Introduction

Body contouring’s deeply rooted history involves the evolution of specialized surgical techniques to sculpt and reshape the human physique. The concepts of panniculectomy and dermolipectomy were defined at the tail end of the 19th century as pioneers of this craft began to remove pendulous adipocutaneous tissue, resulting in improved functionality.¹ In the early 20th century, contour surgery began its transformation from a purely functional modality to an esthetic procedure. As such, Thorek described the first umbilicus preserving abdominoplasty in 1924.² The 1960s and 1970s saw major advances in this field as techniques involving aponeurotic plication,³ refinement in scar placement³^–⁶ and tissue anchoring utilizing the anatomy of the superficial fascial system⁷ were made popular. At the turn of the 21st century, the explosive growth and widespread acceptance of bariatric surgery created a new group of patients, collectively referred to as “massive weight loss patients.” New procedures were necessary to excise the redundant tissue in all areas of the body while achieving an esthetic result. The range of contour deformities seen in these patients experienced a dramatic expansion from “anterior only” to “circumferential,” establishing the circumferential dermatolipectomy as a mainstream operation in plastic surgery today.

Body contour deformities of the lower trunk exist on a spectrum from “anterior only” to “circumferential” deformities. If the lower truncal deformity is limited to moderate lipodystrophy deposits, then liposuction may be the only treatment modality required. Abdominoplasty techniques are useful if anterior skin laxity and/or abdominal wall weakness are encountered. If lateral and posterior lipodystrophy accompany the anterior deformities, then liposuction may be added to abdominoplasty in order to achieve the best possible contour. If circumferential skin and subcutaneous laxity is additionally present, then belt lipectomy procedures are usually required to adequately address the deformities.

Belt lipectomy procedures treat deformities of the lower trunk, from the ribcage to the pelvic rim, and improve the contour of the lower back and the anterior, medial and lateral thighs. It does not, however, address upper back rolls/lateral back rolls, breast, or arm contour. The belt lipectomy procedure, therefore, will not address the upper trunk, which anatomically originates at the inferior border of the neck and extends to include the inframammary fold. To correct deformities of this anatomic unit, the authors suggest using an “upper body lift” procedure.

Relevant Anatomy

It is critical to understand the anatomy, in particular the blood supply, of the abdomen and all its variations when considering a circumferential dermatolipectomy of the lower trunk. This chapter will stop short of a detailed description of the vascular supply as this is covered elsewhere in this textbook. Preservation of the vascular supply as well as the peripheral innervation to the abdomen is a critical consideration in thwarting major complications of these procedures. The superficial fascial system, called Scarpa’s fascia in the abdomen, is a connective tissue network that exists between the subdermal plane and the deep fascia and it separates subcutaneous fat into superficial and deep layers. In thin patients, the two layers are of relatively similar thickness. Both layers demonstrate vertical or oblique fibrous septae; however, the vertically oriented compartments of the superficial layer thicken with increasing body weight and grow proportionally with the body mass index (BMI). Therefore, the superficial layer is often thicker with respect to the deep layer in patients with increased BMI. In well-defined areas of the trunk the superficial fascial system is tightly tethered to the underlying musculoskeletal surface, resulting in restriction of either descent or elevation, which typically occurs with age, fluctuations in weight, or surgical manipulation. These areas are referred to as “zones of adherence,” which behave like “hooks” that grasp the fat/skin envelope as it succumbs to gravitational forces, most noticeably following skin deflation from massive weight loss. It is important to know the anatomy of these zones and how they influence tissue draping. The zones of adherence are located in the inframammary, inguinal, suprapubic, and gluteal regions. The zones of adherence overlying the spine and sternum as well as the area located between the hip and lateral thigh fat deposits are strong and consistently present. On the other hand, the zone of adherence overlying the midline linea alba of the abdomen is relatively weak and occasionally nonexistent. Another strong zone of adherence is in the inguinal region, which plays an integral role in the final scar position following a belt lipectomy. A weaker zone of adherence exists in the horizontal suprapubic area, creating a suprapubic crease, which varies between individuals. Along with the inguinal zones of adherence, the suprapubic zone is responsible for the panniculus overhanging the mons pubis. The zone of adherence between the hip and the lateral thigh fat deposits mentioned above is an important anatomic structure because it prevents superior and inferior movement of lateral thigh tissue, especially during surgical manipulation. Destruction of this zone is often necessary if substantial elevation and redraping of the lateral thigh soft tissue envelope is desired, such as with the lower body lift type II as described by Lockwood.

