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Classification ofContour Deformities
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After Massive Weight Loss: Utilization
forProper Treatment Planning
ErikJ.Nuveen
26
Body contour deformities due to massive weight loss can be
very diverse as well as severe and complicated. Post-bariatric
weight loss is at times greater than 50% of the excess weight
which leads to loose, ptotic skin envelopes and oddly shaped
bulges where the fat deposits are very resistant to reduce. It
has been observed that some fat deposits disappear as though
they were never there while others remain as prominent creating pleats and puckers in previously smooth contours.
Post-weight loss deformity can be loosely predicted based
on the pre-weight loss appearance, extent of weight loss,
genetic predisposition, and age of the patient. An appropriate
treatment plan rst hinges on a correct diagnosis which is
based on a rating system as there are a combination of procedures to choose from such as brachioplasty, mastopexy,
reduction mammaplasty, augmentation mammaplasty,
abdominoplasty, suction-assisted lipectomy, circumferential
lower body lift, upper body lift, medial and lateral thigh plasties, buttock lipectomy, and lower leg lipectomy.
A classication system based on a clinical assessment is a
valuable tool to describe a patient’s deformity in a manner
that is translatable from surgeon to surgeon. This chapter is
based upon the existing literature in the area of classication
of massive weight loss patients. There have been many anatomically limited classications of deformity [1–3]. In 2006,
Song etal. created the rst system that took into consideration the full extent of deformities that occur throughout the
body secondary to massive weight loss [4]. The Pittsburgh
Rating Scale [4] was created to assist in communication,
research, treatment planning, and evaluation of results. An
ideal classication system has high inter-operator consistency and this publication and others have validated this
independently.
The Pittsburgh Rating Scale utilizes a 0–3 scale to consistently identify massive weight loss patients’ 10 regions of the
body into its four categories: 0 to represent normal, 1 to represent mild deformity, 2 to represent moderate deformity,
and 3 to represent severe deformity. The sentinel founded
upon a total of 25 female-only patients who encompassed the
full range of normal to severe deformities of 10 regions of
the body. These 10 regions were included as part of the classication system: arms, breasts, abdomen, ank, mons, back,
buttocks, medial thighs, hips/lateral thighs, and lower thighs/
knees (Table26.1).
The application of the scale can be used in daily practice
to assess the level of deformity, plan appropriate treatment
protocols, and evaluate pre- and post-operative results [5]. In
general, the treatment appropriate to the level of severity
would include non-surgical or minimally invasive treatment
for a severity score of 0. Excision treatment is utilized for
levels 1–3 with 3 requiring combined treatments including
lipoaspiration and/or undermining of wide areas, excision,
and suspension lifting of tissues.
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_26].
E. J. Nuveen (*)
Cosmetic Surgery Afliates, Oklahoma City, OK, USA
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_26
403
404
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Table 26.1 Modied Pittsburgh Rating Scale for massive weight loss patients
Area Scale Preferred procedure
Abdomen 0 Normal
1 Redundant skin with moderate
Adiposity without overhang
2 Overhanging pannus
3 Multiple rolls/horizontal and vertical laxity or
epigastric fullness
Mons 0 Normal
1 Excessive adiposity
2 Ptosis
3 Signicant overhang below symphysis with horizontal
skin excess
Flank 0 Normal
1 Adiposity
2 Prominent rolls
3 Ptosis of rolls
Buttocks 0 Normal
1 Mild to moderate adiposity and/or cellulite
2 Severe adiposity and/or severe cellulite
3 Skin folds with volume loss
Back 0 Normal
1 Single fat roll or adiposity
2 Multiple skin and fat rolls
3 Ptosis of rolls
Hips/lateral
thighs
Medial thighs 0 Normal
Lower thighs/
knees
Arms 0 Normal
Breasts 0 Normal
0 Normal
1 Mild to moderate adiposity and/or cellulite
2 Severe adiposity and/or severe cellulite
3 Skin folds with volume loss
1 Mild to moderate adiposity and/or cellulite
2 Severe adiposity and/or severe cellulite
3 Skin folds with volume loss
0 Normal
1 Adiposity
2 Severe adiposity
3 Skin folds
1 Adiposity with good skin tone
2 Loose, hanging skin without severe adiposity
3 Loose, hanging skin extending to chest
1 Ptosis grade I/II or severe macromastia
