Body contouring after weight loss

After marked weight loss, the skin may not fully adapt to the new volume, leaving excess skin and laxity in various areas.¹ Body contouring after weight loss covers the conditions under which, and the order in which, these problems are addressed. The decision is not made on the amount of skin that can be removed alone; incision scars, nutritional state, the burden of surgery and the help needed for healing at home are considered together.

What is body contouring after weight loss?

This name does not describe a single operation. It refers to planning different operations, individually, for the excess skin remaining in people who have lost a marked amount of weight through bariatric surgery or a change in lifestyle.¹ The scope of surgery is explained through where the remaining problem lies on examination and what change is wanted, rather than through the method of weight loss.

The abdomen, back, arms, thighs, buttocks and breasts can carry separate aims. In one area, for instance, excess skin may need removing, while in another, sagging is accompanied by a loss of volume.² It is not necessary for all these areas to be operated on in the same person. Leaving an unplanned area as it is also forms part of the decision.

This group of operations does not take the place of treatment for weight loss. Assessing the tissues that remain after weight loss is a process separate from the treatment of obesity.¹³ The weight of the tissue removed, or the number of areas operated on in one session, is not on its own a measure of success.

Who is it suitable for?

Skin folds after weight loss can be accompanied by problems with everyday movement, with clothing or with skin care.⁴ The person's discomfort, the change they want and whether they accept the burden of surgery are considered together. Reaching a clothing size, or bringing every body closer to the same appearance, is not imposed as a goal.

The American Society of Plastic Surgeons (ASPS) assesses adults whose weight loss has stabilised, whose general health is suitable, who do not smoke and who have realistic expectations within its framework for candidacy.³ Within that framework, an average of 6 months of stable weight is expected. Where weight loss is continuing, where marked further weight loss is expected soon, or where a pregnancy is planned, the timing is assessed separately.

In a study retrospectively reviewing 43 respondents after bariatric surgery, stable weight for at least 3 months before surgery was associated with lower odds of complications; the odds ratio was 0.24, with a 95 per cent confidence interval of 0.07-0.79.⁵ This is a finding of association; it does not show that 3 months is enough for everyone or that personal risk falls to the same extent. The average of 6 months used here is a separately determined clinical planning interval.

Body mass index is not on its own the decision. In the abstract of a review and meta-analysis of 25 studies on contouring after bariatric surgery, a relative increase of 37 per cent in the risk of complications was reported where the body mass index was 30 kg/m² or above.⁶ This does not mean that the risk is 37 per cent, or that it rises by 37 percentage points. The same review reported a weighted overall complication rate of 31.5 per cent across all the studies, and, for seroma, the most frequent problem, 12.7-13.9 per cent, given in the abstract as a weighted rate; the abstract does not give the total patient denominator or the follow-up periods for these values.⁶ This research grouping is not turned into an automatic threshold for accepting or refusing surgery; general health, the course of weight, nutrition and the procedure planned are assessed together.

What does the examination assess?

The distribution of the excess skin, the fat remaining, any loss of volume present and old surgical scars are assessed.⁷ Several areas causing a problem does not require all of them to be addressed in the same session. Which area affects daily life most, and what the person's own priority is, are established.

The method of weight loss, the course of the change in weight, previous operations, illnesses, medication and allergies are asked about.⁷ Having had bariatric surgery is not enough to assume that nutrition is adequate or that all coexisting illnesses have resolved.⁴ The assessment required is made through the person's history and current state.

After bariatric surgery, deficiencies of protein, iron, zinc and certain vitamins can matter for tissue repair.⁴ Nutritional assessment is not made by the figure on the scales alone. Where intake is inadequate or a deficiency is suspected, the relevant investigations and a plan for correction are determined by your doctor; the same list of supplements is not given to everyone.

Alongside which area can be addressed at the next stage, how you will lie and how you will move after the first operation are assessed as well. The abdomen and the back, or an arm and the trunk, healing at the same time can change how much daily help is needed. Someone to accompany you, time off work and being able to keep up with check-ups are part of the operative plan.

