Next, the anterior markings are performed based on the frontal red line previously marked (Fig. 38.2). We routinely instruct the patient to firmly and symmetrically pull up the entire abdominal tissue, while we initially mark the midline, a minimal distance of 6 cm from the vulvar commissure (or base of the penis), and next the lower incision line from the midline point laterally, where they are connected to the lower dorsal line. Often the resulting scar line is placed too far cranially due to a lower incision line marked in the abdominal skinfold. Consequently, the mons pubis, which is often sagged and slackened, is not lifted. In more severe cases the lower incision line can be extended caudally in an elliptical or triangle shape into the mons pubis region for an effective local skin tightening. Nevertheless, it is essential to leave a distance of 6 cm to the upper vulvar commissure (or base of the penis) (Fig. 38.3). The upper incision line is then continued from the lateral aspect of the dorsal upper line medially to the height of the umbilicus. In cases of distinct tissue surplus in the upper abdomen we routinely inform the patient about the option of a fleur-de-lis incision pattern during the first consultation. If the patient agrees to this additional scar line, we draw the midline cranially to the xiphoid. The vertical incision line is then evaluated by pinching and marked in an elliptical shape, starting two finger breadths below the xiphoid. This is mandatory to avoid a further cranial scar ending. Also, it is advisable to mark the vertical incision lines in standing position, since the tissue tends to drop laterally and backwards in supine position. The upper horizontal incision line is then marked approximately one finger breadth below the height of the umbilicus.

FIG. 38.2 Anatomical landmarks.

Normal abdominal anatomic proportions. The approximate measurements for an average female abdomen are listed. These vary according to individual height and bone structure. The umbilicus is located in line with the most superior point of the iliac crest in 99% of patients. (A) Distance between top of mons and anterior vulvar commissure. Average height is 5–7 cm. (B) Distance between umbilicus and top of mons. Average height is 11–13 cm. (C) = (A + B) Distance between umbilicus and top of anterior and vulvar commissure (C = D)

(from Richter DF, Stoff A. Abdominoplasty procedures. In: Plastic Surgery 3rd edition (Neligan P ed.) Elsevier, Saunders, St. Louis, 2012, with permission from Elsevier).

FIG. 38.3 Anterior (left) and dorsal (right) vectors for medial tissue advancement.

Importantly, dorsal vector lines are marked to allow a mediocranial rotation of the gluteal and thigh region and a consequent sculpturing of the waist (Figs 38.3 and 38.4). A final check of the markings should be performed in the patient’s supine and prone positions.

FIG. 38.4 Intraoperative marking of vectors and intraoperative positioning in prone position (with permission from Elsevier).⁹

For additional liposculpturing of the flank, back or lateral thigh regions, the markings are made in the typical manner. We advise refraining from excessive liposuction in the undermined gluteal area, since any additional impairment of microcirculation in this area may result in skin necrosis. Patients after massive weight loss frequently present with significant adipose tissue redundancy in the area of the circumferential thighs, we routinely perform widespread tissue reduction by vibration-assisted liposuction in this area during the initial circumferential lower truncal dermatolipectomy.⁹

General Considerations

We advise every patient to perform an extensive body scrub with antiseptic soap the night and morning before surgery.

Massive weight loss patients with bariatric therapy may have an increased risk of aspiration, so an experienced anesthesia team should be involved. Hypothermia may occur in these operations because of extended operation times and large wound areas, which may lead to shivering, crouching, and inappropriate cramping postoperatively causing increased wound tension. Preheated infusions, heated blankets and preheated beds can optimize patients’ comfort and safety.

Accurate patient positioning is essential for avoidance of scar asymmetry and impairment of tissue perfusion in the areas of maximal pressure. The entire team, including anesthesiologists, surgical nurses and surgeons must constantly and conscientiously check the patient’s positioning. Pressure necrosis can arise around the periorbital regions and at the breasts, particularly in the prone position.¹⁰

We routinely install a urinary catheter and wrap the lower legs with compression bandages for deep vein thrombosis (DVT) prevention. Further, we administer a single-shot antibiotic to every patient. In specific cases the postoperative continuation of antibiotic prophylaxis may be considered.¹¹

Surgical Technique

We routinely perform the operation with two teams of one surgeon and one medical assistant. The leading surgeon performs all the markings and is responsible for the entire performance. Preparation, dissection, and wound closure are performed simultaneously on each side of the patient’s body. After endotracheal intubation and the installation of a urinary catheter the patient is turned to the prone position on a padded operating table. Next, the patient is scrubbed and covered with sterile drapes, followed by a wide-area infiltration of tumescent solution (1 liter of Ringer solution including 1 ampule of Suprarenin) between the superior and inferior line, which is performed until a satisfactory tissue turgor is achieved. In cases of additional flank, back, or thigh contouring, additional tumescent infiltration is performed.