2 Ptosis grade III or moderate volume loss or
constricted breast
3 Severe lateral roll and/or severe volume loss with
loose skin
No treatment
Mini-abdominoplasty with UAL/SAL
Full abdominoplasty
Modied abdominoplasty including Fleur de lis and/or upper
body lift
No treatment
UAL and/or SAL
Monsplasty
Monsplasty with vertical excision
No treatment
UAL and/or SAL
UAL and/or SAL
Total body or lateral thigh lift
No treatment
UAL and/or SAL
UAL and/or SAL with excision and lift
Excisional lifting procedure ± autoaugmentation
No treatment
UAL and/or SAL
UAL/SAL with Renuvion or excision
Excisional back lift
No treatment
UAL and/or SAL
UAL and/or SAL with excision and lift
Excisional lifting procedure
No treatment
UAL and/or SAL
UAL and/or SAL with excision and lift
Excisional lifting in a vertical and horizontal direction
No treatment
UAL and SAL
UAL and SAL ± excisional lifting
Excisional lifting procedure
No treatment
UAL and/or SAL
Brachioplasty ± lipo
Extended brachioplasty ± lipo
No treatment
Mastopexy/reduction or augmentation
Traditional mastopexy augmentation
Parenchymal reshaping techniques with dermal suspension/
autoaugmentation
E. J. Nuveen
After cosmetic reconstruction of levels 1–3, the ideal
outcome would be to restore the patient’s appearance to a
level 0.
26.1 Limitations ofthePittsburgh Rating
Scale
The most severe levels of deformity often require treatment
and management of adjacent areas, as massive weight loss
patient’s problems in one area are often contiguous with
adjacent areas. As an example, the breast lift (with or without implant placement) very commonly requires a lateral
axilloplasty, a z-plasty in the axilla, and a transition to a
brachioplasty.
The operative surgeon faces many complex surgical and
intellectual challenges in dealing with the massive weight
loss patients. Comorbid medical conditions are very common
in the previously obese patients. The consideration for anticoagulation, nutritional modication, and post-operative management must be addressed pre-surgically. Additional
challenges exist in maximizing operative efciency in order
to reduce surgery and time under anesthesia. The goal is to
reduce revision rates and improve patient safety while maximize normalization toward a 0 rating. Ideally, a classication
system would be purely objective in nature, yet the Pittsburgh
26 Classication ofContour Deformities After Massive Weight Loss: Utilization forProper Treatment Planning
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405
system is purely subjective. Limitation of the system includes
a lack of objectivity and therefore, clinical judgment is imperative to ideal decision-making and subsequent outcomes.
Massive weight loss patients who present with a Pittsburgh
rating of 3 have extreme variations in loss of skin elasticity
and dermal thickness that often dictate a more extensive
multi-layer closure for ideal reapproximation and outcomes.
Also, these patients have been commonly reported to have
higher rates of revision, widened scaring, and recurrent ptosis. With the current classications, there is no method of
evaluation of skin tone, quality of dermis and density of tissues, or the muscularity underlying the skin excess; all of
which play a role in proper decision-making for operative
techniques and associated complications of those
procedures.
The rst step in planning the body-shaping procedure is a
complete preoperative evaluation followed by prioritizing
the areas to be addressed.
26.2 Preoperative Evaluation
It is important to note that these are elective procedures to be
undertaken on complex patients who may have multiple
nutritional deciencies. It is never a bad idea to defer surgery
and modify the risk factors which would be a collaborative
effort between the doctor and the patient. The key assessment areas include:
1. Duration between bariatric surgery/starting of weight loss
to coming in for body contouring—We ideally undertake
body-shaping procedures if the patient is within 10–15%
of his/her ideal body weight and has been with stable
weight for a minimum of 3months. Age of onset of obesity, family history of obesity, a detailed information
about the bariatric procedure including the post-operative
course, and the progression of weight loss help to analyze
the weight loss journey better. The stability of the nal
weight is very important which is dened by not more
than 5lb/2.5kg of weight change per month in the previous 3months.
If the patient is still undergoing rapid weight loss then
it should be taken for granted that metabolic and nutritional homeostasis has not been achieved which could be
a risk for optimal wound healing.
