As introduced in Chap.​ 2, a request for a body-contouring procedure leads to a comprehensive analysis of the torso. For patients inquiring about a TBL, this complete approach is expected. For others who seek limited surgery, such as an abdominoplasty, a thorough body evaluation and treatment recommendation should still be offered. Optimizing fat distribution is essential to women. Highlighting muscularity is important to men. When prompted, patients tend to acknowledge other figure faults and are amenable to suggestions for nearby sculpturing through extended resections and/or liposuction.

Patient preparation is similar to other elective surgery, with special attention to nutrition after MWL (Agha Mohammedi and Hurwitz 2008). The patient needs to be informed as to complications and adverse outcomes. The author’s current complete informed-consent document is in Appendix 1: Consent. That form is modified from a template from American Society of Plastic Surgeons. The consent form addresses the presence and orientation of scars, potential for scar sensitivity and hypertrophy, infection, hematoma, wound dehiscence, asymmetry, and infection, contour irregularities, asymmetries, and partial recurrence of the deformity or even the development of a new aesthetic problem caused by the operation. Major medical complications, potential for hemorrhage and transfusions, are also noted in the form. Importantly, patients are implored to accept a cooperative relationship with the plastic surgeon. The premise should be accepted that the surgeon is doing his or her utmost to achieve the aesthetic goals. Choices are made which may not work out. Delayed wound healing or medical problems may occur that result in suffering and disappointment. However, the patient and surgeon start in this therapeutic relationship together. They should finish together. Recognizing this relationship from the beginning should limit antagonism and facilitate agreement on revision surgery.

Efficiency is essential. Efficiency applies to teamwork, operative planning, patient and operator positioning, and surgical technique. Many plastic surgeons aspire only individual craftsmanship. They are loners, uncomfortable with team dynamics, do not delegate, and prefer to perform every technical maneuver. Efficiency and teamwork are low priority. The do-it-all-by-myself-surgeon should probably stick to one or two operations per session. Otherwise, the operative sessions are too long, and fatigue impedes performance. For the surgeon who embraces leadership, the added factor of managing team dynamics is stimulating.

When there are two or three teams operating simultaneously, each is assigned leaders (Fig. 3.3). The responsible surgeon allows the second surgeon, who is named a first assistant, to similarly incise, undermine flaps, and close. That degree of latitude requires prior experience observing the second surgeon’s skills, ability to dissect smoothly through pertinent anatomy, and confidence that he or she will request assistance when unsure of the next move. When that trust is absent, semi-independent surgery is impossible. As the second surgeon is attempting to replicate the first side, he or she should lag just behind the leader and be instructed as they go along. At the very least, symmetry is at stake.

Ideally, team players are consistent. They are familiar with their responsibilities and master their skills. The leader motivates through proper compensation and encouragement. That idyllic is not possible in a university hospital. Fortunately, the stream of high-quality plastic surgery residents of the University of Pittsburgh provides this author interchangeable quality assistants. The team members are advised their role ahead of time and are apprised of the operative plan and timetable immediately before surgery. Nevertheless, all team members are closely monitored.

Inefficiency is distracting and disruptive. Inefficiency lengthens an already long operative session and increases surgeon frustration and operating room costs. As such, inefficiency would appear to increase bleeding and medical and wound healing complications. Striving for continuous efficiency is stimulating. The surgeon should develop consistent, understandable procedure so that the surgical assistants can anticipate the surgeon’s needs. With several teams requesting instruments from the scrub tech, plan to use as few different instruments as possible and call for them ahead of time by consistent names. Fortunately, body-contouring surgery lends itself to few instruments and a series of predictable maneuvers. Nevertheless, there will be the need for special dissectors, dermatomes, or unusual maneuvers. These equipments or sutures are requested ahead of time. With two or more simultaneous operations, a single scrub tech can be overwhelmed. The surgeon works with the scrub tech to alter his or her interaction. That may mean that another assistant or student be empowered to pass instruments, or that the surgeons may pick a selected number of instruments that they may use without being passed by the scrub tech. The introduction of guarded sharp objects such as needles and scalpel blades has greatly facilitated the safety and efficiency of team surgery. Simply, unguarded sharps are not passed across another operating team.

