Introduction

Although massive weight loss (MWL) affects the body globally from head to toe, the most frequently addressed body region is the central torso, partly because sculpting surgery in this area is frequently covered by health insurance, and partly because this area is most remarkable for deformity associated with MWL ( Fig. 16.1 ).

Abdominoplasty is the fifth most common surgical procedure performed by plastic surgeons overall, with the most recent data indicating almost 123,000 procedures performed per year.1 Circumferential lower body lift, including abdominoplasty and back lift with or without autologous gluteal augmentation, is one of the most powerful surgical procedures a plastic surgeon can apply to MWL patients. Circumferential torsoplasty addresses lax and redundant skin; ptosis of the mons pubis, buttock, and outer thigh; and rectus abdominal muscle diastasis. Results are extreme and include improved contour of the abdomen, waist, back, buttock, and outer thigh, with reduction of back rolls. Secondary gain includes inner thigh lifting ( Fig. 16.2 ). Other benefits are better posture, improved body image, and absence of physical symptoms (e.g., rashes and odor) that are difficult to quantify but are of obvious importance.

MWL patients undergo weight loss through diet and exercise or through surgery. The most successful avenue for maintenance of weight loss over the long term is surgery, and the number of bariatric procedures performed annually continues to grow, with greater numbers being performed laparoscopically.2 The most commonly performed surgical weight loss procedure is the Roux-en-Y bypass, which impacts weight loss through malabsorption.3

MWL patients comprise a challenging patient population with their history of obesity-related medical issues and surgical history. Despite their improved medical profile, with loss of 50% excess body weight commonly observed, MWL patients may still harbor residual medical issues.4–7 Roux-en-Y gastric bypass (RYGBP) surgery results in nutritional deficiencies, including vitamins, B₁₂, thiamine, folate, and calcium. Patients who have undergone RYGBP surgery are often anemic due to malabsorption of intrinsic factor, iron, and folate and can have low albumin levels. Furthermore, there may have been complications associated with gastric bypass surgery, including fascial dehiscence, hernia, wound-healing problems, and fistulae, making abdominal-contouring procedures riskier.8 Tobacco use may portend a bad outcome.9 MWL patients are not the standard cosmetic body-contouring patient. Their physical presentation and history tend to be more complicated. In addition, the complications discussed below may occur in higher frequencies than in the healthy cosmetic surgery patient; thus, the surgeon must be cognizant of their potential, methods of prevention, and treatment. Complication rates have been reported to be as alarmingly high as 50%,9,10 with the most common complication from the lower body lift being seroma.11–13

Seroma

Seroma is a fluid collection occurring postoperatively in the body-contouring patient in a surgically created dead space resulting from skin removal. Seromas may be difficult to distinguish from lymphoceles. Extensive undermining, shear forces, lymphatic disruption, and possible secondary surgery, combined with underlying malnutrition with low albumin levels, make this complication one that is frequently experienced. This is the most common complication after lower body lift, with contemporary reports of clinically evident seromas reported in 8 to 37.5% of cases,14 18%,11 20.9%,10 8%,15 and 37.5%.12,13 When they occur with circumferential torsoplasty, many seromas are posterolaterally located ( Fig. 16.3 ).10,12,13 Location in the flank and thigh is probably secondary to motion of the greater trochanter with ambulation and dependency. Pascal and Le Louarn16 place quilting sutures in this location, which may account for their reported very low seroma rate.

Higher seroma rates are associated with greater skin removal and more rapid drain removal.11–13 Protection against seromas include optimization of patients preoperatively and use of drains. More conservative skin excisions should be performed in patients with a body mass index (BMI) >35 kilograms per height in meters squared (kg/m²) or with medical comorbidities, such as diabetes. Many plastic surgeons specializing in postbariatric body contouring place drains and leave them in until output is less than 30 cc per day.10,17,18 Other protective measures include placement of quilting sutures.16 Some surgeons report a benefit from fibrin glue.15

Seromas may be aspirated after drains have been removed, and drains may be placed transcutaneously if the seroma does not resolve with needle aspiration. Prior to drain removal, seromas may be sclerosed with doxycycline or bleomycin.11

Wound-Healing Problems

Wound-healing problems may occur with circumferential body contouring, with incidences reported between 16% for partial wound dehiscences and 32.5%.9,15 Most appear weeks after surgery, and few require return to the operating room. Treatment generally consists of local debridement and dressing changes. Skin dehiscence most frequently occurs at the buttock cleft and hips due to marginal ischemia, exacerbated with autologous gluteal augmentation and creation of a subcutaneous pocket. Prior scars also present a risk for wound healing. Along the abdomen, scars including subcostal, nephrectomy, appendectomy, and bucket-handle scars, and all may limit blood supply to the closure. Along the back, scars from spinal surgery may impact healing negatively. Elevated BMI has also been reported to impact dehiscence.19

Wounds also may occur secondary to undermining. With regard to abdominal contouring, undermining should be limited to the central region to preserve as many perforators as possible. Wound-healing problems may be more common with fleur-de-lis abdominoplasty, although there are reports of no additional complications with strict patient selection criteria.20

To minimize wound-healing problems, reliable preoperative markings, accurate intraoperative tissue measurement, and closure that minimizes tension along skin edges are important.10 Overly thin skin flaps over autologous gluteal augmentation flaps will lead to marginal ischemia and skin necrosis.

Management of skin necrosis and open wounds primarily requires local wound care, with debridement of nonviable tissue. Acute dehiscence may be managed surgically.