The Massive Weight Loss Patient

The results of massive weight loss are not all positive. The changes in body morphology are significant and can dramatically affect a patient’s physical and emotional well-being. The physical stigma of the massive weight loss patient is the dramatic rolling-over and draping of redundant, atonal skin. This has been described as a deflated appearance secondary to poor skin tone and loss of elasticity. The compromise of skin integrity occurs long before bariatric surgery is undertaken, as the “yo-yo” dieting often attempted by obese patients exerts its toll. Repetitive stretching and contraction of skin eventually crosses a threshold where skin recoil no longer occurs despite sustained weight loss. After massive weight loss, excess skin collapses in a vertical direction as it drapes over a leaner frame. This laxity is most pronounced laterally and anteriorly below the level of the umbilicus ( Fig. 11.1 ). Furthermore, mechanical deficiencies, along with the presence of intertriginous dermatoses, interfere with performing routine tasks, facilitate the development of secondary skin conditions, and, most importantly, worsen patients’ self-esteem.

Significant body contour deformities affect the face, arms, breasts, abdomen, mons pubis, flanks, back, buttocks, and thighs and differentiate the postbariatric patient who has lost a substantial amount of weight from the routine overweight patient. In the most severe cases, these deformities affect all areas and, as will subsequently be addressed, circumferentially. The significant skin excess and laxity, diffuse lipodystrophy, and ptosis in these areas are a source of postural, functional, hygienic, dermatologic, and aesthetic impairment. It is apparent that the possibility of surgically ameliorating these conditions through body contouring renders this operative challenge a worthwhile undertaking.

Relevant Anatomy

The current standard of an aesthetic, youthful abdominal contour is confirmed by the physiologic and anatomic studies of Lockwood.8 He describes the contoured waistline concavity, the inter-rectus valley, and vertically oriented umbilicus—characteristics that have become the intended end points of a well-executed aesthetic abdominoplasty. Similarly, the anatomic characteristics that frame the ultimate goals of circumferential procedures are predominantly rooted in the removal of excess skin and the redistribution of abnormally positioned fat. The procedures used to achieve these goals have undergone multiple evolutions since their original descriptions. It is the elucidation and better understanding of various key anatomic structures and relationships that have allowed circumferential body contouring to become safe, effective, and aesthetically pleasing to both the plastic surgeon and the massive weight loss patient. The contributions made by Lockwood have propelled contouring surgery into the modern era.

The subcutaneous tissue consists of a superficial and deep fat layer, separated by Scarpa’s fascia. The superficial layer is typically dense and fibrous in nature, consistent with what Lockwood9 has described as the superficial fascial system (SFS). It is relatively more tethered in the midline above the umbilicus and along the posterior midline. The lateral aspects of the trunk represent the farthest distances from these tighter adherence points of the SFS, thus providing an anatomic basis for the classic flank rolls that develop in patients with massive weight loss. This pervasive system of connective tissue encases and shapes the fat of the trunk and extremities. In describing the topographic landmarks of the human body, Lockwood9 states that there exist “varying ‘zones of adherence’ of the SFS that cover the trunk and extremities and, along with the fat, produce the creases, folds, valleys, plateaus, and bulges of the normal body contour.” These are the very areas that are overexaggerated with massive weight loss when lipodystrophy occurs beneath skin that has lost most of its elasticity. Scarpa’s fascia is a fibrous layer of connective and adipose tissue that forms a discrete layer in the lower abdominal wall. The deep adipose layer is loose with poorly organized septa.10 It is the disproportionate enlargement of this deep layer in the torso and upper thighs that characterizes fat accumulation, even in thin women.

The overall shape of the abdomen, hip, and buttocks varies depending on the fat distribution and musculoapo-neurotic constitution. The ideal body shape for women is narrow at the waist and wider at the hips, whereas in men it is progressively narrower from the chest to the hips.11 Fat accumulation also differs between the genders.12 Women demonstrate weight gain in the lower abdomen, hips, and buttocks, whereas in men fat accumulation occurs predominantly intraabdominally and circumferentially around the mid-abdomen and flanks. Although abdominal wall lipo-dystrophy can be contoured to obtain a desirable result, intraabdominal adiposity limits the level of improvement and should be recognized preoperatively.

The sine qua non of massive weight loss is excess skin. Altered fat distribution exaggerates the abnormal morphology. Understanding the anatomy allows the necessary undermining, repositioning, and closure of tissues to be performed with the best chance of success, both medically and aesthetically. Excess skin excision and suction-assisted lipectomy are the mainstays of contouring in the abdomen, buttocks, thighs, and lower back. The key anatomic highlights of each region are reviewed in the following subsections.

History

Substantial tissue resection strategies have been in evolution since the original “circular” dermolipectomy was described by Somalo in 1940, and later promoted by Gonzalez-Ulloa15 in 1960 as the belt lipectomy. The thighs and buttocks were not addressed in this early version of the belt lipectomy, and so it may have been more appropriately termed a circumferential abdominoplasty; the results were nonetheless impressive. Dardour and Vilain16 provide an early report of 300 belt lipectomies with only one major complication, a pulmonary embolus. In 1992, Baroudi17 described combining an abdominoplasty with a medial thigh lift and a “flank-plasty” in a single stage. Hunstad18 combined the techniques of circumferential excision and liposuction of the back and abdominal flap but with a high rate of seroma formation. The following summary of the contributions to body contouring illustrates the development and refinement of the techniques and demonstrates their reproducibility, safety, and effectiveness.

Lockwood revolutionized the art and scope of contour surgery by describing the SFS and its vital role in suspending the lower body tissues. He developed the high lateral tension abdominoplasty and combined it with a transverse thigh and buttock lift in 1996, thereby introducing the lower body lift.19 Lockwood reported operating initially with the patient in the lateral decubitus position, then rotating the patient to the supine position.

Hamra20 described circumferential body lifts on 40 patients with the addition of dead-space obliterating sutures that spanned the superficial fascia of the flap to the underlying rectus sheath without any major complications. Multiple positional changes were used, including both lateral decubitus positions and the prone and supine positions.

Aly et al21 reported 32 belt lipectomies combined with liposuction. In this operation, the patient is initially in the supine position and is then rotated to both lateral positions. This order is used based on the concept that the initial operation should be performed on the area of the body that needs a contour advantage.

Rohrich et al22 presented data on 151 central body lift patients. Their emphasis on the need to adhere to strict safety guidelines when operating on this patient population is of paramount importance.