Precise preoperative planning with reliable surgical markings facilitates not only surgeon efficiency but also team surgery. The lead surgeon moves deliberately, and he or she is comforted that there is a road map for the assistant surgeon to do the same. The goal is to remove enough skin to eliminate rolls and laxity and then suspend the minimally undermined relatively mobile broad-based advancement flaps to relatively fixed broad-based flaps. With experience, preoperative assessment of the optimal width of the resection becomes reliable (especially for thinner patients), but does require thoughtful and repeated vigorous skin pushing, gathering, and pinching while the patient lies, sits, and stands for the markings. The more mobile flap is first incised and then undermined to the point that it can be pulled to overlap the soon to be resected tissues. The second long incision is made. Between these incisions the area of excision is rapidly performed along its long axis through the proper depth. Excision in this manner facilitates symmetrical retention of the desired width and depth. Preliminary towel clamping or staple closure confirms adequacy of excision or prompts further wound edge excision.

Rapid single-layer running closure immediately follows, minimizing the time of exposure, keeping tissues warm and moist. There should be no need for saline irrigation of what should be a minimally exposed, sterile field. Copious wound irrigation simply dilutes desirable hemostatic blood products. Wound irrigation is reserved for contaminated, infected, or desiccated wounds, which should not be the case in routine body-contouring surgery. Finally, the practice of preliminary infusion of saline with epinephrine and Xylocaine also includes a gram of Ancef in each three liter and satisfies the urge for antibiotic prophylaxis.

Regarding performance, the surgeon exhibits few wasted motions, no delays, and few repeated moves. Thoughtfully deliberate but steady is the way of expeditious surgery. Approaching the incision, with the next several moves in mind, the surgeon positions everyone and readies instruments and materials. While every practicing surgeon feels they operate that way, over the course of these long operations, there is usually room for improvement. Be self-critical, as long procedures with numerous small inefficiencies cost considerable time. Prolonged waiting, malfunctioning, or inappropriate technology, repetition, unattended bleeding, inadequate exposure, difficulty obtaining hemostasis, or not maintaining a proper surgical plane are avoidable deficiencies magnified by the enormity of the endeavor. The wounds are not deep and there are few vital structures. With much to do, the pace is expeditious. Good surgery looks practiced, polished, and effortless. We should strive to emulate the great ballplayers by appearing effortless during the routine catch and graceful while fetching the well-hit ball. As a rule, if these operations look difficult, they are being done poorly.

For circumferential operations, the most efficient positioning and turning of the patient start prone and end in the supine positions. Routinely, the patient is induced under endotracheal general anesthesia on the transportation gurney and then turned to the prone position for the start of the operations. With the patient lying prone, it is an easy matter to abduct the thighs for a lower-tension lateral hip closure. Later closure of the lower buttocks posterior thigh junction and the medial thigh occurs with adduction of the leg. The prone position offers the opportunity to perform multiple operations at the same time. The operator usually starts the right-side lower body lift with the first assistant performing the same procedure on the opposite side. Elsewhere, a second team can be performing the posterior thighplasty or bra-line upper body lift excision. The surgeon becomes aware of the pace of each of the procedures and adjusts roles to allow for the procedures to be completed at the same time. Once those operations are completed, the patient is then turned supine for the second part of the operation. Hence, prone followed by supine requires only one position change with the legs abducted in the best position for closure. So in the case of a circumferential lower body lift with abdominoplasty, it was sensible to perform the lower body lift first and then turn the patient supine under anesthesia for the abdominoplasty and vertical medial thighplasty.

That practical intraoperative efficiency of only two patient turns appears to be detrimental to wound healing over the sacral promontory. Patients frequently suffered posterior incision breakdown along the central portion of the lower body lift closure particularly when an adipose fascia flap is being used. Recently, it became evident that the most efficient positioning was the source of delayed healing over bony prominences. Starting prone and then turning supine onto the fresh closure over the convex sacral spine and posterior iliac spines would lead to prolonged direct intraoperative pressure. Before making the switch of operative positions, the author has tried a variety of remedial measures. During the supine portion of the operation, an air mattress or silicone padding protected the lower body lift closure. After the operation, the patient was transferred to the recovery room on a KCI air flotation bed with instructions to turn from side to back to opposite side. Nevertheless, presacral focal tissue necrosis often occurred. In hindsight, it is clear that a reversal of the order of positioning would avoid pressure sore-related wound breakdown. Once the operation was started supine and ended prone, there has been no problem with delayed healing along the lower body lift closure, even in the thinnest patients (Fig. 3.4). At times the quest for efficiency is counterproductive, and established practices need to be reexamined for quality improvement. Every surgeon should be introspective to unravel their own recurring patient problems.

Alternatively, the lower torso surgery can be performed in three steps: supine, right lateral decubitus, and then left lateral decubitus as recommended by Lockwood. That requires extra time for the additional positioning as well as special effort to position the upper arm and thigh. The lateral decubitus position with the thigh abducted on several pillows is awkward and the single side does not lend well to team surgery. Symmetry is difficult to obtain, but in other experienced hands, that does not seem to be a problem.

