Essentials of Aesthetic Surgery

822
Body Contouring
• Type IIB: Moderate skin excess of the entire arm (axilla to elbow), minimal fat excess


).

linear horizontal incision in the axilla (Fig. 58-4, B).

A
B
Type IIB markings. A, Markings for vertical excess only. B, L-shaped excision markings
for horizontal and vertical excess.
• Type IIC: Moderate skin excess of the arm and chest, minimal fat excess

wall.


and carried through the axilla down onto the chest
wall.

58-5).
• Type IIIA: Moderate proximal skin excess, moderate fat
excess
• Type IIIB: Moderate skin excess of the entire arm,
moderate fat excess
• Type IIIC: Moderate skin excess of the arm and chest,
moderate fat excess

skin excess is moderate.

before surgery, staged liposuction followed by
skin resection, or concomitant liposuction and
brachioplasty.

as for type II subtypes.
Type IIC
markings for excess along
the upper arm and chest

axilla to prevent scar
contracture.

823
Chapter 58 Brachioplasty
TWO LLIPSE TECHNIQUE
Outer ellipse based on tissue redundancy
Inner ellipse adjusted to allow for closure
• Avoids potential issues with overaggressive resection, vascular compromise
Steps
• Patient is marked seated with arm abducted and elbow at 90 degrees.
• Amount of redundancy marked using pinch test on medial and lateral arm from the
axillary crease to the elbow (Fig. 58-7, ).
• Inner ellipse is designed by cheating in one-half X, where X is pinch thickness (Fig.
58-7, B).
• Orientation marks made for guidance of closure techniques (Fig. 58-7, C)
Amount of tissue resection based on pinch thickness does not take into account the
B, To account for this discrepancy, the amount of resection
is reduced by one-half X on each side.
Correct level
Danger level
Anterior
Posterior



B
Anterior
Posterior
A
Musculoskeletal
core
Anterior marks
A
B
C
Tissue is pinched below the underlying muscle mass, and anterior and posterior
marks are made. Marks can continue to the distal end of the upper arm to eliminate excess tissue.
B, Marks continue around the upper arm to the axillary crease. These marks are used to create the
inner ellipse but serve as the actual resection line. C, A line through the midline is marked to orient
the resection and allow placement of retraction clamps. Cross-hatched marks guide alignment at
closure.

824
Body Contouring
NOTE:





NOTE:





OPERATIVE PROCEDURE

or on the
The arm is circumferentially prepped extending
onto the chest wall.
The hand and distal forearm are wrapped in a
sterile towel to allow full mobility of the arm.
If concomitant liposuction is desired, it is then
performed.
The previously marked skin excision pattern is
again marked.

placed to ensure proper alignment after
resection (Fig. 58-8).
• The inferior line of the incision is estimated
by a simple pinch test and marked.
The brachial groove is marked, followed by the
superior anchor line of the incision.
• This is drawn with downward tension placed
on the skin to simulate skin excursion.
• The superior anchor line is typically 1-2 cm superior to the brachial groove.
The superior anchor line is incised sharply along with the anterior aspect of the chest

direction, taking care not to violate the deep investing fascia.
If the dissection is carried within 5 cm of the medial epicondyle, care is taken to identify
and preserve the often running with the basilic
vein.

determined preoperatively by the pinch test.


Brachioplasty marked
with vertical cross-hatches. Note the

across the axilla.

825
Chapter 58 Brachioplasty
The tissues of the upper arm are redraped to ensure they are not tethered before the
margins of resection are estimated.

superior direction to estimate how much tissue can be safely removed.

amount of tolerated tension is reached.
• This point is then secured to the superior incision line with suture or a towel clamp.
• This is repeated, moving laterally along the remaining three to four cross-hatched
lines, removing the tissue in a segmental manner.
TIP: Sequential resection/closure allows safe closure of the wound and prevents
overresection in light of the expected edema. The edema can be severe, and wound
closure likely will not be possible if performed after dissection of the entire wound.

clavipectoral fascia with a 0 braided nylon suture to keep the tissue suspended in the
axilla.
6
The dermis is then closed in layers over a closed-suction drain. Aligning the skin edges
as soon as possible is essential so the edema does not prevent wound closure.
After wound closure, a gentle compressive wrap is placed on the arm.
The most catastrophic complication directly related to brachioplasty is