Disease Process

In general, there are three groups of patients for which a belt lipectomy is beneficial.⁸ The majority are massive weight loss patients,⁸ who are not a homogeneous group. Although the pathophysiologic processes are similar and the indications and principles in operative design are comparable, their individual BMI at presentation, fat deposition pattern, and quality of their skin–fat envelope can result in a wide divergence in the nature of their physical deformity. Massive weight loss patients must therefore be well informed regarding the expected body contour outcome to avoid disappointment. Bariatric surgeons tend to emphasize overall weight reduction and often neglect to inform patients that many of the changes in their body habitus are not reversible with weight loss and that normalcy from an esthetic standpoint is often unattainable. The redundant skin with irreversible laxity is almost always circumferential in these patients, resulting in a truncal pattern of an inverted cone.

The second group of patients that may benefit from body lift/belt lipectomy are the 9–13 kg (20–30 pounds) overweight patients (BMI of 26–28). These patients have never lost significant weight despite reasonable exercise and nutritional support, which very often results in circumferential lipodystrophy and an overall lack of definition of the lower trunk. A third group is comprised of normal weight patients who desire more dramatic improvements in lower truncal contour than a conventional abdominoplasty can achieve. These normal BMI patients often seek drastic improvement in the contour of their anterior and lateral thighs, buttocks and lower back. Some of these patients can be treated with an abdominoplasty combined with liposuction of specific areas; however, if significant lifting and contour manipulation is required, a circumferential excisional procedure becomes necessary. A subset of this group is made up of older patients whose skin laxity requires the pull created by the circumferential excision. Liposuction alone will not sufficiently address the deformity as irreversible skin laxity precludes the contraction necessary to achieve the desired contour.

Diagnosis and Presentation

The discussions to follow will focus on the massive weight loss patient, with occasional reference to the other groups when appropriate. As discussed previously, massive weight loss patients vary in their BMI level, fat deposition pattern and quality of skin–fat envelope, which influences their presentation. Even though massive weight loss patients, through lifestyle changes or bariatric surgery, will tend to eventually attain a stable BMI, they will still present to the plastic surgeon at different levels. It is important for the plastic surgeon to elucidate a timeline of weight stabilization, as some patients will have a false plateau after which they will resume weight loss. Therefore, it is wise to consult with the bariatric surgeon before considering body-contouring procedures. If the patient loses weight through bariatric surgery, the type of procedure chosen for the patient will likely affect their final BMI. Lap-Band® procedures tend to induce the least amount of weight loss, followed by gastric sleeve resection and gastric bypass, while duodenal switch patients tend to have the most dramatic fall in BMI.

The unique fat deposition pattern also plays an important role in determining the specific contour deformity in massive weight loss patients. A patient’s fat deposition as well as fat loss pattern is genetically regulated and is therefore quite individualistic. For example, men tend to deposit fat intraperitoneally and in the flank region (“love handles”), presenting with mostly central, or “apple shaped,” obesity. Women, on the other hand, tend to store fat in a “pear shaped pattern” in the extraperitoneal space, the lower abdomen, hips, and thighs. These patterns are just two of many potential fat deposition presentations. Weight loss varies similarly, with some patients losing fat in equal proportions throughout their body while others experience more of an asymmetric pattern with relatively more or less lost in different areas. While fat deposition undoubtedly plays a major role in determining overall body contour, it is important to recognize that the underlying musculoskeletal foundation also contributes to the overall appearance of the individual and therefore must be considered when establishing expectations of the final cosmetic result.

The characteristic of the skin–fat envelope is a third factor that affects the presentation of massive weight loss patients. The envelope is of major interest to the plastic surgeon and its intrinsic qualities are critical as it influences overall cosmetic outcome. The thickness of the post-weight loss subcutaneous fat tissue is important, as thin layers generally allow for greater pliability and movement of overlying skin, which is important in predicting the final cosmetic result. The authors introduced the concept of “translation of pull” as an excellent predictor of the final results. Prior to surgery, the lateral abdominal tissues are pinched in order to simulate the effect of the lateral abdominal resection on the distal thigh contour (see Fig. 32.1). Thicker nonpliable skin–fat envelopes, which are typical of patients with higher presenting BMIs, have little translation of pull in these areas, indicating that the potential overall improvement in body contour is limited. As a general guideline, the greater the drop in BMI for an individual patient, the greater the “translation of pull.”

