Introduction

The burgeoning field of bariatric surgery has introduced a new subset of patients to the plastic surgeon. Patients present after massive weight loss with unique anatomical deformities that are particular to each area of the body. Weight loss surgery results in drastic changes in patients’ physiology and blood supply that must be taken into account before successful body contouring surgery can be performed. Weight loss surgery itself is often effective in correcting obesity as well as improving many comorbid conditions, including hypertension and diabetes. On the other hand, the surgery results in a multiplicity of both esthetic and functional problems. Overhanging folds of skin and areas of skin overlap and friction create issues with hygiene, infection, and cosmesis. The folds of skin can be deforming and of as great concern to patients and have as much impact on self-image as had their former obesity. Alterations in anatomy and physiology include increased blood supply that was previously required to support the patient’s excess fat and skin, in addition to issues with macronutrient and micronutrient absorption. While the vascularity of the patient’s tissue may cause issues with hemostasis during and after surgery, it alternatively can be used to support much larger and longer soft tissue flaps than those possible in the nonbariatric population.

Anatomic Considerations

We have grouped the body into six unique anatomic areas that require surgical attention.

Mid-body Excision

The mid-body is usually addressed with circumferential abdominoplasty. In contrast to the nonbariatric patient, these patients typically present with skin excess that extends onto the hips and lateral thighs and posteriorly to the back and buttocks. In patients with limited posterior excess, a near-circumferential abdominoplasty that extends to the posterior axillary lines may be indicated. In the era before laparoscopic bariatric surgery, up to 20% of patients presented with ventral hernias after open bypass surgery. These abdominal wall defects are frequently addressed at the time of body sculpting.¹

Surgery of the Breast

We have described a variety of deformities of the female breast as well as a classification of these deformities (Table 53.1).²

TABLE 53.1 Classification of the Deformities of the Female Breast

The anatomic innervation to the breast has been described in multiple articles, dating back to Sir Astley Cooper’s description in 1840.³ Craig and Sykes identified the role of the third, fourth, and fifth anterior cutaneous nerves, and the fourth and fifth lateral cutaneous nerves, in supplying sensation to the nipple–areola complex.⁴ The importance of the lateral cutaneous branch of the fourth intercostal nerve as innervation to the nipple–areola complex was documented by Courtiss and Goldwyn.⁵ In light of these anatomic considerations, we generally employ a superolateral dermoglandular pedicle in our reduction mammaplasty and mastopexy cases.

In the female patient, the skin envelope, degree of nipple ptosis, and deficiency in volume must all be considered in selecting the appropriate technique. In patients with excess residual volume as well as ptosis, a standard reduction mammaplasty may be effective. Many patients, however, have a deficiency in volume, particular in superior pole fullness, combined with excess ptotic skin. In these patients, mastopexy alone may be indicated, or mastopexy with “autologous augmentation” using a dermoglandular flap in continuity with a pedicle that is rotated into the superior pole of the breast, or a mastopexy combined with augmentation using a mammary prosthesis. The male breast generally requires a reduction of excess skin, typically with an inferior pedicle reduction.