• If this happens one could attempt liposuction to debulk the remaining arm;
however, split-thickness skin grafting using the resected tissue as the donor site may
be necessary.
CAUTION:


TIP:
to prevent contracture across the axilla (see Fig. 58-8).
LIPOSUCTION
In arms (minimal skin excess, moderate fat excess), is the
treatment of choice.
In arms (moderate skin excess, moderate fat excess), one option is to perform


brachioplasty or at an earlier stage.
All agree that edema in the arms can be very problematic for skin closure.

excision during the brachioplasty.8,9

assist with general debulking and smooth contouring into the region in which excision
is performed.

826
Body Contouring
Those who perform liposuction at the same time as the brachioplasty suggest
operating on each arm separately in this order:

removed).
• Wait 5 minutes.
• Perform suction-assisted lipectomy.
• Resect tissue immediately.
• Close the wound.

the medial aspect of the purposed incision.
TIP: Avoid placing the liposuction incisions at the medial epicondyle to prevent ulnar
nerve injury.
SENIOR AUTHOR TIP:

POSTOPERATIVE CARE
After wound closure over a closed-suction drain, a compressive wrap is placed around
the entire arm to decrease swelling.
• Make sure this wrap starts distally at the hand and extends up to the shoulder.
The wrap is typically removed after 48 hours, and the wounds are checked.
Patients are then allowed to shower; however, they are encouraged to keep the arms

Patients should be instructed not to raise their arms or abduct their shoulders for
2 weeks.
• After 2 weeks, gentle range of motion exercises begin.

COMPLICATIONS
By far the most common complaint after brachioplasty is
Counseling patients preoperatively that the scar will not reach maturity until 12 months
postoperative is critical.
Common brachioplasty complications include widened hypertrophic scar, wound
dehiscence, seroma, infection, paresthesias/numbness, scar tethering across the axilla,
residual standing cone of tissue deformities, and recurrent skin laxity.
Complication rates after brachioplasty range from 25%-40% and revision rates range
from 3%-25%.10-12
13 showed that 8.3% of the brachioplasty patients needed a revision
because of scarring.
The most common complication not related to the scar is
(6%-70%).10,13

827
Chapter 58 Brachioplasty
TOP TAKEAWAYS

The most common postsurgical complaint is the scar; therefore, remember to
mark patients using a red marker during consultation to show them where the
scar will be. Have them leave the consultation with the markings to see if they
can get used to it.

Identify your preferred scar placement, and use anatomic landmarks for its
placement.

Combining liposuction with brachioplasty will enhance the overall result.



Consider intraoperative drain placement.
REFERENCES

a retrospective review and cadaveric study. Plast Reconstr Surg 117:2219, 2006.
2. Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to upper arm contouring. Plast Reconstr
Surg 118:237, 2006.

evaluation. Plast Reconstr Surg 126:77, 2010.

Surg 114:1631, 2004.


96:912, 1995.
7. Shermak MA, Mallalieu J, Chang D. Barbed suture impact on wound closure in body contouring.
Plast Reconstr Surg 126:1735, 2010.

the massive weight loss patient: is it safe? Plast Reconstr Surg 131:357, 2013.
9. Baroudi R. Body sculpturing. Clin Plast Surg 11:419, 1984.

loss: a statistical analysis from a prospective registry. Plast Reconstr Surg 122:595, 2008.
11. Cannistra C, Valero R, Benelli C, et al. Brachioplasty after massive weight loss: a simple algo-
rithm for surgical plane. Aesthetic Plast Surg 31:6, 2007.
-
plasty: as retrospective review and cadaveric study. Plast Reconstr Surg 117:2219, 2006.

practice cohort. Plast Reconstr Surg 131:883, 2013.

828
BACKGROUND1
Buttock augmentation rapidly increasing in popularity
• 58% increase in 2014 in the United States according to the American Society for
Aesthetic Plastic Surgery
• Over 35,000 patients have had gluteal implants placed in the United States and
Brazil.
• Approximately 10,000 patients per year undergo buttock augmentation with fat
grafting in the U.S.
• Celebrity and social media attention to gluteal augmentation has attracted even
more interest in the general population.

