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R. Calderon
1. Timing of surgery—These procedures should ideally be
done when the weight of the patient has been stable for at
least 3–4 months. This is possible 12–18 months after
bariatric surgery. Weight stability before body contouring
is important even in people who have lost weight
naturally.
2. BMI of the patient at the time of body contouring surgery—Lower the BMI, lower are the complications and a
better cosmetic result. Higher BMIs have been seen to be
associated with not so aesthetic outcomes and a higher
number of complications [6].
3. Nutritional status—Adequacy of patient’s nutritional status with a lower BMI has to be assessed.
4. Associated medical problems and any psychosocial
issues should be diagnosed and treated by a specialist.
5. Smokers are required to stop smoking 1 month before
surgery. Urine nicotine test should be undertaken before
scheduling the surgery.
6. A complete clinical examination will help in assessing
anatomic defects such as hernias and weakness of muscle
wall. Presence of hernias in people who look for major
abdominal recontouring surgery will impact the surgical
plan [3].
Physical examination—Examine and assess features of
the skin such as elasticity of tissues, skin laxity, presence of
wrinkles, surface irregularities, and presence of scars and
their attachment to deeper structures.
Umbilicus—Examine the umbilicus with regard to its
position, its distance from the xiphoid process and from the
pubic symphysis, any deviation from the midline, presence
of any scar in the umbilicus or a hernia. The position of the
umbilicus and presence of any scar (surgical or traumatic) on
the abdomen are some of the parameters which help decide
the extent of skin excision and the future positioning of the
umbilicus.
Fat deposits in the abdominal wall—The thickness of the
abdominal pannus, the location of the fat, and its amount
have to be assessed to evaluate the extent of liposuction and
estimate the fat aspiration.
Assessment of muscular abdominal wall—Clinically
assess presence of muscle wall weakness specially in the
midline (rectus abdominis diastasis) and check for hernias in
umbilicus, groin or along any surgical scar. This will help
plan the best possible technique for plication of the abdominal wall.
Body contouring lipodystrophies in other areas, such as
anks, gluteus, sacrum, and pubis, must be also evaluated [7].
30.8 Endocrine-Metabolic Response
inPatients Undergoing Multiple Body
Contouring Surgeries [8]
There is a very complex metabolic response to trauma or
surgery which is caused by the combination of tissue injury
as well as ischemia and reperfusion in the tissues. Stress is
considered as any condition in which homeostasis is not
maintained which is especially seen in surgical stress. The
surgical stress response is characterized by increase in
release of catabolic and immunosuppressive pituitary hormones and activation of the sympathetic nervous system,
causing catabolism, thermogenesis, and hyperglycemia.
Gene expression further modies this response which can
be aggravated by events such as long duration of surgery,
need for blood transfusion, lowered core temperature, and
signs of infection [9].
Activation of the hypothalamic-pituitary-adrenal axis is
necessary for an endocrine-metabolic response during surgery but excessive activity can be detrimental. Based on the
extent of injury, the response to surgical stress including
autonomic, hormonal, and metabolic changes can be on different levels [10].
Blood pressure and heart rate is controlled by the sympathetic neural and autonomic humoral pathways.
Neuroendocrine hormones such as cortisol, growth hormone, ADH, and ACTH released due to stress along with
cytokines (interleukin-6 [IL-6]) may cause thermogenesis,
hyperglycemia, loss of muscle protein, acute phase protein
synthesis, and reduced levels of zinc and iron in plasma
[11]. Reduced insulin levels due to stress causes gluconeogenesis causing reduced systemic immunity and causing
increased morbidity and mortality in the postoperative
period [12].
Cortisol affects all major homeostatic systems of the
body, including innate and acquired immunity [13]. High
levels of cortisol in patients undergoing surgery will delay
healing by increased catabolism and suppression of the
immune system, leading to immunosuppression and postoperative infection [14].
