Patients with Massive Weight Loss

Patients with massive weight loss have a wide range of body contours and sizes. Multiple factors contribute to this diversity: the BMI at presentation, the quality of the skin/fat envelope, and the fat deposition pattern. BMI at presentation ranges on a continuum, placing individuals in categories from still significantly obese to those near ideal weight. Whether from bariatric surgery or lifestyle changes, weight loss stabilizes or plateaus at different levels in different individuals and this plateau is not easily altered. The second factor affecting diversity in presentation is the quality of the skin/fat envelope, which includes its thickness and elasticity. An important determinant of skin/fat envelope quality is its translation of pull. Translation of pull is assessed before surgery by pinching the intended area of resection and examining the mobility of surrounding tissues. The third major factor, the fat deposition pattern, describes the genetically controlled amount and location of fat deposition during weight gain and fat loss during weight loss.

Although variable in presentation, patients with massive weight loss share many common body features, particularly an inverted-cone appearance to their inferior trunk with a narrow ribcage and wide pelvic rim. Patients with massive weight loss often lack lateral waist definition because of excess tissue draping, concealing the underlying musculoskeletal anatomy. Many patients have large and distinct hip rolls.

Patients with massive weight loss have pendulous anterior panniculi, typically with 1 to 3 soft tissue rolls. Almost all patients with massive weight loss present with some degree of abdominal wall laxity, caused by rectus muscle diastasis. Some also present with hernias, especially if they have had open bariatric surgery procedures. The mons pubis most often presents with ptosis and lipodystrophy, as well as vertical and horizontal excess. The opening of the vulva in women and the penis base in men are directed downward, rather than the normal anterior inclination.

The buttocks may be overprojected in patients with high BMI, or underprojected in patients with low BMI. Almost all patients lack definition of the buttocks because of a lack of a distinct transition from the lower back to the buttocks. The superior extent of the central buttocks crease may be low and may present with loss of soft tissue overlying the coccyx. The infrabuttocks crease varies greatly with BMI. Patients with high BMI often have an abnormal, horizontally oriented infrabuttocks crease, whereas patients with low BMI may present with crease redundancy.

Back rolls are variable in their presentation and depend on the patient’s fat deposition pattern. Some patients present with no back rolls, whereas others present with multiple rolls.

The overall goal of belt lipectomy is to return the patient’s inferior truncal contour to within normal range of the general population. Specific goals for the abdomen include elimination of hanging tissue and rolls, creation of a flat contour, restoration of an anterior-facing vulva in women, and restoration of an anterior penile takeoff point in men. Goals for the lateral aspect of the lower trunk include an hourglass figure with narrowing at the waist for women. Goals for the posterior aspect of the lower trunk include reduction or elimination of lower back rolls if present and creation of demarcation between the lower back and the buttocks. If the buttocks are overprojected, this projection should be reduced. If the buttocks are underprojected, definition should be improved and, if needed, projection should be improved. If inferiorly displaced, the superior extent of the buttocks crease should be elevated. Also, the infrabuttocks crease ideally should be returned to a normal semicircular appearance.

Patients with Massive Weight Loss Status Post Anterior-only Resection Surgery

An enlarging subgroup of patients with massive weight loss includes individuals who have previously undergone anterior truncal resections but are disappointed with their lateral and posterior contours, presenting in the form of dog ears and a lack of waist definition. In some of these patients even the anterior resection is inadequate, as shown in Fig. 1 . The goals of this subgroup of patients are similar to those of patients with massive weight loss who have not undergone prior resection.

A 57-year-old woman presents status post an anterior-only procedure; in this case an abdominoplasty. The patient was unhappy with the persistent anterior excess, the lateral dog ears, the lack of waist definition, and the lack of definition of the buttocks.

History

Belt lipectomy should not be performed on patients with significant uncontrolled medical problems or psychiatric disorders. Weight history, exercise routine, and nutritional habits should be specifically documented. Patients must achieve stable weight loss, preferably for a 1-year period, but most experienced postbariatric surgeons are willing to operate if patients have stabilized their weight loss for at least 3 months. Patients with ongoing weight fluctuation or nonsustainable diet efforts are not ideal operative candidates.

Cardiac, pulmonary, and vascular medical comorbidities should be considered when evaluating a patient’s candidacy for belt lipectomy. The possible fluid shifts and changes in intravascular volume during and after a belt lipectomy may place unacceptable stress on a poorly functioning heart. Patients with significant underlying lung disease may not tolerate abdominal wall tightening with rectus fascia plication and may develop pulmonary compromise. With the inherent compromise of blood supply of undermined abdominal tissues during the procedure, conditions associated with decreased vascularity, such as smoking, should also be avoided in most instances.

The thorough medical history taken on all candidates for belt lipectomy should include psychiatric disorders and treatment history. A preoperative psychiatric clearance should be considered given the emotional, physical, and psychological stress involved in recovering from a belt lipectomy. All patients, not only those with psychiatric diagnoses, should be counseled extensively before surgery given the long recovery and possibility of complications.