• Autologous fat grafting
• Silicone implants

INDICATIONS
Ideal for patients in good health who desire improved gluteal shape and contour
Thin patients typically have very dramatic results.
Overweight patients require additional liposuction to improve contour.
Slightly overweight patients are excellent candidates for autologous fat grafting.
• Excellent results seen for patients with excess sacral, lower back, and posterior
triangle fat
SENIOR AUTHOR TIP: The choice of operation, autologous fat grafting versus silicone
implants for gluteal augmentation is typically based on amount of fat available. If the
patient has enough fat, a fat grafting is performed. If not, a gluteal implant is performed.

two strategies (particularly for implants).
CONTRAINDICATIONS
Pregnancy
Neoplasm
Severe comorbid conditions

Sammy Sinno, Constantino G. Mendieta

829
Chapter 59 Buttock Augmentation
PREOPERATIVE EVALUATION
Understand the anatomy of the gluteus maximus muscle (Fig. 59-1).
• Origin along lateral sacrum and continues upward to posterior iliac spine
• Attaches to superior iliac crest
• Inserts into iliotibial tract and greater trochanter
Ideal
diamond
space
Pelvis
Gluteal
muscles
Fat
Midreference line
or midgluteal line
Gluteus maximus muscle anatomy.
Divide each buttock into four quadrants.
TIP: Ideally, each quadrant should have equal volume.
Understand key anatomic landmarks (discussed below).
TIP: The lower inner gluteal fold ideally is diamond shaped.
Evaluate the buttock laterally.
• Presacral area should have a lazy-S shape.
Preoperative pinch test to evaluate donor fat areas
SENIOR AUTHOR TIP: For autologous fat grafting, ensure patients have enough donor
fat, because the amount of fat needed can range from 450-1800 cc or greater per side.

830
Body Contouring
INFORMED CONSENT
Fat grafting patients should be informed that lipoharvest, not liposuction, for removal is
goal.
Silicone implant patients should be informed of risk of wound dehiscence, implant
exposure, capsular contracture, infection, seroma, extrusion, and displacement.
Patients should be encouraged to avoid any medications that may promote bleeding
before surgery.
Enema is given day before surgery.
Preoperative antibiotics are commonly given.
SENIOR AUTHOR TIP: Keep in mind that aesthetic ideals for gluteal augmentation
may vary between ethnic groups.
EQUIPMENT
AUTOLOGOUS FAT GRAFTING

Several techniques for processing, including centrifugation, can be used but are time
consuming.
TIP: A metal strainer can be used to irrigate and purify autologous fat.

SILICONE IMPLANTS


Implant selection (silicone)


• Elastomer solid implant
• Can be anatomic, oval, or round shaped
TECHNIQUE
AUTOLOGOUS FAT GRAFTING ENDIETA
Conceptualizing the 10 aesthetic units of the posterior region is essential.
Respecting these aesthetic units is crucial to obtain a smooth contour (Fig. 59-2).

831
Chapter 59 Buttock Augmentation
Gluteus
Sacrum
Flank
Upper back
Lower back
Outer leg
Diamond zone: inner gluteal/leg injection
Midlateral buttock point C
Inferior gluteal/posterior leg junction
Upper back
1
2
3
8
4
10
6
7
5
9
Mendieta’s 10 aesthetic units or zones. ( Sacrum; upper back; lower
back; outer leg; gluteus; diamond zone: inner gluteal/leg injection; midlateral buttock
point C; inferior gluteal/posterior leg junction; upper back.)
General or IV sedation
Patient marked standing; all zones

• Posterior superior iliac spine (marks gluteal muscle height)
• Presacral “V” (superior point of intergluteal fold and posterior iliac dimples)


• Midlateral buttock contour


will be in prone position)
Wetting solution injected
Supine position

• Most fat in buttock removed from zones 1, 2, 3, and 4
TIP: Typically, liposculpt zones 1 through 4, carefully liposuction in zone 5, and

Suctioning can be performed with patients in either lateral decubitus or prone
positioning, depending on zones targeted.
TIP: It is helpful to have sterile straps to move patients frequently on the operating
table.
Fat is strained in metal strainer.
Fat is loaded into larger syringes and injected.
• Goal is to add volume and improve contour.