The endocrine-metabolic response to surgery is proportional to the extent of surgical injury and very little is
known about the interactions when multiple procedures
are carried out at the same time. By understanding risk factors which may cause increased release of stress hormones,
the intra- and postoperative morbidity and mortality can be
signicantly reduced when undertaking combined procedures [15].
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30.9 Optimization ofPatient Safety
inPostbariatric Body Contouring [16]
1. Weight of the patient should have been stable for at least
3months and there should ideally be no further weight
loss.
2. Patient should have completely stopped smoking and use
of nicotine is a contraindication for surgery.
3. IV antibiotics should be given at least 30min before starting surgery.
4. Precaution for thromboembolism including graded stockings and calf pumps should be initiated before
anesthesia.
5. Low molecular weight heparin should be used along with
mechanical prophylaxis and should be started within 12h
of surgery for 3–5days.
6. Nutritional assessment should be done through laboratory tests to detect low protein levels and anemia.
7. Accredited facility with all possible support systems
should be used for the surgery.
8. Air warming blankets, warm IV uids, warm antiseptics
for painting, and raising of temperature in the operation
theater may be required to prevent hypothermia. A temperature probe should be used to continuously monitor
the temperature.
9. Patient should be positioned in such a way that there is no
pressure point or compression injuries. A reverse
Trendelenburg of 15 degrees should be given when
patient is prone to reduce intraocular pressure.
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Fig. 30.2 Technique “lift and drop”
30.10 Ideal Scar Position andScar Control
Body contouring surgery in a patient with massive weight
loss focusses on treating the redundant skin so as to improve
the contour of the area along with placement of the scar in an
inconspicuous position so that it has a good quality and is not
visible.
Pre-surgery marking of patients with massive weight loss
is undertaken through a “lift and drop technique” (Fig.30.2)
which involves displacing the ptotic tissues which are at times
heavy and difcult to stabilize. Since the displacement is
asymmetric and signicant, a photographic assessment of the
area has to be undertaken after marking prior to surgery to
conrm the symmetry and placement of the suture lines.
Given that asymmetries in weight loss patients are noticeable
and tough to revise, this preoperative assessment has greatly
contributed to a more predictable operative plan (Fig.30.3).
The markings of the lower limit of excision are usually at a
much lower level in a MWL patient than undertaken traditionally [17].
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Fig. 30.3 Operative plan
R. Calderon
tures contribute to the contour of the anterior torso following
MWL.
1. The skin after massive weight loss is usually of a very
poor quality, very thin, and has striae. It usually hangs
like an apron over the genital area and may extend up to
the anterior thighs.
2. There may be variable amounts of residual fat pockets in
the subcutaneous layer which may be resistant to further
weight loss.
3. The muscle is usually stretched prior to weight loss, but it
does not shrink sufciently with MWL and there may be
associated divarication with ventral hernias specially in
people who have undergone surgeries previously.
4. The shape and tone of the umbilicus are often altered
after MWL.
5. There is usually marked ptosis of the soft tissues of the
Mons pubis.
The upper back rolls are continuous laterally with the
breast extensions and anteriorly with the ptotic deated
breast. The lower back rolls similarly are continuous with the
looseness of skin on the anks and the abdominal pannus.
Noting these associations is important for treatment planning
so that scars of the abdomen are continuous with those on the
back and are well hidden. After MWL, the buttock appears
attened and lacks shape. Lower body lift procedures without gluteal augmentation can accentuate this attening.
30.11 Contouring Procedures [18]
Massive weight loss causes anatomical distortion of the
skin covering the various structures such as the abdomen,
back rolls, thigh folds, gluteal region, breast, neck, and
face. Many of these areas tend to overlap into each other.
For example, the ptotic abdominal pannus continuous with
the decent of the pelvic region, the lateral thigh skin laxity
continues with the ptotic buttocks and the abdomen, and
the loose back Rolls continue with the deated breasts;
hence, it is preferable to correct segments which are continuous with each other. If correction of a single area is
considered without contiguous tissue reduction, then careful planning for future procedures and to prevent dog ears
is required.