2. Present body mass index (BMI)—High BMI will cause
patient safety issues and will also compromise the aesthetic outcomes specially if patient loses signicant
weight. The ideal BMI for multiple body-contouring procedures is to be considered as 25–30 kg/m2. At higher
BMIs between 30 and 35kg/m2, one must be more selective and evaluate individual patterns of body fat distribution to guide surgical planning. Patients with BMI of
more than 35kg/m2 usually have a much thicker subcuta-
neous tissue along with signicant fat deposits in the
intra-abdominal area. In such patients, further weight loss
is recommended and surgery is only indicated in a localized area if there is a functional issue. When a patient
with such high BMI or higher is encountered, then he/she
should be referred back to the bariatric surgeon and/or
nutritionist for further weight loss.
3. Medical comorbidities—Cardiac and lung issues will
complicate any surgery and will increase the stress on the
body, thus increasing the risk of complications. Weight
loss improves health in a signicant manner and patients
having multiple medical conditions see a signicant
improvement be it diabetes, hypertension, sleep apnea, or
arthritis. Up to 80% of obese patients with type II diabetes mellitus nd that their diabetes has resolved and they
don’t need medications anymore. HbA1C is the best
long-term predictor of their diabetes control which has to
be assessed. For all diabetic patients, glucose should be
monitored postoperatively and treated with an insulin
sliding scale for tight glycemic control.
Hypertension is present before weight loss would
have signicantly reduced due to weight loss but a complete cardiac assessment is mandatory to rule out any
underlying cardiac concerns which might be unmasked
due to the stress of the body-contouring procedure.
Cardiac function tests and at times stress test should be
undertaken preoperatively.
Obstructive sleep apnea can sometimes be resistant to
weight loss and because there are signicant risks such as
myocardial infarction, stroke, arrhythmia, and sudden
death that are associated with it, an assessment with a
pulmonologist and use of CPAP devices is strongly
recommended.
Risk of thromboembolism should be assessed specially in people who have had a previous history, are
immobile, older and have varicosities. Any hereditary
coagulopathy has to be recognized and managed.
Smoking is shunned upon and patients are asked to
abstain from smoking for at least 2 weeks before to
2weeks after surgery.
4. Nutritional evaluation—Evaluation of iron deciency
anemia, protein deciency, and deciency of other fatsoluble vitamins will need to be assessed prior to surgery. If operated without a complete assessment, the
chances of delayed healing and breakdowns are higher.
Restrictive weight loss procedures such as gastric banding and sleeve gastrectomy usually have low nutritional
deciency risks as compared to bypass procedures which
are restrictive as well as malabsorptive. Specic nutritional deciencies such as protein deciency, iron deciency as well as deciencies of water-soluble vitamins
such as those in the B complex have to be assessed and
their serum levels corrected before undertaking any
body-contouring surgery.
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E. J. Nuveen
5. Psychological and/or physical issues—Body dysmorphic
disorders should be ruled out. The patient expectations
should be realistic with a knowledge that all procedures
will lead to scars which will have to be camouaged specially in people with type 3–6 skin. Anatomical areas
causing physical disability should be discussed and prioritized. Patient’s motivations and priorities have to be
understood so as to set the right expectations for the
patient. Most patients have a positive tone, express pride
in their accomplishments, and articulate what they expect
from the body-contouring operation. Patients must accept
the scars and signicant recovery period, and embrace the
concept that they will be signicantly improved but not
“perfect.” Patients tend to forget their preoperative
appearance hence a review of their presurgery photographs
helps remind them how far they have progressed and
improved.
26.3 Anatomic Area Evaluation
andPlanning ofProcedures
Once a preliminary evaluation of the patient has been undertaken, a thorough physical evaluation and understanding of
the patient requirements according the Pittsburgh rating
scale described above should be undertaken. The clinical
examination should not be specic to just the loose skin
rather should include the following:
1. Type of body habitus-android vs gynecoid.
2. Extent of skin laxity and its points of adherence.
3. Presence of asymmetry and any deviations from the
midline.
4. Presence of resistant fat deposits, overall body fat distri-
bution, and requirement of liposuction in the area.
5. Tissue deciency or volume loss needing volume
replacement (e.g., breast and buttocks).