832
Body Contouring
Fat injections should be performed with patients in supine, lateral decubitus, and prone
positions.
Penrose drains can be placed to reduce occurrence of seromas but are not necessary.
SILICONE IMPLANTS11,12
(rarely used),

• Submuscular approach has potential for sciatic nerve injury

incidence, although it is more commonly used in the United States.
de la Peña described anatomic basis of subfascial technique, capable of securing
implant with little associated morbidity.13
• Requires textured gel implants
Common locations for silicone implant placement for gluteal augmentation: A, sub-
muscular, B, intramuscular, and C, subfascial.
A
B
C
General or epidural anesthesia
• Paramedial incisions are marked 1 cm lateral to midline.
• Markings must respect gluteal shape (Fig. 59-4).
TIP: Preserve the sacral triangle and infragluteal fold.
• Incision begins 4 cm above the anus and extends superiorly for 6-7 cm.
• Dissection is above presacral fascia, then proceeds laterally to sacral bone.
• 8-10 cm incision is made parallel to lateral sacrum in gluteal aponeurosis, to the
subfascial space.
TIP: Hydrodissection under the gluteal aponeurosis can help to identify the avascular
plane.

833
Chapter 59 Buttock Augmentation
Sharp dissection is performed between
aponeurotic expansions.
Superior and inferior gluteal artery perforators are
ligated, if encountered.

Meticulous hemostasis is achieved and drain
placed.

technique.
Closure with aponeurosis reinsertion is performed
using 2-0 Monocryl.

closed with 4-0 Monocryl.
Skin is closed distinctly and skin glue applied.


One incision is made in gluteal cleft or two incisions separated within the cleft.

Muscle is entered with tonsil.
Using alternate spreading achieves muscle depth of 2.5-3 cm.
Muscle is opened along entire length of fascial incision.
Deaver retractors are used to create a pocket intramuscularly.

Curve deeper as dissection proceeds laterally.
TIP:
Wound is packed with lap pads for hemostasis.
AUTOLOGOUS FAT AUGMENTATION UTOAUGMENTATION OLWELL
AND BORUD
Massive-weight-loss patients have excess skin and fat between the iliac crest and
superior gluteal margin.
• Also have dropping of central crease and inferior gluteal crease
Patient is in standing position while marked.
Anatomic zones are marked as detailed previously.

Upper incision is made just above posterior superior iliac spine and continued laterally
just above the gluteus medius muscle.

TIP:
region and the back.

Skin markings.

834
Body Contouring

Flap is designed around two perforators 6-9 cm from midline on each side (Fig. 59-5).
Superior
gluteal
artery
Flap design with inferomedial rotation.
Midline tissue that does not contain perforators is excised to reduce fullness.
Flaps are deepithelialized.

which is tacked to fascia with 0 PDS suture.
Inferior gluteal skin is advanced superiorly.
Incisions are closed in layers.
Two drains are placed.
POSTOPERATIVE CARE
Similar for all techniques of gluteal augmentation
• Precise details vary from surgeon to surgeon.
Compressive garments worn for 1 month
Sitting restricted to bathroom only for 2 weeks
Otherwise, pressure on buttocks avoided for 6 weeks
Normal activity resumed at 2 weeks
Refrain from exercise for 3 months, refrain from bicycle or horseback riding for
3-6 months (risk of wound dehiscence).
COMPLICATIONS

• Skin irregularities
Infection: 2%
• Pain or sciatica: 2%
• Seroma: 3%
• Fat resorption
• Oil cysts
• Wound-healing problems