The structures of the abdominal wall include skin, subcutaneous tissue, fascia Scarpa and Camper, various abdominal
muscles, umbilicus, and the pubic region. All of these struc-
30.12 Belt Lipectomy
The belt lipectomy is the most common procedure undertaken with patients of massive weight loss. The circumferential lift surgery addresses the drooping outer thighs,
deated drooping buttocks, and hips along with removal of
the abdominal pannus (Figs.30.4 and 30.5). The outer thighs
and buttocks are lifted during this surgery while the abdominal skin is pulled down along with tightening of the muscles
if they are lax. This muscle and fascia can be tightened in
the midline to get horizontal tightening and/or in an oblique
fashion to get a narrow waist. This surgery is rst started in
the prone position. Liposuction is rst undertaken to remove
any residual fat bulges followed by excision of the supragluteal tissues (resection the lower back belt) is performed
followed by turning the patient to a supine position and then
completing the liposuction and abdominoplasty.
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Fig. 30.4 Belt lipectomy markings
a
Fig. 30.5 Belt lipectomy: (a) Preoperative marking showing the extent of skin excision. (b) On table after excision and closure
b
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30.13 Extended Abdominoplasty [19]
The patient after being marked in the standing position
(Fig.30.6) and anaesthetized on a side trolly is rst placed in
the prone position or in one lateral decubitus protecting all
pressure points. The tissues on the posterior and lateral extent
of the incision in the gluteal and hip area is excised rst. The
plane of tissue excision is such that there is a small layer off at
left behind on the muscle. The tissues excision begins in the
area adjacent to the sacrum and extended laterally to remove
the excess tissue marked in the hip region. The pannus is
removed lateral to medial continuously achieving hemostasis
using a Bipolar cautery. The superior and inferior suture lines
are brought together using Vicryl 2-0 sutures in the deep layer
and the dermis with 3-0 PDO inverted deep dermal suture and
3-0 Monocryl by a continuous intradermal suture.
The patient is then placed in the supine position and the
surgical area is prepared with betadine solution. Anterolateral
abdominoplasty is now performed through an incision in the
groin crease and undermining of the superior ap to the subxiphoid region (Fig.30.7). Electrocautery is used throughout
the dissection. If a hernia is present, it is then repaired; the
rectus muscle plicated with continuous 1 polypropylene
suture. Deep 2-0 Vicryl is used in the deep layers. Two
R. Calderon
Fig. 30.6 Lateral markings
Fig. 30.7 Anterior lipectomy
Jackson-Pratt drains are placed anteriorly via separate
wounds in the mons. The dermis is closed with buried 3-0
Nylon, and the skin is closed anteriorly and laterally with
Monocryl 3-0. The umbilical stalk is delivered via horizontal
incision approximately 6 cm above the incision and the
umbilicus sutured using interrupted sutures.
30.14 Fleur-DE-Lis [20]
Most patients of MWL can be treated using the traditional
abdominoplasty techniques and they can be categorized
according to the abdominoplasty system of classication. In
many patients such procedures would not give adequate
relief due to the signicant amount of skin and subcutaneous
tissue laxity associated with weight loss. These patients have
skin laxity in both the vertical and the horizontal abdominal
axis.
Fleur-de-lis is the only surgical technique which can
simultaneously address the two components. This is undertaken by removing the vertical skin excess through the circumferential body lift and the horizontal component through
the midline vertical excision of skin and subcutaneous
tissue.
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Fig. 30.8 Fleur-de-lis
markings (a and b)
a
Initially, the traditional abdominoplasty skin excision is
marked as part of the circumferential body lift taking care
that the lower incision should be lowered to address the ptosis of the mons tissues. Once the vertical excess has been
marked, the horizontally lax skin is now pinched in the midline and an inverted “V” or triangle of excess skin is determined which when excised will decrease the abdominal
girth. The widest portion at the base of the triangle is determined by using a “pinch test”, and is commonly 10 to 16cm
wide (Fig.30.8a, b).
