Introduction

Body contouring after significant weight loss has become very popular among patients after massive weight loss (MWL). Massive weight loss itself is associated with negative consequences for the body and creates new and unique dysfunctions1 that can severely affect the patient’s quality of life. The abdominal apron is generally the greatest and the first disturbance faced by the postbariatric patient. Redundant skin may become a medical problem if it leads to dermatitis, ulceration, infection, or difficulty with ambulation; these conditions are associated with significant hygiene problems. In some cases, excess skin is a cosmetic problem, and surgical removal of such skin is an elective procedure that is not covered by health insurance.2 In cases presenting with functional disability, panniculectomy may be the only body-contouring procedure covered by third-party payers.3 Surgical correction of these body deformities can significantly enhance patients’ physical and physiologic well-being. The treatments in body-contouring procedures include lipoplasty, excisional surgery, or a combination of the two procedures. Total abdominal liposuction performed with abdominoplasty allows for the preservation of lymphatic vessels below Scarpa’s fascia and eliminates the need for upper flap undermining.4,5

Although diet and exercise may be the first line of treatment, the severely obese patient has often reached a tipping point at which his or her immense size limits mobility and the potential for exercise. For these patients, the journey starts with bariatric surgery and usually ends with plastic surgery after 12 to 18 months. Ideally, the role of plastic surgery should be discussed with patients in the phase preceding bariatric surgery, so that they can understand what to expect from plastic surgery. Patients who seek body contouring following MWL have their own set of criteria.6

They need to be evaluated regarding their candidacy for a belt lipectomy instead of abdominoplasty. Although excess skin after bariatric surgery is seldom considered a medical complication, it is certainly a psychosocial complication that patients may not think about before surgery.7

Relevant Anatomy

The abdominal wall is embryonically derived in a segmental manner, and this is reflected in its blood supply and inner-vation. It becomes a definitive structure after the umbilical cord is separated. The musculature of the abdominal wall includes the paired rectus abdominis muscles, which meet in the midline at the linea alba. These muscles are enclosed by a fascial sheath. In the upper two thirds of the rectus fascia, the anterior sheath is formed by the external and internal oblique aponeurosis, and the posterior sheath is formed by the internal oblique and transversalis aponeurosis. In the lower third, the posterior sheath is absent, and all three apo-neurotic layers pass anterior to the rectus muscle, except the internal lamina of the transversus abdominis, the transversalis fascia, and the peritoneum, which pass posteriorly. The blood supply of the abdominal wall has connections between the deep superior and deep inferior epigastric systems with contributions from the superficial inferior epigastric vessels and the intercostal vessels.8 A clear understanding of the arterial supply of the abdominal wall is crucial to operative planning, especially when the patient’s history includes prior abdominal or chest wall surgeries. One area is fed anteriorly by the vertically oriented deep epigastric arcade. The lateral aspects of the abdominal wall (flanks) are fed by the six lateral intercostal and four lumbar arteries. The lower abdominal circulation is provided by the superficial epigastric, superficial external pudendal, and superficial circumflex iliac systems. A rich plexus between these systems allows collateral flow.

During abdominoplasty, the cutaneous blood supply is divided, with the abdominal flap circulation fully dependent on lateral intercostal and lumbar arteries mentioned above. A vertical midline incision can jeopardize flap circulation. The superficial fascial system (SFS), the connective tissue network that resides below the dermis, has been implicated as a pivotal structure in body-contouring procedures. Surgical repair of the SFS has been shown to increase wound strength and decrease seroma formation. Lockwood is credited with the concept that repair of the SFS results in a stable scar that heals without migration. Incorporation of this layer into the body-sculpting operation has the potential of enhancing outcomes, as the surgeon is dealing with large surface areas of tissue that need to be approximated under significant tension. The nerve supply to the abdominal wall is via intercostal nerves VIII to XII. These nerves pass between the internal oblique and transversus abdominis muscles,9 penetrating through the muscle as perforating anterior cutaneous nerves supply sensation to the skin of the abdomen in a stepwise fashion. During abdominoplasty, these perforating nerves are necessarily severed as the anterior abdominal skin and subcutaneous fat are raised from the underlying fascial plane. Sensibility is often decreased after abdominoplasty, particularly in the torso and suprapubic region. The loss of sensation is usually transient, with pain, temperature, and pressure sensation returning after an average of 6 to 7 months.10 The skin of the abdomen is usually quite loose, except at certain points of adherence, namely the anterosuperior iliac crests and the linea alba. The subcutaneous tissue is divided by two layers of fascia, the superficial fascia (Camper) and the deep fascia (Scarpa), which is continuous with the fascia lata of the thigh. With aging and pregnancy, fat tends to be distributed into the lower infraumbilical abdomen.

Indications

Our technique after MWL is indicated both in patients who present with skin redundancy only and in those who also complain of fat accumulation in the abdominal region.

In the former, liposuction is used only to perform a less traumatic undermining of the skin, with preservation of most of the perforating vessels and nerves. This maneuver is started from the central area of the abdomen, where skin and fat undermining is complete and performed with a Bovie cautery or scalpel, to the more lateral parts. In the case of patients who present with both skin and fat excess, more aggressive liposuction undermines the abdominal flap and reduces its thickness.