6. Can autologous tissue be used to replace the volume at
the same stage.
7. Extension of skin laxity from one anatomical area to the
other.
8. Skin tone in different body areas.
9. Presence of pigmentation +/− fungal infection and
maceration.
10. Presence of scars and previous surgeries to assess the
vascularity pattern of the tissue to be left behind.
26.4 Combining andStaging Procedures
Most patients come with multiple areas of deation (volume
loss) but they may be concerned of only a few areas and the
nal treatment plan may be somewhere in between. A com-
bination of procedures may be required in a single stage
which will be complementary to each other.
Generally favorable combinations
1. Abdomen with breast-abdominoplasty and augmentation
can be undertaken but abdominoplasty and breast lift/
reduction is not recommended if the inframammary
crease is signicantly mobile.
2. Abdomen with back and buttocks.
3. Abdomen and thighs (spiral lift).
4. Circumferential body lift with buttock augmentation.
5. Circumferential body lift with mastopexy (male/female).
6. Breast surgery with brachioplasty.
Procedure combinations that are considered unfavorable
1. Circumferential lower body lift with a circumferential
upper body lift-too extensive a procedure.
2. Thigh lift and brachioplasty (patient will not be able to
move around)—all four limbs are involved, getting out of
bed will be an issue.
3. Circumferential body lift with thigh lift—has opposing
vectors of pull. Healing is delayed.
4. Circumferential upper body lift and brachioplastycrossing of incisions with risk of breakdown.
26.5 Factors tobeConsidered Before
Undertaking Combination
Procedures
1. Whether procedure undertaken as a day care or hospital
based—If surgeries are to be scheduled as day care, then
it is suggested to undertake shorter procedures in limited
areas so that there is less stress on the system. Combination
procedures should always be carried out as a hospitalbased surgery.
2. Medical condition of the patient—Combination surgeries
are best undertaken in patients having an ASA score of 1
or 2 since they extend for longer duration, require change
in position as well as have a longer recovery period. Any
medical comorbidity if present should be under control.
3. Complementary procedures—Combination procedures
should always be complementary and should not involve
surgeries where the nal vectors oppose each other. For
example, abdominoplasty and a breast lift have opposing
forces. Also it is necessary to keep in consideration the
vascularity of the area which will help in the healing and
prevent breakdown. Any incision compromising the vascularity is doomed to fail and give serious complications.
Finally, it is important to visualize the nal scars which
have to be well hidden. If better scars can be provided by
having single procedures, then it should be done in that
manner.
26 Classication ofContour Deformities After Massive Weight Loss: Utilization forProper Treatment Planning
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407
4. Comfort of the surgeon—This is of paramount impor-
tance when planning a combination procedure. Any surgery more than 6h usually saps the creative juices of the
surgeon. After 6h the surgeon only operates to nish the
surgery hence plan for procedures which take less than
6h in your hand. It all depends on how much can you
handle.
5. Support of ancillary staff—Combination procedures are
best undertaken when you have a team to work with you.
One surgeon cannot do everything no matter how skilled
and fast you are. If you have a decent assistant surgeon,
nurses, and fellows then you can consider combination
surgeries as it can be a two-team approach. Also, the
operation theater should be spacious and facility should
be able to handle the patient stay and sometimes ICU stay
as well.
26.6 Staged Procedures
26.6.1 Advantages
1. Reduced operative time for individual procedure.
2. Staged procedures allow areas to heal before the next procedure is done thus preventing opposing vector pulls.
3. Less complications and faster recovery.
4. Can be safely undertaken as day care procedure many
times just with local anesthesia.
5. Surgeon does not suffer from fatigue.
6. Moreover, there is an opportunity to assess previous healing and small touch up procedures in the next stage.
26.6.2 Disadvantages
1. Overall longer period of time for all the procedures to
take place.
2. Larger nancial burden overall.
3. May need a longer period of recovery in total.
26.7 Combination Procedures
26.7.1 Advantages
26.7.2 Disadvantages
1. All the advantages of staged procedure are a disadvantage
here.
2. May need blood transfusion since it involves extensive
tissue excision.
3. Revision surgery may be required which cannot be part of
a staged surgery.