FIG. 32.1 The “translation of pull” is shown by the red arrow, which demonstrates the extent of improvement away from the area of resection (simulated by the pinching of tissues).

Nearly all massive weight loss patients present with a “hanging panniculus,” the size and shape of which varies with the patient’s intrinsic fat deposition pattern. Additionally, almost every massive weight loss patient will present with “ptotic mons pubis,” most commonly exhibiting vertical excess and varying degrees of horizontal excess. The hanging skin/fat envelope often blunts the waistline as it drapes from the ribs to below the pelvic brim. Despite weight loss, there are often residual fat deposits in the hip and lower back region that add to this blunting. The anterior and lateral thighs are greatly affected by the weight gain/weight loss process and are therefore typically ptotic. The effect on the thighs is less dramatic in the “20–30 pound overweight group” and the “normal weight group,” but nevertheless it remains an area of concern for these patients.

Back rolls can be located in the lower, mid or upper back and are particularly displeasing to many patients. High back rolls, which are usually contiguous with breast rolls, are not affected by the belt lipectomy and require an upper body lift. Low back rolls are generally improved with the belt lipectomy. Few patients present with mid back, or “no man’s land,” rolls, which are difficult to treat with either an upper body lift or a belt lipectomy.

The psychiatric presentation of the patient requires special consideration. Although the plastic surgeon may be successful in reshaping the patient’s abnormal contour, psychological issues may persist. An obesity-associated depression may persist as well as estrangement from family and friends who might feel as if they have lost a fellow “sufferer.”

Preoperative Preparation

Patient Selection

Patients should be selected for their suitability to undergo circumferential excisional body contouring. Medical, as well as psychiatric, stability is of high importance. Conditions with a documented impact on wound healing such as diabetes, smoking, or connective tissue disorders must be approached with caution as they greatly increase the complication rate. Similarly, the BMI at presentation must be a factor in the plastic surgeon’s decision to operate, as complications are positively correlated with BMI.⁹ Reasonably, few plastic surgeons agree to operate on patients with a BMI higher than 32. Higher BMIs require surgeon acceptance of increased complication rates, with nearly 100% of patients experiencing some complication with a BMI above 35.

Low intraabdominal fat content and weight stability at the time of the surgery are critical to achieving the best overall outcome. Therefore, it may be necessary to delay body-contouring procedures until the patient can achieve weight stabilization without “heroic efforts,” such as unconventional diets and overly excessive exercise. A stable weight plateau is often difficult to identify with certainty and many patients will have “false plateaus” during which weight stabilization will be briefly apparent before the patient experiences further weight loss. If the patient had bariatric surgery, it may be beneficial to consult the bariatric surgeon to assist with delineation of true and false plateaus. Generally speaking, the length of weight stabilization is positively correlated with the patient’s chances for long-term success and most surgeons recognize 3 months as an acceptable minimum period of weight maintenance. The length of time necessary to reach maximum weight loss differs between the various bariatric surgical options. Empiric data suggest that an average of 2 years is necessary for Lap-Band® patients, 12–14 months for duodenal switch patients, and roughly 18 months for gastric sleeve resection and gastric bypass patients. These ranges are not absolute and can vary considerably between patients. Duodenal switch procedures are no longer routinely performed at most centers. Additionally, gastric sleeve resection is gaining considerable popularity over the past few years and is currently considered the treatment of choice by many bariatric surgeons.

Intraabdominal content is an important determinant of overall abdominal contour. Adequate flattening of the abdominal contour via muscle wall plication is heavily dependent on the amount of intraabdominal content. If excess exists, then the result of a circumferential procedure is similar to that attainable by panniculectomy.¹⁰ Therefore, in these situations it would be sensible to limit the procedure to a panniculectomy and avoid the increased risk that accompanies the circumferential excision.