The orientation of the tissue excision is dictated by the direction of maximum laxity and best aesthetic placement of the scar. A strip or elliptical excision primarily removes excess skin along its short axis. Since skin redundancy is multidirectional, a single-oriented excision takes in slack primarily in one direction, and in many instances that will suffice. Complicating matters are linear subdermal to muscular fascia adherences. Patterns of laxity vary according to the region, which encourage rather standard excision designs. For instance, the abdomen is predominantly vertically lax and most often treated with the low transverse excision of skin between the umbilicus and mons pubis. The Fleur de Lys abdominoplasty (FDL) removes both vertical and horizontal excess but with the disadvantage of a long midline scar and possible delayed healing at the trifurcation closure at the mons pubis.

Crisscrossing vertical and transverse excisions is one solution to diffuse tissue redundancy; however, that would leave a double set of scars and possible vascular compromise. The FDL abdominoplasty is an example of crisscrossing excisions. That operation is favored when there is already an upper midline abdominal scar, severe horizontal tissue excess, or when an upper body lift is not being considered. Fortunately, it appears that when a circumferential lower body lift is combined with a circumferential upper body lift, at the same time or later, most all vertical and some transverse excess tissue is removed. In that manner, most skin redundancy is corrected, leaving behind only transverse scars.

There are conflicts between best orientation of the skin excision and unaesthetic scars. The artistic resolution of these conflicts has resulted in innovative approaches: L-brachioplasty, J-torsoplasty extensions of Spiral Flap reshaping of the breasts, boomerang correction of gynecomastia, oblique flank excision of abdominoplasty, and Spiral thighplasty. These operations are thoroughly explored in Chaps.​ 4 and 5. Ultimately, technique selection is an interplay between surgical judgment, anticipated contour improvement, and patient acceptance of anticipated scars.

In the torso, skin redundancy is predominantly vertical, which lends itself to transverse excisions, which are readily covered by underwear. Transverse scars of the lower torso are easily placed within panties, and these scars are unlikely to hypertrophy. Whenever possible, excise within the bikini line, which represents the greatest circumference of the female torso. When the relatively narrow waist level excess skin is advanced over the iliac crests, much of the transverse excess is taken in. Nevertheless, a low-lying lower body lift (LBL) excision is at time problematic because the superior anchor line may sag, leading to inferior drift causing lateral gluteal depressions and partial recurrence of lateral thigh laxity (Fig. 3.5).

In men, low transverse excisions between the back and upper buttocks have often been disappointing. Not only has the redundancy in the flanks been inadequately treated but also leaves an unaesthetic contour depression along the closure. With that in mind, the posterior extensions of the male abdominoplasty are now positioned obliquely over the flank rolls. While leaving a scar above the waistline, the narrowing of the waist at the appropriate level has made pants belts lay more comfortably.

While there is no aesthetic issue with the LBL-abdominoplasty combination crossing either the anterior or posterior midlines, that is not the case for the upper body lift (UBL). In the upper torso, there is rarely skin redundancy over either the lower sternum or thoracic spine. So unless there is no way to otherwise avoid a dog-ear deformity, transverse excisions should stop short of the midtorso midlines. Should there already be scars or synmastia, the midline intrusion may be appropriate. In such instances over the sternum, an inverted V-shaped excision between the breasts is considered. A lack of posterior midline deformity in all but the most severe cases supports the notion that crossing the back midline is inappropriate. In women, the posterior excision, not only hazards an unsightly scar but also disrupts subtle and attractive feminine undulating spinal curvature. For the most part, bra-line transverse excisions should stop short of crossing the posterior midline. For milder cases of redundancy and where the patient refuses a posterior scar, the author has favored vertical excisions along the lateral chest.

Since tissue redundancy of the extremities is mostly transverse, it is most effectively removed by longitudinal excisions. Unfortunately, that leaves long scars along the inner aspects of the upper arm and thighs, which may not be accepted. For the less severe redundancy, oblique excision limited to the proximal medial arm or thigh may be a reasonable compromise.

Experience in techniques helps proficiency to plan reliable lines of incisions for tissue excision, harvest, and shaping. Both the proper width of excision and the stability of the anchor line are appreciated. A squeeze, push, or a shove to mark the width of excision, when thoughtfully done, can be remarkably accurate. Nevertheless, it is difficult to predict accurately breath of excision when skin is tense by underlying adipose excess, tethered to dermal fascial adherences or exhibits profound atrophy. When there is uncertainty about the appropriateness of excision width, then the excision breadth is conservatively drawn. If the initial excision proves inadequate, then an additional strip of skin along the wound margin is excised.