
gery, which could be mostly explained by weight
regain. Quality of life in post–bariatric surgery
patients at a mean follow-up of 7 years after body
contouring surgery is significantly improved com-
pared with their appraisal of preoperative quality
a plastic surgeon in the multidisciplinary treat-
ment of morbid obesity.
Eva S. J. van der Beek, M.D.
Department of Plastic and Reconstructive Surgery
St. Antonius Hospital
3435CM Nieuwegein, The Netherlands
1. O’Brien PE. Bariatric surgery: Mechanisms, indications and
outcomes. J Gastroenterol Hepatol. 2010;25:1358–1365.
2. Torquati A, Lufti RE, Richards WO. Predictors of early qual-
ity of life improvement after laparoscopic bypass surgery.
Am J Surg. 2007;193:471–475.
3. Kinzl JF, Traweger C, Trefalt E, Biebl W. Psychosocial con-
sequences of weight loss following gastric banding for mor-
bid obesity. Obes Surg. 2003;13:105–110.
4. World Health Organization. Obesity: Preventing and Managing
the Global Epidemic. Report of a WHO Consultation. WHO Tech-
nical Report Series 894. Geneva: World Health Organization;
5. Thonney B, Pataky Z, Badel S, Bobbioni-Harsch E, Golay A.
tioning among bariatric surgery patients. Am J Surg. 2010;
6. Dixon JB, Dixon ME, O’Brien PE. Quality of life after lap-
band placement: Influence of time, weight loss, and comor-
bidities. Obes Res. 2001;9:713–721.
7. Nickel MK, Loew TH, Bachler E. Change in mental symp-
toms in extreme obesity patients after gastric banding, Part
II: Six-year follow up. Int J Psychiatry Med. 2007;37:69–79.
8. Zijlstra H, Larsen JK, de Ridder DT, van Ramshorst B,
Geenen R. Initiation and maintenance of weight loss after
expectation and satisfaction with the psychosocial outcome.
Obes Surg. 2008;19:725–731.
9. Sarwer DB, Thompson JK, Mitchell JE, Rubin JP. Psycholog-
ical considerations of bariatric surgery patient undergoing
body contouring surgery. Plast Reconstr Surg. 2008;121:423e–
10. Hafner RJ, Watts JM, Rogers J. Quality of life after gastric
bypass for morbid obesity. Int J Obes. 1991;15:555–560.
11. van de Weijgert EJ, Ruseler CH, Elte JW. Long-term fol-
low-up after gastric bypass surgery for morbid obesity:
Preoperative weight loss improves the long-term control of
morbid obesity after vertical banded gastroplasty. Obes
12. van der Beek ES, Te Riele W, Specken TF, Boerma D, van
Ramshorst B. The impact of reconstructive procedures fol-
lowing bariatric surgery on patient well being and quality of
life. Obes Surg. 2010;20:36–41.
13. Mitchell JE, Crosby RD, Ertelt TW, et al. The desire for body
contouring surgery after bariatric surgery. Obes Surg. 2008;
14. Magdaleno R Jr, Chaim EA, Pareja JC, Turato ER. The psy-
chology of bariatric patient: What replaces obesity? A qual-
itative research with Brazilian women. Obes Surg. 2001;21:
15. Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fern-
strom MH. Body image and quality of life in post massive
weight loss body contouring patients. Obesity (Silver Spring)
16. Menderes A, Baytekin C, Haciyanli M, Yilmaz M. Dermali-
pectomy for body contouring after bariatric surgery in Ae-
gean region of Turkey. Obes Surg. 2003;13:637–641.
17. Stuerz K, Piza H, Niermann K, Kinzl JF. Psychosocial impact
of abdominoplasty. Obes Surg. 2008;18:34–38.
18. Hasen KV, Few JW, Fine NA. Plastic surgery: A component
in the comprehensive care of cancer patients. Oncology (Wil-
liston Park) 2002;16:1685–1698; discussion 1698.
19. Pecori L, Serra Cervetti GG, Marinari GM, Migliori F, Adami
GF. Attitudes of morbidly obese patients to weight loss and
body image following bariatric surgery and body contouring.
Obes Surg. 2007;17:68–73.
20. Karlsson J, Taft C, Ryde ´n A, Sjo ¨stro ¨m L, Sullivan M. Ten-year
trends in health-related quality of life after surgical and con-
ventional treatment for severe obesity: The SOS intervention
study. Int J Obes (Lond.) 2007;31:1248–1261.
21. Larsen JK, Geenen R, van Ramshorst B, et al. Psychosocial
functioning before and after laparoscopic adjustable gas-
tric banding: A cross-sectional study. Obes Surg. 2003;13:
ed. Hillsdale, NJ: Lawrence Erlbaum; 1988.
23. Rosen JC. Improving body image in obesity. In: Thompson
JK, ed. Body Image, Eating Disorders, and Obesity. Washington,
DC: American Psychological Association; 1996:425–440.
24. Stunkard AJ, Stinnett JL, Smoller JW. Psychological and so-
25. van Hout GC, Boekestein P, Fortuin FA, Pelle AJ, van Heck
GL. Psychosocial functioning following bariatric surgery.
Obes Surg. 2006;16:787–794.
26. Mathus-Vliegen EMH, de Wit LT. Heath-related quality of
life after gastric banding. Br J Surg. 2007;94:457–465.
27. Coriddi MR, Koltz PF, Chen R, Gusenoff JA. Changes in
quality of life and functional status following abdominal con-
touring in the massive weight loss population. Plast Reconstr
28. Cash TF, Counts B, Huffine CE. Current and vestigial effects
of overweight among women: Fear of fat, attitudinal body
Plastic and Reconstructive Surgery • November 2012
image and eating behaviors. J Psychopathol Behav Assess. 1990; Download full-text
29. 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:
30. Singh KA, Pinell XA, Losken A. Is reduction mammaplasty
a stimulus for weight loss and improved quality of life? Ann
Plast Surg. 2010;64:585–587.
31. Wouters EJ, Larsen JK, Zijlstra H, van Ramshorst B, Geenen
R. Physical activity after surgery for severe obesity: The role
of exercise cognitions. Obes Surg. 2011;21:1894–1899.
New Submission Guideline: Level of Evidence
Beginning with submissions made July 1, 2011, and going forward, all manuscripts amenable to Level of
Evidence grading need to indicate the clinical question addressed by the article and the Level of Evidence.
The clinical question will be one of three categories: Diagnostic, Therapeutic, or Risk. Please use the ASPS
Levels of Evidence and Grading Recommendations: Evidence Rating Scales to grade the level of evidence
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studies because the information gained from these studies is not something that can be applied directly to
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See the article “The Level of Evidence Pyramid: Indicating Levels of Evidence in Plastic and Reconstructive
Surgery Articles,” in the July 2011 issue (Plast Reconstr Surg. 2011;128:311–314), for more information on
determining the Level of Evidence of your manuscript.
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Volume 130, Number 5 • Body Contouring after Bariatric Surgery