Workup

Although many massive weight loss patients experience significant improvement in their medical problems following weight loss, they still require a thorough medical workup by the plastic surgeon during preoperative planning and evaluation. Patients should be carefully examined for cardiovascular disease, high blood pressure, diabetes, collagen vascular disease, bleeding disorders, smoking history, alcohol history, history of deep venous thrombosis/pulmonary embolus, previous abdominal scars, bariatric surgery, psychological problems, and nutritional habits. Bariatric surgery patients are typically treated with oral vitamins, so a history devoid of oral supplementation probably reflects poor follow up with resultant nutritional deficits. This should prompt the plastic surgeon to thoroughly evaluate their laboratory workup. Massive weight loss patients should additionally be questioned about signs and symptoms that may point to a history of anemia, hypocalcemia, iron deficiency, vitamin B deficiency, albumin/protein deficiency, hypomagnesemia, elevated liver function tests, and thiamine deficiency. It is also important to elucidate abnormalities in the patient’s bowel habits such as frequent diarrhea, which can put the patient at risk for nutritional deficiencies and wound contamination.

Many weight loss patients have life-long psychiatric problems, even after losing weight. The evaluation of the patient’s psychiatric stability is critically important as belt lipectomy surgery is a major life event and is associated with an arduous recovery. The authors have found it necessary to obtain psychiatric clearance for each belt lipectomy patient prior to consideration for surgical intervention. Additionally, mental health care providers must be alerted that maintenance may be required in the postoperative period.

An extensive history of the patient’s weight should be elicited from patients presenting for lower truncal contouring. First, it is important to ascertain the specific etiology of the patient’s lower trunk abnormalities. These can include aging, childbirth, sun-induced skin laxity, and massive weight loss. If the major cause is weight loss, then it is prudent to obtain a more specific history regarding the patient’s weight progression. This includes determining the patient’s weight at presentation, length of time at present weight, method of achieving weight loss and the patient’s historical maximum and minimum weights.

A careful physical exam should be followed by an evaluation specific to the body contouring procedure. It is important to note the degree of skin laxity, amount of subcutaneous fat tissue and resultant translation of pull in the various areas of interest. Waist definition, the presence of abdominal and/or back rolls, degree of rectus diastasis, presence of hernias, degree of buttock projection and ptosis, degree of anterior and lateral thigh lipodystrophy and ptosis, and the presence of any scars must be additionally noted. Any abdominal scar will alter the anatomy of the subcutaneous fat and the superficial fascial system, which ultimately influences the final contour result. Subcostal scars from gallbladder, gastric, liver, or pancreatic procedures can have a detrimental effect on the vascularity and the viability of the flaps. Additionally, vertical midline scars from previous surgeries may limit the inferior mobility of the abdominal flap. The amount of intraabdominal content must be ascertained as it considerably influences the final cosmetic result. Rather than performing the traditional “diver’s test,” as the surgeon would do in preparation for an abdominoplasty, the authors find it more effective to evaluate the patient’s abdominal contours while in a supine position. The diver’s test is less effective in a massive weight loss patient due to the thickness and laxity of the abdominal wall and subcutaneous fat. If the exam reveals a scaphoid abdominal contour and the abdominal wall falls below the ribcage, then rectus fascia plication during body contouring surgery will likely be effective in flattening the abdomen.¹¹ However, if the abdominal tissues do not fall below the ribcage, then it can be inferred that the intra-abdominal contents are considerable and will blunt the effect of plication in this area.

The altered absorption and dietary manipulation in the massive weight loss patient can create significant abnormalities that must be addressed prior to surgery.¹² Exhaustive lab work should be obtained early on in the care of the patient so that ample time exists for correction of any observed abnormalities. The labs should include: CBC, BUN, creatinine, electrolytes, glucose, urinalysis, LFT, iron, calcium, albumin, prealbumin, total protein, vitamin B, magnesium, and thiamine. Chest X-ray and EKG should be obtained as indicated on an individualized basis.

It is important to elicit and address the patient’s priorities. Massive weight loss patients often present with multiple concurrent deformities in areas such as the arms, breasts, upper back rolls, thighs, face, and lower trunk. The lower trunk and hanging panniculus is usually the chief complaint; however, many patients are fixated on improving just a few areas with less concern over others. In some situations, it may be necessary to plan and stage multiple procedures in order to achieve the maximal desired result and this should be communicated and discussed with the patient. Typically, the lower trunk deformity is addressed first, followed by arms, the thoracic region, and then the thighs.

Facial rejuvenation is also a frequent concern for patients. The authors often address this after the body contouring procedures are completed. In addition to a discussion regarding the risks and complications associated with each procedure, it should be made clear that the agreed plan might require modification as the body’s contour changes with each stage. For all major complications, a full disclosure of its occurrence, prevention, and treatment should be provided, as proper consultation should result in a well-informed patient who understands each stage of the contouring process.

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