A “pinch test” is performed circumferentially to conrm
excision of the excess tissue which usually involves removing 12 to 16 cm of tissue at the greatest width along the
anks. These markings are then joined with the anterior
abdominal marks to complete the incision design.
Reference vertical markings are made circumferentially
starting at the midline anteriorly and posteriorly, mid- axillary
line bilaterally and in paramedian áreas so as to orient the
superior and inferior aps in such a way that the wound is
closed without any deviation. Vertical references are also
drawn along the back to aid in aligning the upper and the
lower back incisions for closure.
30.15 Operative Technique
Those patients undergoing circumferential treatment must be
placed in a prone position. Incision on the lower back is
made rst and the tissue to be excised is raised at the level of
the muscle fascia. The premarked tissue is excised and the
gluteal a pis pulled superiorly and the superior ap is pulled
b
downwards to check for adequacy of tissue excision. No tension should be placed on the closure of the wounds. Complete
hemostasis is performed during the excision of the redundant
tissue to prevent collection of blood and hematoma. The
supercial fascia system is repaired with 0 Vicryl. The deep
dermis is repaired in interrupted fashion using 3-0 PDS followed by an intracuticular repair using 3-0 Monocryl.
The excision and closure are performed to the midaxillary line previously delineated. The patient is then positioned supine.
The anterior abdominal portion of the procedure is performed in a similar fashion for both the circumferential and
isolated abdominoplasty. The umbilical stalk is rst circumscribed from the surrounding abdominal pannus. The lower
abdominal incision is made extending to the mid-axillary
line or, if the back was treated, to the previous incision lines
laterally. The ap is undermined at the level of the anterior
rectus sheath and continued cephalad to the xiphoid centrally
and the costal margins laterally. The elevated ap is divided
along the midline in a vertical fashion. Excision of the redundant tissue is now undertaken after conrming that the marking of the eur-de-lis tissue excision is adequate and the
marked skin edges would meet at the lower midline
(Fig.30.9a). The muscle diastasis if present is plicated using
permanent sutures. The umbilical pedicle (stalk) if too long
after coring it out is xed to the fascia. This is also done if the
abdominal ap is very thin. Two closed suction drains are
placed and are brought out through stab incisions in the mons
pubis region.
Skin closure of the abdominal incision is undertaken in
the same way as that on the back without any tension on the
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R. Calderon
Fig. 30.9 Fleur-de-lis
procedure. (a) Fleur-de-lis
procedure with suture
providing central anchorage
of lateral aps to mount of
venus, rest of ap remains
unsutured. (b) Same
Fleur-de-lis procedure, now
having been closed, note the
use of micropore tape to
relieve tension on incision site
a
suture line. Finally, the umbilicus is inset in the midline at
the level of the superior iliac crest. A rim of abdominal skin
enough to match the circumference of the umbilicus is
excised in the neo-umbilicus location and the umbilicus is
sutured with 3-0 Nylon (Fig.30.9b).
30.16 Mastopexy
One-stage augmentation mastopexy is a controversial procedure as the required aesthetic outcome may not always be
achieved but is still performed very frequently as the patient
wishes to correct the breast ptosis as well as undergo volume
replacement at the same time in a single surgery [21].
The inherent challenge with undertaking a combined surgery is the pull of opposing forces which complicate operative predictability. The two main components of the deated
breast in a MWL patient include breast hypoplasia with volume loss in the superior pole and excess skin envelope due to
ptosis as well as due to volume loss. To achieve the two
goals—volume addition is undertaken by using a breast
implant while the excess skin envelope is tailored to reposition the nipple areola complex (NAC), reduce breast ptosis as
well as enhance the aesthetic appearance of the breast [22].
b
1. The overall shape of the breast—Whether at with central depression, droopy with empty skin envelopes or
plain small.
2. Position of nipple areola complex—The NAC is assessed
in relation to the inframammary fold according to the
Regnault classication. The NAC is also assessed with
regard to its shape, diameter and position on the breast
mound and checked if it is along the breast meridian.
