Regardless of the etiology of the deformity, body contouring surgery focuses on the removal of excess tissue followed by suspension and reshaping of the remaining skin. The recontouring has become more sophisticated through new patterns of excision, concomitant liposuction, lipoaugmentation, selective retention of tissues, and shaping with neighboring flaps. The sheer magnitude of deformity after massive weight loss imposed a global approach with multiple procedures. The severity of the deformities leads to the acceptance of extensive scars in exchange for satisfying contours. Nevertheless, techniques for minimizing scars are introduced throughout this compendium. A coordinated, well-planned bold approach best preserves adequate excess tissue for recycling. The outcome is focused more on gender-specific features than how much tissue was removed or the length of the scars. The background and temperament of the broadly trained plastic surgeon makes him or her the best-prepared specialist to take on these challenges. The technical complexity, requisite artistry and patient interaction, and high rate of complications thwart encroachment from other specialties.

Over a decade ago, total body lift (TBL) surgery was conceived as the coordinated artistic surgical effort to correct complex and severe weight loss deformity of the entire torso in as few stages as safely possible. The initial experience was presented and published in multiple scientific forums (Hurwitz 2004), followed by an analysis of the first 75 cases (Hurwitz et al. 2008). There were 59 single-staged, 15 two-staged, and 1 three-staged TBL, having 605 separate procedures, for an average of 8.2 per patient. Patient satisfaction and analysis of photographic results demonstrated excellent reduction in deformity and comparable rates of complications regardless of staging. While 66 % minor complication rate per patient encounter was concerning, it distilled down to a reasonable 11 % per procedure. Since then, improvement in technique and technology has reduced the rate of complications.

While the underlying concepts of TBL surgery are unchanged, the reality is that the transformations are mostly performed today in two to three integrated stages. With the abdominoplasty being the keystone procedure, the lower body, buttocks, and thighs are preferably corrected first. Although, there are many exceptions such as when the thighs are too heavy and need preliminary liposuction. At a second stage, the upper body, breast, and arms are approached along with any revisions needed from the first stage. The staging may be reversed due to patient preference or an oversized lower body. Body contouring surgery in the male, especially in the chest and waist, has unique challenges that relate to gender-specific musculoskeletal shape that is not well appreciated by female-centric plastic surgeons. After a dozen years experience, the single-stage TBL is limited for the treatment of ideal presentations by an organized team. As predicted in 2004, the male torso transformation appears to be best treated through a single-stage TBL. The occasional facial rejuvenation is often last, but may be done at any time. The extent of skin deformity treated by facelifts in the MWL patient presents special surgical challenges, which justifies its inclusion in this body contouring text. At the core is adroit handling of fat and a reproducibly secure SMAS and platysma suspension system with barbed sutures.

Comprehensive body contouring surgery reflects an emphasis on accentuating gender. Chapter 2 presents relevant gender-specific aesthetics and perioperative care. Chapter 3 details surgical principles and technique. Interrelated operations demand complex aesthetic analysis, fine technical skills, organized efficient teamwork, and attentive perioperative care. Chapter 4 is TBL surgery to shape a female. After a detailed presentation of the lower body lift, the two major variations of the upper body lift are discussed. Several deviations on the common theme are presented. Then there are Mommy Makeover cases. Chapter 5 is treatment of the muscular male. First, there are cases on gynecomastia, and then skin tightening for the entire torso is presented. Chapter 6 details the efficient and effective facelift surgery after MWL in the presentation of both full and deflated faces.