A 2-position circumferential approach for body contouring of the lower trunk is presented. Mostly indicated in patients after massive weight loss, this approach allows the simultaneous skin resection and reshaping in the abdominal, flank, lateral thigh, back, and gluteal region in the same operation, with only one position change during surgery. Reconstruction of the abdominal wall and gluteal restoration allow volume and shape enhancement with autologous tissue transpositioning. This article explains the required preconditions, assessment of gluteal deformities, and perioperative management of this procedure, and presents common complications.
Key points
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Lower body lift (circumferential lower truncal dermatolipectomy, CLTD): Modification of the lower body lift procedure as an alternative to the belt lipectomy.
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Perioperative optimization: Standardized perioperative requirements and settings are highlighted and described in detail.
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Technical details: The correct choice of technique is the key to a higher patient satisfaction. Massive-weight-loss patients are far more tolerant of longer scars, allowing a generally high acceptance of, for example, the fleur-de-lis excision pattern.
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Gluteal enhancement: The loss of gluteal volume is a frequent consequence of weight loss. For specific cases the transposition-gluteoplasty is incorporated, which allows a gluteal reshaping with autologous tissue.
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Procedure combination: The combination of liposuction and lower body lift can be performed for additional contouring of the abdomen, the flank, and gluteal region. For selected cases the harvested fat tissue may be transferred for additional improvement of gluteal volume and shape.
Introduction
The overweight and massively obese population is growing continuously every year. With the success and increasing number of bariatric procedures, the authors have registered a yearly increase of body contouring procedures. In addition, owing to the rising experience in this field of plastic surgery, these procedures have wider ranges of indications, including patients after massive weight loss, patients with primarily cosmetic indications (aging process), or patients who seek correction of contour deformities after previous liposuction. Coincidentally, the requirements and demands for such operations are continually increasing. In addition to the typical problem areas such as the abdomen, the mons pubis, and hip region, patients frequently present with growing attention to the aesthetic restoration of the gluteal area.
The variety of gluteal deformities after weight loss results in a wide range of patient complaints and discomfort. Some patients complain of an enlarged buttock, some of a deficient gluteal volume with gluteal flattening (platypygia), and yet others suffer from cellulite or a lengthening of the infragluteal fold. However, patients primarily seek an enhancement of the gluteal shape and projection.
A well-shaped buttock is characterized by several factors: it is more rounded than angular, the intergluteal fold is short rather than long, and the feminine gluteal cleavage has a superior and inferior buttock separation. Dividing the buttocks into an upper, middle, and lower section, the ideal maximum projection lies between the upper and middle third. The infragluteal fold should run in a round rather than horizontal curve with a minimal crease, ideally without any droop. The side view should illustrate an S-shaped contour in relation to the back and thigh, as a smooth inward sweep of the inferior back and waist area. To meet these ideal characteristics, several techniques are available to plastic surgeons. In the late 1960s surgeons performed gluteal augmentation with existing breast implants. Today various gluteal implants are accessible, which can be implanted epifascially, subfascially, or submuscularly. Nowadays gluteal contouring is most frequently performed through liposuction, particularly by sculpturing the adjoining regions such as the hips, flanks, and saddlebag deformities, achieving excellent results without any direct buttock approach.
During the past decade, buttock augmentation by autologous fat grafting has gained wider acceptance and success. Many different techniques such as macrografting or micrografting are available for contour improvement of the gluteal region, solely or in combination with liposculpturing.
These techniques, however, are not suitable for patients after massive weight loss. These patients suffer from atonic skin quality with a high degree of laxity and, consequently, with the indisputable requirement of tissue resection. These severe deformities have caused a continuous development of various lifting procedures, such as the pioneering circumferential lower body lift described by Ted Lockwood in 1993. Further developments of these procedures in combination with autologous tissue augmentation, such as the deepithelialized gluteal flaps for buttock reshaping, enable an improvement in the postoperative results. In 2005, Sozer and colleagues reported of a series of 20 deepithelialized turnover dermal fat flaps for buttock augmentation in bariatric and aesthetic patients undergoing lower body lifts. After more than 200 cases, the technique has evolved to include a split portion of the gluteus maximus muscle, resulting in a better blood supply to the flap, more caudal reach, and a dramatic decrease in fatty necrosis.
In this context, the authors have established a technique of gluteal fat tissue transpositioning (transposition-gluteoplasty) during modification of the lower body lift (circumferential lower trunk dermatolipectomy [CLTD]), which has been shown to be a reliable alternative for enhancement of the gluteal projection and shape.
Introduction
The overweight and massively obese population is growing continuously every year. With the success and increasing number of bariatric procedures, the authors have registered a yearly increase of body contouring procedures. In addition, owing to the rising experience in this field of plastic surgery, these procedures have wider ranges of indications, including patients after massive weight loss, patients with primarily cosmetic indications (aging process), or patients who seek correction of contour deformities after previous liposuction. Coincidentally, the requirements and demands for such operations are continually increasing. In addition to the typical problem areas such as the abdomen, the mons pubis, and hip region, patients frequently present with growing attention to the aesthetic restoration of the gluteal area.
