The Clinical Problem ( Fig. 34.1 )
Truncal body-contouring surgery aimed at excising large quantities of redundant skin and subcutaneous tissue, especially after massive weight loss, with or without bariatric surgery, is not without risk, but can be made safer and more rewarding for many patients. Liposuction-assisted pseudo-undermining technique helps preserve the lymphatics around intact Scarpa’s fascia and reduces the problems with seroma formation, wound healing and flap necrosis. It also allows enhanced sculpturing of the flanks (love handles), as well as epigastric fullness. Liposuction-assisted pseudoundermining is time-efficient and causes less blood loss, and suction drains may not be required. This facilitates early mobilization and reduces hospital stay. Postoperative use of compression garments for at least 6 weeks is advised.
Surgical Preparation and Technique
Body-Contouring Surgery
Body-contouring surgery has become increasingly popular over recent years, owing to increasing number of weight loss surgery procedures being performed as a definitive treatment for morbid obesity. It is now recognized as a subspecialty of plastic surgery. These procedures are rewarding, with very good patient satisfaction.
Detailed preoperative counseling, selection of safe procedure, meticulous planning, attention to minute aesthetic details, adequate investment of time, and personalized postoperative care are essential for the best outcome to be attained. A liposuction-assisted pseudoundermining technique is preferred for surgical undermining for all skin reduction procedures. This technique preserves perforators and lymphatics, minimizing the incidence of flap necrosis and seroma. Adjunctive liposuction debulks the skin flaps, improves flap mobility, and facilitates sculpturing.
Conventional procedures carry a higher risk to skin flap vascularity and of wound dehiscence. Pseudoundermining using a power-assisted liposuction device mostly preserves the integrity of Scarpa’s fascia.
This chapter focuses on truncal body contouring procedures following massive weight loss, emphasizing key technical features and perioperative care.
Patient Selection
Patients with a stable weight for at least 12 months following massive weight loss, absence of major comorbidities, and abstinence from smoking are the main criteria for selection. It is advisable to defer patients who are younger than 16 years, are active smokers, and have psychosocial conditions until they are no longer smoking and are clearly motivated. Patients who are young and fit can be considered for longer duration combined procedures.
A multidisciplinary approach for an individualized management plan is essential.
Preoperative Planning
There should be at least two preoperative consultations with time to reflect on the benefits and risks, with preoperative patient photographs and detailed documentation, including measurements. A thorough clinical examination is necessary, particularly examining the divarication of recti, hernial sites, and muscle tone. There should be an assessment of redundant excessive skin and residual fat to determine the type of procedure required.
Counseling of the patient about the procedure includes providing the patient with an information leaflet. The patient should sign a consent form and given the opportunity to speak to a patient who has previously undergone a similar procedure.
There should be a preoperative anesthetic assessment. The standard preoperative investigation should include the use of methicillin-resistant Staphylococcus aureus swabs.
This is a summary of the suggested preoperative routine:
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Completion of consent form
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Preoperative photography
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Marking for procedure in standing position
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Pinch test and use of multicolor permanent marker
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Marking the proposed site of skin excision and extended zone of liposuction
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Application of compressive stocking
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General anesthesia
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Intravenous broad spectrum antibiotic on induction, continued orally for 5 days postoperatively
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Aqueous povidone-iodine (10%) for skin preparation
Operative Steps ( Table 34.1 )
Lower Body Lift ( ; Figs. 34.2 to 34.4 )
Begin with the patient in the prone position, using tumescent infiltration, power-assisted liposuction, with no. 4 and 5 cannulae. The ratio of tumescent versus aspirate is 1 : 1.
| Procedure | Indication | Key features |
|---|---|---|
| Lower body lift | Circumferential panniculus of loose redundant skin over lower abdomen | Umbilicoplasty; correction of divarication of recti |
| Upper body lift | Saggy skin forming so-called banana roll on posterolateral aspect of upper back | Precise placement of scar under horizontal strap of the bra |
| Post–massive weight loss gynecomastia | Loose saggy skin, with severe ptosis of the nipple-areola complex | Liposuction-assisted skin excision, free nipple-areola composite graft |
| Mastopexy | Severe ptosis of the breasts | No liposuction |
| Brachioplasty | Loose redundant skin over the upper arms, forming bingo wings | No undermining of adjoining flap, extensive liposuction underneath proposed skin excision |
| Thigh reduction | Loose redundant skin, with extensive sagginess over inner thighs | Absolute attention to tension-free closure, no undermining of adjoining flaps |
| Liposuction | Residual saddle bag deformity of outer thighs | Improves the sculpturing and assists in thigh lift in conjunction with a lower body lift |
| Power-assisted liposuction | For pseudoundermining, volume reduction, and body sculpturing | Extensive liposuction with 4- and 5-mm cannulae |
A so-called flying bird incision is made within the bikini line ( ). The incision and flap are created with pseudoundermining ( and ). Only flaps of the proposed zone of skin excision are harvested. The staple test is carried out—stapling future skin edges before excision of excess skin to confirm a tension-free apposition. These temporary staples are then removed before skin excision.
Skin excision ( )—uses meticulous hemostasis for skin closure using the halving technique, planned at the time of marking, with 2-0 Monocryl sutures (Ethicon, Somerville, NJ), deep dermal sutures, and 3-0 Monocryl subcuticular sutures ( ).
Tumescent infiltration is done with bupivacaine with epinephrine for long-term analgesia. Tincture of benzoin Steri-Strips and a padded Opsite dressing (Smith & Nephew, Fort Worth, TX; ) are applied.
The patient is then turned to the supine position. Skin preparation and tumescent infiltration are carried out as described above ( ). Exteriorization of the umbilicus is done with power-assisted liposuction ( ). A suprapubic incision is made ( ).
The flap is harvested adhering to the principle of Saldanha ( ). A full-thickness, skin-only flap is harvested up to the proposed site of excision, with preservation of Scarpa’s fascia ( Fig. 34.5 ).