4. Risk of cumulative complications, when things go south,
they do in a very bad way.
Finally to maintain patient safety during multiple procedures, uid balance, blood loss, and body temperature
are carefully monitored during the procedure. The patient
is advised preoperatively that the surgeon will truncate
the operation if there is evidence of increased risk.
26.8 Special Considerations
inPreoperative Counseling
Most massive weight loss (MWL) patients, with proper
counseling, are very satised with their surgery. Important
concepts to emphasize are scarring, lack of effect on regions
outside those being treated, potential for recurrence of skin
laxity, magnitude of recovery, and risk of wound-healing
complications. It is essential that the patient recognize the
trade-off between removing excess skin accepting scars. For
MWL surgery, the phrase holds true that “minimal access
scars equals minimal results.” It is often useful to draw the
anticipated scar position on the patient with a marker in front
of a full-length mirror. These marks can also be photographed to document the discussion. The best way to simulate the effect of surgery during the consultation is by
pinching together the tissues to be manipulated and demonstrating the pull on the adjacent tissues. Just as important as
explaining what the operation will accomplish is describing
what the operation will not do. Patients must be properly
informed about the magnitude of recovery. Given the popularity of laparoscopic bariatric surgery, patients should be
educated that body-contouring procedures are much more
invasive and not “simple skin tucks.” Patients must also
understand the high incidence of wound-healing complications in MWL body-contouring procedures, including wound
dehiscence and seroma.
1. The disadvantages of staged procedures become the
advantages of the combined procedure.
2. Another major advantage is that complementary procedures such as use of autologous tissue from contiguous
site can be used for buttock and breast augmentation. Fat
can be used for buttock and face, etc.
26.9 Case Examples
Case 1
See Fig.26.1.
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Fig. 26.1 This 37-year-old lady underwent a weight loss of about 100
lbs after bariatric surgery. Her weight has been stable for the last
10months. She was interested in a body-contouring surgery. Her concerns included loose skin in her abdomen, anks, thighs, and arms
along with large drooping breasts. We discussed about her priorities and
based on that a treatment plan was nalized. Stage 1: Circumferential
body lift with Fleur de lis abdominoplasty and touch up liposuction.
Stage 2: Breast lift and a brachioplasty. Stage 3: Thigh lift and any corrective surgery if indicated
26 Classication ofContour Deformities After Massive Weight Loss: Utilization forProper Treatment Planning
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Case 2
See Fig.26.2.
409
Fig. 26.2 This 46-year-old underwent a weight loss of 160 lbs through
diet and exercise. His weight has been stable over the course of time.
His concerns were of total body skin laxity, with primary concerns to
his chest and arms. Following a discussion of priorities, the following
treatment plan was nalized. Stage 1: Male chest reconstruction with
axilloplasty and brachioplasty. Stage 2: Circumferential body lift with
Fleur de lis abdominoplasty and touch up liposuction. Stage 3: Thigh
lift and any corrective surgery if indicated
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References
1. Bozoloa AR, Psillakis JM. Abdominoplasty: a new concept and
classication for treatment. Plast Reconstr Surg. 1988;82:983–92.
2. Matarasso A.Abdominolipoplasty: a system of classication and
treatment for combined abdominoplasty and suction-assisted lipectomy. Aesthetic Plast Surg. 1991;15(2):111–21.
3. Nahas FX.An aesthetic classication of the abdomen based on
the myoaponeurotic layer. Plast Reconstr Surg. 2001;108(6):
1787–97.
4. Song AY, Jean RD, Hurwitz DJ, Fernstrom MH, Scott JA,
Rubin JP. A classication of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast Reconstr Surg.
2005;116(5):1535–46.
5. Ching S, Thoma A, McCabe RE, Antony MM.Measuring outcomes
in aesthetic surgery: a comprehensive review of the literature. Plast
Reconstr Surg. 2003;111(1):469–82.
Thighplasty
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ErikJ.Nuveen
27
There has been a tremendous increase in awareness, safety,
and success of bariatric surgery techniques to achieve massive weight loss. This causes signicant reduction in tissue
volume in the abdomen, breast, buttocks, thighs, and arms
leading to deation of these areas. As a result, the volume of
patients presenting to the cosmetic surgeon for correction of
skin excess has shown the greatest percentage increase
among all areas of cosmetic surgery over the last 3years. A
thigh lift (thighplasty) is an invasive procedure that removes
excess skin and fat from the thigh area to address the skin
redundancy.