How is the operation planned?

Which area is addressed first?

The order is determined by a joint decision between the surgeon and the patient. A fixed order in which everyone has the abdomen first and then an arm or thigh operation is not imposed. Priority is determined together with the severity of the complaint, general health and the pattern of movement that can be maintained during the first recovery period.

A tummy tuck and a back lift address different excesses of skin. An arm lift and a thigh lift also require separate incision and movement plans.² Where breast contouring or a procedure for the buttocks is to be added, what problem it is meant to correct is explained separately. Operation names written side by side are not on their own a workable plan.

Is it done in one session or in stages?

A combined operation can address several aims within a single recovery period. In a staged plan the procedures and the recovery periods are separated; ASPS states that this group is often planned in stages.² The choice is not made on the wish to undergo surgery fewer times alone.

In a registry study examining 661 operative sessions involving 1,070 procedures in 609 people with massive weight loss, seroma and wound dehiscence were reported to be strongly associated with the number of procedures; an association was also found for tissue loss and infection, whereas haematoma was not associated with the number of procedures.⁸ Length of hospital stay increased with the number of procedures, and no increase was found in major complications.⁸ In the same publication, 60 second-stage sessions had similar complication rates and length of stay.⁸ These results, from selected patients, do not prove that carrying out all procedures together or separately is equivalent.

Operating time and blood loss are assessed together as well. In another series retrospectively reviewing 653 people who had lost weight through bariatric surgery, a gastric balloon or diet and exercise and who had completed at least 12 months of follow-up, 22 of the 99 people in whom 4 or more areas were addressed in the same session received a blood transfusion; 2 of the 106 people in the 3-area group did, and none did in the groups of 378 with 1 area and 70 with 2 areas.⁹ In the same table, the complication rate was given as 7.4 per cent for 1 area, 17.1 per cent for 2 areas, 24.5 per cent for 3 areas and 39.4 per cent for more than 3 areas.⁹ The group sizes and baseline characteristics differ; these figures do not give a safe limit for the number of areas or a definite risk coefficient tied to operating time. Nor does this comparison show what the same person's total risk would be if all their procedures were completed in separate sessions.⁹

How long is left between sessions?

The number of sessions varies with the procedures to be carried out. At least 4-6 months is planned between sessions. The next session is not begun merely because the calendar has run its course, without the state of the wounds from the previous operation, the person's capacity for movement and their general recovery being assessed.

This interval is not the interval for returning to work or to daily life. Being able to carry out everyday tasks again does not mean that the whole operative plan is complete. According to the result of the first session and the person's wishes, the scope of the next procedure can be reassessed; carrying out all the sessions considered at the outset is not obligatory.

A planned second session and further surgery needed to correct a complication are not the same thing. The first is another aim set aside in advance; the second is treatment for an unexpected problem. The rates of further surgery in research are not used as the answer to the question of how many sessions are needed.

Are excess skin and loss of volume addressed in the same way?

Removing excess skin and assessing lost volume are different aims. Where sagging and a loss of fullness occur together in the breast, what a skin adjustment alone will change is explained separately.² A breast lift is the subject of that regional assessment; it does not follow that volume needs adding in every patient after weight loss.

A procedure addressing sagging of the skin of the buttocks is not the same as buttock augmentation with fat grafting or an implant. A lower body lift can address excess skin; the decision on augmentation is made separately for a volume goal.² Liposuction is likewise directed at fatty tissue; it is not thought of as the same step as removing marked excess skin.

How are the incisions and the healing burden planned together?

A scar forms in procedures involving skin excision. The length and pattern of the incision change with the position and amount of the excess to be removed; in some plans the incision can extend around the trunk.² The limit between the wish for a shorter scar and the excess that can be corrected is explained at the outset.