Physical Examination

The patient’s BMI is determined to help predict results and potential complications. The patient’s overall body contour is examined circumferentially, with close attention to the inferior truncal subunit, superior truncal subunit, thighs, and upper arms. The surgeon should search thoroughly for hernias, because incisional, ventral, and umbilical hernias are common in patients with massive weight loss who have undergone open bariatric surgery procedures.

The patient’s fat distribution, subcutaneous fat thickness, skin mobility, and skin quality should be examined. In general, skin with a thinner subcutaneous fat layer is more likely to be mobile when resection is attempted.

During abdominal examination, the extent of abdominal wall laxity should be determined and excessive intra-abdominal content should be assessed. Excessive intra-abdominal content is a contraindication to both abdominoplasty and belt lipectomy. The authors find that the best way to determine the extent of intra-abdominal content is to note the patient’s abdominal contour in the supine position; if the abdomen is scaphoid, intra-abdominal content is not excessive, which should lead to successful abdominal wall plication. In contrast, if the abdomen in the supine position is convex and protrudes above the ribcage, intra-abdominal content is excessive and not likely to allow a successful abdominal wall plication.

Preoperative evaluation of the mons pubis is important because it is usually one of the patient’s main complaints. If the mons pubis is extremely ptotic and redundant, normal contour should neither be expected nor promised. A compromise should be accepted rather than risking over-resection, which can potentially lead to permanent lymphedema of the mons pubis. After complete healing from belt lipectomy, a separate monsplasty can be considered and discussed with the patient.

Testing and Imaging

Because patients with a history of bariatric surgery have a higher likelihood of metabolic abnormalities, the following laboratory tests should be obtained before surgery: complete blood cell count, blood urea nitrogen, creatinine, electrolytes, glucose, urinalysis, liver function, iron, calcium, albumin, prealbumin, total protein, magnesium, and thiamine. Chest radiographs and electrocardiograms should be obtained if indicated.

Markings

The markings are the road map of the surgery and should be tailored for each patient’s anatomy and deformity to attain optimal results. The authors prefer markings to be performed in clinic, 1 to 2 days before surgery to allow for accurate photographic documentation and analysis of the markings, which often require adjustments in order to attain the best possible results.

First, the patient’s anterior midline is marked. Next, the horizontal mons pubis mark is made with the patient supine and traction placed on the mons pubis to create a more pleasing appearance. With the tissues under tension, the horizontal mark is made 1 to 2 cm superior to the pubic bone extending to the lateral edges of the mons, which results in excision of hair-bearing skin of varying degrees in almost all patients with massive weight loss.

With the patient in the supine position and slightly bent at the waist, traction is placed on the abdominal pannus in a superior medial direction. Next, a line is drawn from the lateral aspect of the mons pubis mark toward the anterior superior iliac spine (ASIS). The angulation of this mark varies depending on the surgeon’s preference. Some surgeons prefer the line to end up below, at, or above the ASIS. Regardless of preference, this mark should be made while elevating the abdominal tissue superomedially to simulate the balance of forces between the inguinal zone of adherence and the pull from abdominal closure after resection, thus allowing better prediction of final scar position.

The abdominal contour typically shows greater deformity and is more visible to the patient, so it should have a higher priority than the posterior contour. The central aspect of the anterior mark is made based on pinching the tissues from the proposed superior mark to the inferior mark, similar to that for a traditional abdominoplasty. However, in most patients with massive weight loss the vertical excess is more extensive and the superior mark is often much higher than the traditional abdominoplasty just above the umbilicus. The lateral extent of the superior abdominal mark, which matches the inferior mark that spans from the lateral edges of the pubic mark to the ASIS, should be fairly flat if the patient is marked in the supine position. Angulating this mark aggressively may result in central flap necrosis caused by compromise of the abdominal flap’s intercostal, subcostal, and lumbar vessels.

The markings for posterior resection are made with the patient standing. The back midline is marked. In general, the posterior back excision is more aggressive laterally than centrally because the greatest decent of tissues occurs at the level of posterior axillary line. The resection is thus designed to reverse this deformity. This type of excision allows for greater elevation of the lateral buttocks and lateral thigh regions, which improves lateral contour and the shape of the infrabuttocks crease.

The midline inferior extent of excision is marked first, a little above the midline buttocks crease. Next, the superior extent of the midline back excision is marked using the pinch technique with the patient flexed at the waist, which simulates the patient’s position at the conclusion of anterior resection and is important in preventing posterior dehiscence. Next the inferior mark from the midline of the back to the anterior marks is made in a lazy S to reverse the deformity as described earlier. The superior mark, from the midline of the back to the anterior mark, is made by pinching the tissues using the inferior mark as the starting point.

Next, a series of vertical marks are placed to aid with tissue alignment at closure. If anterior and lateral thigh liposuction are needed, those areas are marked. In addition, the patient is placed in all operative positions (supine and both lateral decubitus positions) to assess symmetry and placement of markings.

The inferior marks control scar position anteriorly, which means that the final scar will be considerably closer to the inferior marks because of the zone of adherence located in the inguinal region. In contrast, posteriorly, the superior marks control final scar position. Lower back tissues have stronger zones of adherence and are restricted in their movement, whereas the tissues from the buttocks and lateral thighs are considerably more mobile.