The variety of gluteal deformities after weight loss results in a wide range of patient complaints and discomfort. Some patients complain of an enlarged buttock, some of a deficient gluteal volume with gluteal flattening (platypygia), and yet others suffer from cellulite or a lengthening of the infragluteal fold. However, patients primarily seek an enhancement of the gluteal shape and projection.
A well-shaped buttock is characterized by several factors: it is more rounded than angular, the intergluteal fold is short rather than long, and the feminine gluteal cleavage has a superior and inferior buttock separation. Dividing the buttocks into an upper, middle, and lower section, the ideal maximum projection lies between the upper and middle third. The infragluteal fold should run in a round rather than horizontal curve with a minimal crease, ideally without any droop. The side view should illustrate an S-shaped contour in relation to the back and thigh, as a smooth inward sweep of the inferior back and waist area. To meet these ideal characteristics, several techniques are available to plastic surgeons. In the late 1960s surgeons performed gluteal augmentation with existing breast implants. Today various gluteal implants are accessible, which can be implanted epifascially, subfascially, or submuscularly. Nowadays gluteal contouring is most frequently performed through liposuction, particularly by sculpturing the adjoining regions such as the hips, flanks, and saddlebag deformities, achieving excellent results without any direct buttock approach.
During the past decade, buttock augmentation by autologous fat grafting has gained wider acceptance and success. Many different techniques such as macrografting or micrografting are available for contour improvement of the gluteal region, solely or in combination with liposculpturing.
These techniques, however, are not suitable for patients after massive weight loss. These patients suffer from atonic skin quality with a high degree of laxity and, consequently, with the indisputable requirement of tissue resection. These severe deformities have caused a continuous development of various lifting procedures, such as the pioneering circumferential lower body lift described by Ted Lockwood in 1993. Further developments of these procedures in combination with autologous tissue augmentation, such as the deepithelialized gluteal flaps for buttock reshaping, enable an improvement in the postoperative results. In 2005, Sozer and colleagues reported of a series of 20 deepithelialized turnover dermal fat flaps for buttock augmentation in bariatric and aesthetic patients undergoing lower body lifts. After more than 200 cases, the technique has evolved to include a split portion of the gluteus maximus muscle, resulting in a better blood supply to the flap, more caudal reach, and a dramatic decrease in fatty necrosis.
In this context, the authors have established a technique of gluteal fat tissue transpositioning (transposition-gluteoplasty) during modification of the lower body lift (circumferential lower trunk dermatolipectomy [CLTD]), which has been shown to be a reliable alternative for enhancement of the gluteal projection and shape.
Patient selection and screening
A precise physical examination and assessment of patients’ medical history during the first consultation is mandatory for every patient. The authors recommend a repeat of evaluation before surgery, if it is performed after a delay since the first consultation. The assessment of medical history includes: the current weight; initial and current body mass index or, in future, the A body mass index; the weight history with weight fluctuations and constancy periods; the frequency of exercises; former bariatric procedures; nutritional disorders; medication; the number of pregnancies and children; history of cesarean section, abdominal surgeries, and abdominal hernias; gastrointestinal, cardiac, and pulmonary history; and smoking history. Previous liposuction in the abdominal area has to be asked after from patients, because they might conceal this before treatment. Patients must present a stable weight for at least 6 to 12 months preoperatively; required weight loss should be completed before the surgery.
The clinical examination is the essential part of every medical history assessment. The examination of the lower trunk should include an accurate palpation of the abdominal, lateral thigh, and gluteal adipose tissue in patients while in upright, prone, supine, and lateral position. This approach enables the examiner to assess the tissue conditions in regard of volume and mobility by pinching and metrically measuring. It is crucial to consider the existent adipose tissue at the lateral and posterior lower gluteal and proximal thigh region. Unfortunately, untreated distinct masses of local adipose tissue in these regions will assuredly limit the gluteal improvement, because downward tractions will consequently displace gluteal tissue in the caudal direction. Skin quality with the presence of striae must be evaluated, explaining to the patient that supraumbilical striae will not be resected in abdominoplasty procedures (except for fleur-de-lis procedures). Furthermore, any existing lower and upper abdominal pannus has to be assessed and measured, documenting any existing eczema or consequent hyperpigmentation. Any preexisting scar (subcostal, midline, horizontal) in the abdominal and gluteal area must be documented in writing and photographically, as they can impair the blood supply of the tissue flap. The status of the abdominal muscles must be assessed and any existing rectus diastasis, incisional, epigastric, or umbilical hernia excluded, in specific cases, by supportive computed tomography or magnetic resonance imaging. In cases of elevated intra-abdominal pressure, the abdominal wall elevates above the costal margin and the level of the iliac crest in supine position. Abdominoplasty procedures with fascial tightening should be performed cautiously in such cases.