Where there will be several incisions, the dressing for each area, the pressure of garments and stretching with movement are considered together. A position that relieves one area can put pressure on another incision. Advice on lying and sitting is therefore not assembled by picking from separate articles; a single care plan covering the procedures actually carried out is prepared.

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.¹⁰ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.¹¹ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹² Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹³ The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Tests and anaesthetic assessment: The tests required are determined by general health and by the anaesthetic assessment.¹⁴ Any previous problem with anaesthesia or drug allergy should be declared. The instructions given about fasting and about how to take medication on the day of surgery are followed.

Home and transport: Someone is arranged to accompany you home on discharge.¹⁴ The timing of check-ups, the help you may need in the first days and the plan for time off work are organised beforehand. Follow the surgical team's guidance on preparing the operation area; do not shave or prepare the incision area at home on your own initiative.

Nutrition: A protein-rich diet is advised for wound healing. Where there is a nutritional deficiency, correcting it is planned separately. Reviews describe the relationship between protein deficiency after bariatric surgery and tissue repair.⁴ Increasing protein intake, however, is not a guarantee that no complication will develop. A prospective study found an association between adequate protein intake after surgery and fewer wound problems, but the 95 per cent confidence interval included the null value; the odds ratio was 0.27, with a confidence interval of 0.07-1.02.¹⁵ This result cannot be presented as a definite protective effect or as a new instruction to take supplements.

The instructions given on discharge for drains, dressings, the compression garment and movement need to be understood. Where more than one area is to be operated on, the person helping at home also needs to know how each area is to be cared for. The plan for help is arranged to cover not only the first night but the check-ups and daily needs as well.

What is recovery like?

The box of key facts does not show the fixed timetable of a single operation but the range expected for the procedures that can be carried out in this group. Under general anaesthesia, 2-6 hours are planned for the operation and 1-3 nights for the hospital stay. These are not the total duration of all sessions. The actual procedure to be carried out in each session, and the care it needs, are explained separately.

The first check-up takes place within the first week. Drains are planned to be removed within 1-3 days on average. 2 weeks are expected for stitch removal; where there is more than one incision, each is checked before a decision is made. Stitches being removed in one area does not mean that care for the other areas has ended.

7-10 days are expected for bruising to settle and 2-4 weeks for marked oedema to subside. The shape becomes assessable within 2-4 months; residual slight swelling can last 3-4 months. Assessing the shape is not the same moment as the end of all swelling. Different operated areas are not expected to recover at the same rate.

6-8 weeks are expected for a full return to daily life. This interval does not mean moving on to the next session, or that the incision scars have matured. The whole of a multi-session plan can extend over a longer period; ASPS states that completing the results of contouring can take as long as the weight loss itself, that is 2 years or more.²¹⁶ The timetable of the first operation should not be read as the end date of the whole plan.

What to pay attention to after surgery

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply.

Drain and dressing: A drain helps to remove blood and tissue fluid collecting in the operated area.¹⁷ Removal is planned within 1-3 days on average. The dressing is continued according to your surgeon's advice until the wound has healed. The drain is not tugged, is not removed on your own initiative, and its connections are not altered outside the instructions given. Where there is more than one drain, which area each one is draining and the arrangement for checking them are explained on discharge.

Compression garment: It is worn for 2-4 weeks, including at night. The arrangements for putting it on, taking it off and cleaning it are determined by the surgical team's instructions. The garment is not tightened in the belief that firmer use will give a better result. Where the pressure leads to marked pain, a change in skin colour or difficulty breathing, assessment is requested. The garment to be used and the area to be supported are determined by the procedures carried out. Finishing the period of compression garment use does not mean that all physical activities are permitted.

Sleeping: Rest with the head elevated. Your surgeon decides how long that position and the avoidance of physical strain are continued. A sleeping position that puts no pressure on the incision is preferred. Returning to sleeping on the side or front is assessed according to the state of the incision and the swelling.