3. The skin of the breast envelope—The amount of skin
excess is assessed by moving the NAC to its ideal position
and then pinching the skin in the lower quadrant of the
breast. The vertical movement of the NAC to bring to the
ideal position is also conrmed as a vertical skin excess.
4. Choosing an implant—The choice of the Implant depends
on the breast size that the patient looks forward to achieve,
extent of soft tissue and skin envelope, breast footprint
and the nipple to fold measurements. A vertical skin
excess of <2 cm or appearance of a tuberous breast
requires a circumareolar mastopexy, if the skin excess in
the vertical dimension is 2–5cm then a short scar with a
circumvertical or vertical mastopexy but if the NAC has
to be removed vertically for >5cm then an inverted “T”
mastopexy is the procedure of choice.
30.17 Preoperative Assessment
andSurgical Technique
The patient is always examined and assessed in the upright
position. A dimensional analysis of breast tissue is performed. The things to be examined include
30.18 Steps oftheProcedure
1. Always to be marked in the standing position.
2. The most important markings include- marking the inframammary crease on both sides (asymmetries are common), New position of the NAC, marking of the breast
meridian and the medial and lateral skin incision edges.
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3. The new position of Nipple is marked on the breast
meridian at a point 18–21cm from the sternal notch (this
position varies depending on the patient height and the
overall dispensation of the breast which can be low
strung or high strung.)
4. 2cm superior to the nipple position is the upper border
of the new areola.
5. The excess breast envelope is now marked in the lower
quadrant by pinching the skin together in the midline
called the skin-pinch technique (Fig.30.10). The excess
skin is marked in an oval fashion with the lower point
ending 1cm above the existing IMF (Fig.30.11). This
pattern of marking the skin excess prevents overresection of breast skin prior to volume correction.
6. The breast implant is rst placed in the sub glandular
plane using a 4.5cm inframammary incision 1cm superior to the IMF taking care of the inframammary ligaments and preserving the IMF.
7. Once the implant is placed and is centered under the
neo- NAC, the de-epithelization of the NAC is undertaken after using a cookie cutter to mark the residual
NAC diameter as 38 and 42mm.
8. The excess skin to be removed is rechecked and the secondary incision is made just superior and circumferential to the existing areola incorporating a small segment
of periareolar breast skin to release the NAC and allow
movement of the areola to a higher level.
9. A superior or superior-medial pedicle for NAC vascularity is planned and excess breast tissue around the pedicle
and areola is excised. A central segment of the breast
parenchymal tissue is excised as indicated depending on
the presence or absence of redundant tissue centrally and
inferiorly.
10. The central vertically oriented skin is excised and the
medial and lateral aps are undermined. The two pillars
are sutured in layers with adequate closure of the posterior lamella supercial to the implant surface.
11. The nipple-areola complex is now inset into the ideal
position after conrming adequate tightening of the
inferior pole of the breast. The circumareolar suturing is
now completed and the vertical suturing completed with
the length of the vertical limb to be kept between 6 and
8cm (Fig. 30.12). If the skin laxity or the NAC movement superiorly is such that the vertical limb length is in
excess of 8cm then a horizontal incision is made at the
lower aspect of the incision. It is important to control the
position of the NAC in relation to the IMF because this
directly inuences postoperative breast shape
(Fig.30.13).
12. In general, the upper pole of the breast will increase
2cm after augmentation. The goal is to maintain a relationship of 45% superior breast border to NAC and 55%
nipple-areola complex to inframammary fold. A layered
closure is performed [22]
Fig. 30.10 Breast markings
(a and b)
a
b
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R. Calderon
Fig. 30.11 Marking IMF
Fig. 30.12 Vertical limb 6–8cm
Fig. 30.13 Breast symmetry
30.19 Circumareolar Mastopexy [22]
This technique of mastopexy is usually indicated in patients
having Grade I or II breast ptosis or asymmetry of nipple
with minimal or no skin laxity as periareolar mastopexy only
allows elevation of the NAC by at most 2cm [23].