835
Chapter 59 Buttock Augmentation
Fat embolus syndrome and macroscopic fat embolism
• Complications that occur when fat enters bloodstream
• Fat can be introduced into the which drains into the iliac veins
then into the inferior vena cava.
• More likely to occur with increased volumes, intramuscular placement, and injection
near the piriformis muscle (location of gluteal vessels)
• Maintain high index of suspicion if patients show signs of
postoperatively.
• Can result in major complications including
• Can be avoided by keeping injection cannula parallel (not perpendicular) to patient and
injections subcutaneous, avoiding excess volumes of injection, and maintain hydration
TIP: A review of the literature showed an approximately 8% complication rate with
autologous fat injection.
: More common19
• Implants have been shown to cause muscle atrophy in CT and three-dimensional
volume studies.
• Wound dehiscence: 10%
• Seroma: 5%
• Infection: 2%
• Paresthesia: 1%
• Implant exposure
• Capsular contracture
• Chronic pain
TIP: A review of the literature showed an approximately 20%-40% complication rate
with silicone implants.
TOP TAKEAWAYS

Buttock augmentation is rapidly increasing in popularity.

Three major methods of augmentation are autologous fat grafting, silicone


The choice of operation for gluteal augmentation—autologous fat grafting
versus silicone implants—is typically based on available fat.

Know and understand Mendieta’s 10 gluteal region zones; zones 1-4 are
typically liposculpted.

Hydrodissection under the gluteal aponeurosis can help to identify the avascular
plane.

Autoaugmentation can be used for gluteal contouring in massive-weight-loss
patients.

In the available literature, gluteal augmentation with implants appears to be
associated with a higher overall complication rate compared with augmentation
using autologous fat. Fat is the preferred reshaping and augmentation method.

Implant augmentation is reserved for patients who do not have enough fat
available for transfer.

836
Body Contouring
REFERENCES
1. American Society for Aesthetic Plastic Surgery. Statistics, surveys, and trends. Available at


Aesthetic Plastic Surgery. Philadelphia: Saunders Elsevier, 2009.

of evolution and experience. Plast Reconstr Surg 128:545, 2011.

Surg 33:347, 2006.
5. Guerrerosantos J. Autologous fat grafting for body contouring. Clin Plast Surg 23:619, 1996.

7. Mendieta CG. Gluteal reshaping. Aesthet Surg J 27:641, 2007.
8. Mendieta CG. Gluteoplasty. Aesthet Surg J 23:441, 2003.

2005.
10. Peren PA, Gomez JB, Guerrerosantos J, et al. Gluteus augmentation with fat grafting. Aesthetic
Plast Surg 24:412, 2000.
11. Robles JM, Tagliapietra JC, Grandi MA. Gluteoplastia de augmento: implante submuscular.

12. Serra F, Aboudib JH, Marques RG. Intramuscular technique for gluteal augmentation: determi-

scan. Plast Reconstr Surg 131:253e, 2013.
13. de la Peña JA. Subfascial technique for gluteal augmentation. Aesthet Surg J 24:265, 2004.
14. Vergara R, Amezcua H. Intramuscular gluteal implants: 15 years’ experience. Aesthet Surg J
23:86, 2003.
15. Vergara R, Marcos M. Intramuscular gluteal implants. Aesthet Plast Surg 20:259, 1996.


2007.
-
agement, and prevention. Clin Plast Surg 33:449, 2006.
-
mentation: a systematic review of outcomes and complications. Plast Reconstr Surg 137:1151,
2016.

implants: a multicenter survey review of 2226 patients. Plast Reconstr Surg 131:897, 2013.

837
ANATOMY

1. Skin
2. Subcutaneous fat

4. Subscarpal fat
5. Anterior rectus sheath
6. Muscle
7. Posterior rectus sheath
SKIN
The skin of the abdominal wall receives a rich vascular supply from multiple muscle and
fascial perforating vessels.
The skin of the abdominal wall can vary in quality depending on a person’s genetics,
age, previous pregnancies, and history of weight gain and loss.
The skin of the abdominal wall may feature multiple which are evidence of

FAT
The abdominal wall has layers of fat, separated by Scarpa
fascia (Fig. 60-1).

Deep subscarpal fat
Abdominal muscle layer
Skin
Scarpa fascia (SFS)

• The of fat is thicker, more dense, more durable, and has a heartier
blood supply.
• The of fat is less dense and receives most of its blood from the
subdermal plexus and underlying myocutaneous perforators.
SENIOR AUTHOR TIP: Because the blood supply to the deeper fat is distinct from the
blood supply to the skin, it can be more easily excised when thinning the abdominal

to vascular compromise of the overlying skin.