Lying and sitting with more than one operated area: Elevating the head does not mean that you should lie on your back after every operation. In a procedure directed at the buttocks, lying face down or on the side can be the starting position; after repair of the abdomen a different arrangement of supports may be needed. Where these areas have been operated on together, a discharge plan that takes both the incision lines and the pressure limits into account is followed. Help is taken where needed for sitting, getting out of bed and going to the toilet.

Cold application: Cold is applied to the operated area without pressing on it. The form and duration of the application are determined by your surgeon's instructions.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Shower timetable: A return to showering is assessed within 1-2 weeks, according to the state of the wound and the dressing. Earlier removal of the drain is not by itself permission to shower. The care instructions given for each incision are followed; crusts are not picked off. Where the incision cannot be checked by eye, help is taken.

Movement: Strain such as bending the head down, straining and heavy lifting is limited in the early period. Movements that stretch or rub the incision area are avoided. Even if you feel well, do not return to strenuous activity suddenly. Activity and rest through the day are organised according to the plan given on discharge.

The controlled way of walking leaning forwards that can be advised after repair of the abdomen is not the same as standing bent over for long periods or forcing yourself to bend. Where there is more than one operated area, the movement plan is arranged according to all of them; one area becoming comfortable does not mean that the other restrictions have been lifted.

Pain: There can be tenderness, tightness and pain in the treated areas.¹⁸ The painkillers given are used as instructed. Pain that markedly prevents walking or changing position is reported to the team; rather than abandoning the movement plan altogether, pain control and the need for help are assessed. No new painkiller or additional medicine is started on your own decision.

Returning to work and sport: 2-4 weeks are set aside for a return to work. In jobs involving constant strain on the operated areas or heavy lifting, suitability is assessed separately. A return to sport is planned in stages within 4-6 weeks; approval from your doctor is awaited before moving on to movements that strain the operated areas. 6-8 weeks are expected for a full return to daily life. Being able to carry out a task at home comfortably does not mean that all physical activities are permitted.

Driving: A return can be assessed within 1-2 weeks. There must be no effect of medication reducing attention, no dizziness and no pain preventing movement. You need to be able to sit with a seat belt, to check your surroundings and to brake suddenly or manoeuvre comfortably. Where a restriction on sitting or movement still applies to the abdomen, the buttocks or another operated area, this interval running its course is not enough on its own. Someone accompanies you home on discharge.

Sexual activity: A return can be assessed once everyday movements no longer cause marked pain and you feel comfortable. Pressure on the treated areas, movements that stretch the incision line, and marked straining are avoided. Rather than a fixed day, the course of healing and the surgeon's advice are taken as the guide.

Smoking: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete.

Findings that are normal: Bruising, swelling, tightness and altered sensation around the incision can occur.¹⁸ What matters is that the findings are decreasing. Swelling that grows rapidly, is painful, or gathers markedly on one side should not be attributed to the healing period given alone. Where there is a new fullness, no attempt is made to press on the area to drain fluid.

How are early walking and prevention of clots planned?

Walking is begun 6-8 hours after leaving the operation, on the assessment of the healthcare team. This early walking is not the same thing as a return to sport. The need for rest does not mean remaining motionless in bed throughout the day; the movement plan given by your surgeon is a basic part of care. Help is taken at the outset; where there is dizziness or marked weakness, you do not push on and the team is informed.

The risk of clots is assessed routinely before surgery. A compression stocking is put on before the operation; after surgery it is removed by the surgeon's decision once you have begun to walk comfortably. A compression garment and a compression stocking are not products used for the same purpose and are not used in place of one another.

Where operations will be long, or where there are risk factors creating a predisposition to clots, prevention with medication is assessed. Which measures are applied together is determined according to the person's risk. Following the movement plan should not be neglected; equally, walking or any other measure should not be thought of as removing the possibility of a clot altogether.¹⁹

How do the scars change?