Perhaps the most common reason for a thigh lift is to help
reshape and smooth the thigh area which becomes ill shaped
after losing weight. Some people also opt for the procedure
to gain more shapeliness and to feel more comfortable wearing swimsuits, shorts, and jeans.
27.1 Anatomy oftheThigh Region
(Fig.27.1)
The thigh is from the pelvis to the knee and it is commonly
divided into three compartments;
1. Anterior compartment muscles of the thigh include sarto-
rius, and the four muscles that comprise the quadriceps
muscles—rectus femoris, vastus medialis, vastus intermedius, and vastus lateralis.
2. Posterior compartment muscles of the thigh are the ham-
string muscles, which include semimembranosus, semitendinosus, and biceps femoris.
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_27].
E. J. Nuveen (*)
Cosmetic Surgery Afliates, Oklahoma City, OK, USA
3. Medial compartment muscles are pectineus, adductor
magnus, adductor longus and adductor brevis, and also
gracilis.
The arterial supply is from the femoral artery and the
obturator artery (Fig.27.2).
The thigh is covered with a thin dermis. The fat is divided
by a poorly dened layer of supercial fascia into superior
and inferior compartments. The tissue layer that lies below
the adipose tissue of the perineum is the supercial perineal
fascia. This attaches to the ischiopubic rami of the pelvic
bone and is contiguous with Scarpa’s fascia. Colles’ fascia is
very thick at the medial thigh and the perineum, and used for
support of the lower skin ap in all medial thigh procedures.
Preservation of the femoral triangle and its contents
(Fig.27.3) should ensure minimal injury to the lymphatics.
John R.Lewis published the rst description of a traditional thigh lift in 1966 [1]. This initial effort resulted in wide
scaring, labial distortion, and lymphatic damage as a result
of no signicant xation to an immobile structure. Later in
1971, Pitanguy used dermal rolls and xed them to the periosteum and fascia with decreased complications [2].
Lockwood then lent his revolutionary advancement to the
technique by anchoring the distal dermal tissue to the Colles’
fascia in 1988 [3]. Today, we know that age, gender, BMI
>35, smoking status, method of weight reduction, hypertension, lymphedema, history of DVT or PE all contribute to
increases in complications of thighplasty surgery. The complication rate of these procedures ranges from 46 to 59%,
many of whom will be required to endure weeks or months
of postoperative wound care management [4]. Dehiscence,
seroma, hematoma, necrosis, infection, and erythema are
common and must be an integral part of the preoperative discussion and consent process [5]. Massive weight loss patients
present with additional challenges that commonly include
atrophic or extremely thin dermis, lost skin elasticity, and
lymphedema. Regionally, the thigh area is humid and tends
to slow wound healing. The medial thigh skin is very thin
and is difcult to suture without signicant dermal strength.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_27
411
412
Femur
m
Adductor magus m.
Vastus lateralis m.
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E. J. Nuveen
Fig. 27.1 Cross-sectional
anatomy of the thigh.
(Gray432.png: Marshall
Strother derivative work:
McStrother / CC BY (https://
creativecommons.org/
licenses/by/3.0)
Rectus femoris m.
Vastus intermedius m.
Linea aspera
Intermuscular septum
of lateral femoral
Biceps femoris m.
(short head)
Biceps femoris m.
(long head)
Deep femoral a.
and v.
Sartorius m.
Saphenous n.
Femoral a.
and v.
Intermediate
cutaneous n
Great saphenous v
Adductor longus m.
Gracilis m.
Intermuscular septu
of median femoral
Perforating a. and v.
Semimembranosus m.
Semitendinosus m.
Post. femoral cutaneous n.
Sciatic n.
The perineal region is associated with a high level of bacterial involvement. The lymphatic vessels are more supercial
in this region and thus more likely to be damaged during
surgical interventions. This can result in signicant and
debilitating edema for an unknown duration after surgery. As
a result of high tension, the scar may widen, caudally reposition or may result in vulvar distortion and introital show. In
addition, bariatric patients often present with nutritional
deciencies.
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