The authors highly recommend preparing a photographic documentation of preoperative and postoperative conditions, consisting of different views (anterior, oblique, lateral, and posterior). Postoperative photo documentation can be made at 3, 9, and 12 months. In individual cases it is recommended that the clinician add photographic documentation of various arm and thigh positions, tissue characteristics with relaxed and contracted muscles, the patient in sitting position to demonstrate redundant upper abdominal laxity and tissue excess, and views of the patient holding up and pinching excess tissue in the specific region. For a classification of the different deformities, the Pittsburgh Rating Scale is helpful for patient demonstration and selection of the adequate operative approach. However, the authors have experienced wider indications for the combined technique of liposuction and excisional procedures in all body regions.
Detailed information should be given to patients regarding the operative procedure, alternative techniques, the general and operation-related risks and benefits is an essential part of preoperative documentation. Besides standard and individualized consent forms, which have to be reviewed and signed by the patient at the earliest opportunity and at latest 24 hours before the operation, the authors recommend an audio-visual demonstration of intraoperative details, preoperative and postoperative results, and possible complications. Patients should be informed about their postoperative care including their expected level of activity; they have to understand the limitations of the surgical result in cases of existing variables of bone structure, fat distribution, and any existing scars.
Recent studies evaluated differences in collagen and elastin contents in the abdominal skin of patients without weight loss in a comparison with those with bariatric weight loss, showing impairment in skin quality in the bariatric group. This fact should be made clear to every patient to limit their postoperative expectations. Patients with multiple striae must be informed that secondary relaxation in their specific case may require a repetitive skin-tightening procedure.
During clinical examination of the abdominal region, the following parameters should be acquired:
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Abdominal tissue excess
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Abdominal skin quality (striae?)
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Umbilical stalk deformity
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Number of skin folds and their continuity to the flanks
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Skin quality
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Adipose tissue volume and mobility
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Abdominal muscle tone
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Mons pubis region
During clinical examination of the gluteal region the following parameters should be acquired:
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Gluteal height
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Gluteal width
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Maximum height of projection
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Round shape versus rectangular shape
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Skin quality
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Adipose tissue volume and mobility
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Gluteal muscle tone
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Back folds
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Vertebral status (eg, scoliosis)
In their massive-weight-loss patient group the authors have established a classification for surgical planning of the gluteal region, which can be simply divided into 3 groups ( Fig. 1 ):
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Large buttocks with excess amount of gluteal adipose tissue
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Normal-sized buttocks with ptosis and skin redundancy
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Flattened, hypoplastic buttocks with ptosis and skin redundancy
The adipose tissue in the upper third of the gluteal region has an excess lobular and lamellar structure with a ratio of 1:2 in females and 1:1 in males, whereas the lower third presents a 1:1 ratio in both sexes ( Fig. 2 ).
Patients who belong to group 1 may present with residual overweight. To reduce gluteal adipose tissue, preparation is performed below the superficial fascia to eliminate larger amounts of lobular and lamellar adipose tissue. In patients with a group 2 deformity, an epifascial preparation is maintained with preservation of the entire superficial fascia. In this regard the authors refrain from an extensive adipose tissue resection, maintaining the lobular adipose tissue. In cases of deflated and flattened buttocks of group 3 deformities, the authors stringently refrain from any adipose tissue reduction and perform preparation at a superficial subcutaneous level. In contrast to the technique of subfascial dissection described by Lockwood, the authors generally remain above the superficial fascia, which is a constant and strong structure, separating the lamellar and lobular adipose tissue. The gluteal superficial fascia provides comparable features such as the fascial superficial muscular aponeurotic syndrome (SMAS) during facelift surgery, for example, the reduction of tension on the skin level and the opportunity to provide a multivectoral remodeling on different tissue levels.
Treatment goals and planned outcomes
Circumferential tightening procedures have the goal of restoring and improving the body shape, including the abdominal, flank, and gluteal regions. The abdominal region can be reshaped through preparation steps derived from a standard abdominoplasty, a lipoabdominoplasty, or fleur-de-lis abdominoplasty. The main goals are maximal skin and fat tissue reduction with contouring of the abdominal wall. The flanks are mainly restored by vertical tissue resection; additionally in fleur-de-lis procedures the waist circumference may be reduced by horizontal tissue resection. In the gluteal region there are different approaches available, depending on the patient’s preoperative conditions. The available options are gluteal tissue reduction by direct excision or gluteal autoaugmentation in cases of volume and shape deficiency. In both cases, the goal of the body lift procedure is a restoration of gluteal volume and gluteal reshaping in relation to the surrounding regions ( Fig. 3 ).