Permanent incision scars form in the areas where skin has been removed. Procedures on more than one area can mean more than one scar; the incision lines are planned according to the distribution of the person's excess skin.² Even where the aim is for a scar to stay under clothing, no promise is made that it will be invisible in every garment.

6 months to 1 year is expected for a scar to mature. Scars in different areas may not change at the same rate. An incision line can widen or remain more prominent than expected.²⁰ Stitch removal and maturation of the scar are separate processes.

Scar care: Silicone gel or a silicone sheet is used after the wound has closed and your surgeon considers it suitable. No product is applied on your own initiative to an incision that is open, discharging or not yet healed. Which form of product is used, when and how, is determined by the check-up findings. Where irritation develops, an assessment by your doctor is sought regarding use of the product.

Where the wound in one area has closed while another is still open, the same care decision is not applied to all of them at once. Where a scar opens, discharges or shows a new change in the tissue, a check-up is requested. ASPS states plainly that visible scars are something that has to be accepted for the result; a correction without scars is not to be expected.¹⁶

Risks and complications

In this group, wound dehiscence and seroma need separate consideration when reaching a decision.²¹ A registry that counts only major complications and a series that also records small wound openings are not measuring the same thing. The rates below are limited to the procedures and patient groups they come from; they are not an estimate of personal risk or a shared percentage for all body contouring procedures.

Wound dehiscence and seroma

In a series of 100 people undergoing circumferential lower body lift followed for 6 months, 87 had lost weight through bariatric surgery and 13 through a change in lifestyle. In this series, in which wound dehiscence of every size was counted, the three most frequent problems were wound dehiscence (61 people), infection (44 people) and seroma (32 people).²¹ A seroma is a collection of tissue fluid under the skin; it is different from a collection of blood. The same publication notes that the definition of infection was kept broad, with everyone taking oral antibiotics after surgery counted as having an infection.²¹

In the same series, at least 1 complication was recorded in a total of 78 people. In 56 people the problems were minor and in 22 they were in the major class requiring intervention; further surgery under general anaesthesia was reported in 13 people.²¹ Most of the minor problems were managed with conservative care.²¹ The figures are not added together: of the 78 people who developed a complication, 53 were reported to have more than one problem.²¹ This result is not applied at the same rate to someone who will have only an arm, breast or back operation.

A wound opening requires care and a check-up even where it is small. In some cases following it with dressings is enough, while in others the wound may need closing again or another intervention.²⁰²¹ Increasing swelling or discharge should not be attributed to the healing timetable alone.

Bleeding, infection and tissue loss

Haematoma, infection, delayed wound healing or tissue loss can develop.²⁰ As the scope of surgery grows, the total wound area and the care burden also form part of the planning. Blood loss and transfusion where needed are assessed separately; it is not assumed that blood needs to be given in every operation.⁹

A nutritional deficiency is assessed as it bears on tissue repair, but not every wound problem can be explained by nutrition alone.⁴¹⁵ Using a supplement, or weight being stable, does not guarantee that no wound problem will occur. Where a problem develops, the conditions of the surgery and of healing are reviewed together.

Clots and problems related to anaesthesia

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

The approach to preventing clots is decided according to the person's risk and the operation planned. The measures to be used are explained in the discharge and care plan. No blood thinner is started without being prescribed, and existing treatment is not altered on the person's own decision.

A systematic review examining 31 publications and 2,264 people with massive weight loss receiving medical prophylaxis against clots reported that prophylaxis practices and the recording of events were inconsistent between studies.¹⁹ These data do not produce a single medication regimen for all patients or a reliable shared percentage for clots. Operating time, restriction of movement and the person's own risks are assessed together.

General anaesthesia and complications related to the heart and lungs are also assessed.¹⁸ Having had bariatric surgery does not on its own attach the same additional percentage of anaesthetic risk to everyone. Existing illnesses, medication in use and previous problems with anaesthesia are explained during preparation; where a new problem arises, the plan is reassessed.