Dorsal Preparation

The initial skin incision (utilizing the cold blade or alternatively the Colorado® Microdissection needle) is made along the superior marking line and is carried out down to the level of the underlying superficial fascia, which is exposed using the Colorado® Microdissection needle or alternatively the Harmonic™ ultrasound scalpel, both of which easily separate the superficial lamellar from the subfascial lobular fat. Next, the dissection is continued inferiorly just above the robust white superficial fascia. The dissection level above the superficial fascia differs considerably from the original technique by Lockwood, who dissected subfascially. The preservation of fascia to the deep gluteal fat as the “gluteal SMAS” is conceptionally similar to the “facial SMAS” used in face-lifts. The superficial fascia is dissected at the height of the inferior resection line, before flap mobilization is continued caudally. Further, this allows a reconstruction of superficial fascia upon wound closure. Lateral gluteal adhesions are released caudally up to the gluteal fold height, before dissection is continued to the lateral thigh, where the preparation level is above the aponeurosis of the tensor fascia lata muscle. Further distal mobilization of the lateral thigh can be carried out bluntly using the Lockwood underminer. With completion of dissection, the waist and gluteal fatty tissue is widely mobilized and covered with robust superficial fascia. This is particularly suited for autologous gluteal augmentations, since patients after massive weight loss frequently suffer from flattened buttocks. For this purpose, two to three 1×0 Ethibond threads (Ethicon, USA) are sutured from lateral to medial, grasping the stable fascia and consequently displacing the gluteal fatty tissue to the middle of the buttock. For cranial repositioning, three to four 1×0 Ethibond threads (Ethicon, USA) are sutured from caudal to cranial at the medial aspect of the buttocks. By reconstruction and tightening of the gluteal adipose tissue, the gluteal flaps are lifted cranially with a consequent final skin closure under less tension. Further, this maneuver is able to improve the shape of the waist (Fig. 38.5).

FIG. 38.5 Intraoperative view of the transposition-gluteoplasty procedure.

The detachment in the zones of adherence combined with an extended mobilization allow an enormous tightening of the skin. The stage of resection should always be supervised by the “leading” surgeon in terms of symmetrical resection. We advise to utilize bullet forceps for determination of the amount of resection. The marked vector lines (Fig. 38.4) are incised from medial to lateral and adjusted for maximum tension. The redundant medial, central and lateral gluteal flaps arising in this way are measured precisely in tensed condition for symmetrical resection, which is subsequently carried out between the clamps (Figs 38.6 and 38.7).

FIG. 38.6 Intraoperative demonstration of flap dissection to ensure symmetrical resection (with permission from Elsevier).⁹

FIG. 38.7 Each flap should be measured in comparison to the contralateral side (with permission from Elsevier).⁹

Reconstruction of the superficial fascia system (SFS) is then performed with PDS 2×0 (Ethicon, USA). The SFS is extremely stable, allowing avoidance of any suturing of fat tissue in terms of consequent fat necrosis. After readapting the SFS, wound closure is performed in layers with resorbable suture material (see below). Two suction drains are placed in each gluteal/back and lateral thigh region and buried in the wound for sterile turning of the patient.

Before patients are turned into the supine position we perform a temporary closure of the lateral skin surplus utilizing a stapler and occlusive Opsite® foil.⁹

Anterior Preparation

Standard Technique

The inferior incision is checked and re-marked before the patient is scrubbed, adjusting the initial inferior line to the laterally ending gluteal incision line. Infiltration of tumescent solution is then performed in the marked areas. Vibration-assisted liposuction, however, is performed at the time of wound closure, again avoiding excessive liposuction in the areas to be undermined.

With all techniques the dissection level is performed above Scarpa’s fascia (Figs 38.8–38.10), entailing a number of key advantages: long-lasting swellings can be prevented because the underlying lymphatic vessels are preserved, and the stretching of the SFS craniomedially provides an additional “inner traction” on the deep penetrating fascia system of the thigh. The SFS may then be fixated with 1/0 Ethibond sutures (Ethicon, USA) to the anterior rectus fascia (Fig. 38.11). Approximately three finger breadths below the umbilicus, Scarpa’s fascia is dissected and further mobilization of the abdominal flap is performed cranially on the anterior rectus fascia (Fig. 38.12). The central supraumbilical adhesion zone is sharply dissected between both rectus muscles, preserving the laterally incoming perforator vessels (Fig. 38.13).