The marking of the new NAC is undertaken similar to the
vertical and T mastopexy discussed before with the upper
border of the new NAC marked rst. The new location is
conrmed by gently pinching the upper edge of the existing
areola border and moving it upwards to a point at the apex of
the breast mound. The skin is marked at this point in the
midsagittal plane and then released. An oval marking is now
made in the periareolar area extending from the apex point
and within 2mm of the areola medially, laterally and inferiorly. An Implant is placed in the subglandular pocket through
the circumareolar or the inframammary incision following
which the incision is made in the periareolar region. The proposed periareolar skin resection is tailor-tacked to conrm
preoperative markings. The tissue between the peri areolar
incision and outer incision is de-epithelized and the dermis
incised at the outer margins. This will limit the excision of
ac
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b
Fig. 30.14 Circumareolar mastopexy: (a) Preoperative, (b) intraoperative, (c) 3months postoperative
465
the normal breast skin and tissue and thus the suture line will
have minimal tension. The incision edges are all undermined
minimally to achieve tissue distribution by using a purse
string suture around the nipple and areola (Permanent Nylon
or Gore-Tex suture). Final adjustments to the skin resection
pattern are made at this point to create the desired effect with
regard to nipple-areola placement. If additional renements
in areola shape are indicated aesthetically, additional skin is
deepithelialized and areola is inset with a 4-0 monolament
suture (Fig.30.14a–c).
30.20 Inverted T Mastopexy
When the breast is signicantly deated, having extremely
loose skin and grade III ptosis so that the vertical mastopexy
will cause a skin excess which is greater than 5cm, then an
inverted “T” mastopexy is considered. The superior or the
supero-medial pedicle is used for the NAC.After the implant
has been placed, NAC repositioned, and the plication of the
medial and lateral vertical pillars, the loose skin is plicated
along the horizontal plane 1cm superior to the IMF.Care is
taken to avoid an extended IMF incision unless absolutely
necessary to reduce postoperative scar visibility, medially
and laterally.
30.21 Complications
Delayed wound healing and seromas were the most common
complications [24].
The higher BMI in MWL patients is associated with
increased occurrence of complications after body contouring
procedures [25].
Messa [22] reported in his series of augmentation mastopexy procedures in 1131 patients that 40 patients had to
undergo revision of the persistent breast drooping or recurrence of the ptosis. This complication is a consequence of
skin stretching or inadequate resection during the primary
procedure. Circumareolar mastopexy was associated with
the higher reoperation rate of 25.7% compared with vertical
(12.7%) and inverted T mastopexy (13.6%) techniques. This
was observed due to higher risk of areola widening causing
asymmetry of the areola size as well as use of circumareolar
breast lift techniques in people who needed a more than 2cm
lift. Massa noted a higher incidence of delayed wound healing, scar hypertrophy, increased signs of localized infection
as well as resurgery in people who smoked.
Seroma formation and skin necrosis were the most common complications after abdominal procedure with Khan
etal. reporting a 12.6% seroma rate and a 1% wound necrosis rate. Sanger and David reported their experience with
18 massive weight loss patients undergoing body contouring surgery. They noted a 27% overall wound complications. Seroma (11%) was their second most common
complication [26].
30.22 Complications inBreast Procedures
Combined withAbdominoplasty
Combined breast and abdominoplasty procedure has a higher
incidence of any major complication, hematoma, infection,
and conrmed VTE (venous thromboembolism) compared
to either procedure performed alone.
Gupta etal. reported the incidence of complications was
higher for the corresponding combined procedure compared
to augmentation (3.48% vs. 1.40%), augmentationmastopexy (4.5% vs. 1.86%), mastopexy (3.96% vs. 1.15%),
and reduction 7.06% vs. 1.58%). A similar observation was
made when comparing the incidence of hematoma, infection
and conrmed VTE [27].
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