Shape, sensation and the need for further surgery

Remaining skin laxity, contour irregularity, a marked scar and altered sensation can occur.²⁰ Differences present at the outset may not disappear entirely. A change in one area is not expected to correct all the others.

Further correction may be needed because the result does not meet the expectation or because of a wound problem.¹⁶ This is not confused with a second session planned in advance. Which area the next stage is directed at is explained separately from the treatment of any complication. As each procedure is added, its own risks are explained; the general information for the group alone is not relied on.⁷

Does the result change over time?

Changes in weight and laxity of the tissues over time can affect the result.¹⁶ Keeping weight stable matters in the long-term assessment; but no promise is made to anyone of a result that will not change over a particular number of years.

In a staged plan, the appearance of an area not yet operated on does not mean that the completed session has failed. The goals set at the outset are compared with the current result. Whether the next session is needed is reassessed through the person's remaining complaint and general state.

Contouring does not take the place of the health follow-up needed after weight loss. Nutritional requirements after bariatric surgery need following over time as well.⁴ Where there is a new change in weight or a health problem, the plan for the next operation is reviewed.

What can be expected from the result?

The expectation is a change in the excess skin and tissue distribution of the areas selected.¹ The person's priority may be reducing a particular fold, or addressing an area that causes discomfort in daily life. It is not necessary to operate on every excess that can be seen.

Permanent scars and a period of recovery are accepted in return for a reduction in excess skin.¹⁶ Removing more tissue, or addressing more areas in the same session, is not the same thing as a better result. Goals are compared against the scope of surgery; the list of procedures is not extended for an expectation that cannot be met.

Returning to work, driving, returning to daily life, assessing the shape of one session and completing the whole plan are separate times. The end of compression garment use does not mean that all of these are permitted. The next stage is not carried out on the initial timetable alone, without the result of the first operation being checked.

When should you contact a doctor?

In the situations below, the planned check-up is not waited for.

• Rapidly increasing swelling or tightness in one of the operated areas
• Pain that increases rather than settling, or becomes marked despite the pain treatment given
• Fever, spreading redness or discharge from the incision line
• The wound opening or bleeding that does not stop
• Newly developing marked pallor, darkening or blistering of the skin
• The drain coming out of place, or increasing swelling in an operated area while the drain output changes
• Steadily increasing pain or pressure under the compression garment

These findings may require assessment for bleeding, fluid collection, infection or problems with the circulation to the tissue.²⁰ Rather than trying to work out the cause of a new swelling at home, report it to the surgical team. The drain having been removed, or another incision area healing well, is not a reason to leave new findings.

One-sided leg pain and swelling, sudden shortness of breath or chest pain are emergencies. Where there is a sudden breathing problem in particular, urgent assessment should not be delayed while trying to reach your doctor. That the movement plan has been followed or a preventive measure used does not lessen the importance of these symptoms.

About the numbers in this article

The key facts and recovery intervals are the clinical framework approved for the procedures that may be carried out. They do not mean that all the lower limits, or all the upper limits, will occur together in one person. The minimum of 4-6 months between sessions and the 6-8 weeks for a full return to daily life describe different decisions. Maturation of the scars and completion of all the stages are longer processes.

The complication figures come from separate groups. Poodt's result belongs to one particular series of circumferential lower body lifts, Marouf's weighted result to a review combining operations on different areas, and Ibrahiem's results to groups divided by the number of areas addressed in the same session; these values cannot be added together, or chosen between, to calculate one person's risk.²¹⁶⁹ The series of 100 people undergoing circumferential lower body lift is not a study of frequency for all areas.²¹ In registries of combined surgery, the numbers of people, operative sessions and procedures are not used in place of one another.⁸ Results that also include minor wound problems are not compared directly with results covering only outcomes requiring further surgery.

The period of weight stability in the research and the average of 6 months applied here rest on separate grounds.⁵ The smoking cessation sources cover a range of operations; the relative risk reduction in them is not an absolute complication rate specific to this group of operations.¹¹¹²¹³

References

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