838
Body Contouring
There are of the abdominal wall.
1. Rectus abdominis
2. External oblique
3. Internal oblique
4. Transversus abdominis
The aponeurotic portions of the transversus muscle and the two oblique muscles
envelop the rectus abdominis muscles, forming the anterior and posterior rectus
sheaths and meeting in the midline to form the linea alba.
The represents a transition point.
there are distinct anterior and posterior rectus sheaths.
contributions from the internal oblique and transversus
abdominus join contributions from the external and internal obliques to form a
single anterior rectus sheath with no posterior rectus sheath.
• The arcuate line is roughly halfway between the umbilicus and symphysis pubis.
VASCULARITY OF THE ABDOMINAL WALL
Huger1 divided the vascular supply to the abdominal wall into (Fig. 60-2).
I
II
II
III
III



Deep superior
epigastric artery
Femoral artery
External pudendal
artery

epigastric artery

femoral artery
Eleventh posterior
intercostal artery
Deep inferior
epigastric artery
Huger vascular zones.
• Zone I

horizontal line drawn between the two anterior superior iliac spines (ASIS)


• Zone II

creases
and

• Zone III

and vessels
Sensation to the abdomen is from

839
Chapter 60 Abdominoplasty
NERVES AND THE ABDOMINAL WALL
LATERAL CUTANEOUS BRANCHES
Perforate the intercostal muscles at the midaxillary line
Travel within the subcutaneous plane
ANTERIOR CUTANEOUS BRANCHES
Travel between the transversus abdominus and internal oblique muscles to penetrate
the posterior rectus sheath just lateral to the rectus
Eventually enter the rectus muscles and then pass to the overlying fascia and skin
LATERAL FEMORAL CUTANEOUS NERVE
Innervates the skin in the lateral aspect of the thigh
Emerges close to the ASIS
Inguinal ligament
Femoral nerve
Femoral artery
Femoral vein
Pectineus muscle
Gracilis muscle
Adductor longus muscle
Vastus medialis muscle
Rectus femoris muscle

cutaneous nerve
Tensor fascia
lata muscle
Vastus lateralis muscle
A
B
A, Diagram of the nerve anatomy. B,
ASIS in relation to the umbilicus.
TIP: To prevent injury, a layer of fat should be left over the ASIS.

840
Body Contouring
The umbilicus is located
• The umbilicus is located exactly in the midline of the body in only 1.7% of patients.2
• An has the following characteristics3:




(Fig. 60-4)




Flow along
ligamentum teres
Subdermal vascular
plexus
Small perforators from deep
inferior epigastric artery
Flow along median
umbilical ligament
Superior epigastric artery
Arcuate line

inferior epigastric artery
Deep inferior
epigastric artery
Blood supply to the umbilicus.
AESTHETIC ASPECTS OF ABDOMINOPLASTY4
Incision should be low and symmetrical
Umbilicus
• Inverted scar
• Superior hooding
• Circular or ellipsoid
Scaphoid abdominal wall
Smooth transition at the incision
Aesthetic appearance of mons pubis
INDICATIONS AND CONTRAINDICATIONS
Due to the number of variations of the abdominoplasty procedure, it is key to select the
appropriate technique for each patient to minimize morbidity and deliver the intended
result (Table 60-1).
5 Selection of appropriate technique is based on the patient’s
expectations and physical examination.

841
Chapter 60 Abdominoplasty
Indications






6
Mild
None
Good
None

endoscopic repair
Mild
None
Good
Present
Miniabdominoplasty
Infraumbilical
Infraumbilical
Good
Present
Traditional or
lipoabdominoplasty


infraumbilical
region


infraumbilical
region
Fair to poor
Present
Circumferential
Mild to moderate
Extends to back
Fair to poor
Present
High-lateral-tension
Mild to moderate

area and thigh
Poor
Present
Fleur-de-lis
Mild to moderate
Vertical and
horizontal
Fair to poor
Present
Reverse abdominoplasty
Mild to moderate
Upper abdomen
Fair to poor
Present
CONTRAINDICATIONS


contraindications for an abdominoplasty.

• Right, left, or bilateral upper abdominal scars

cigarette smoking)
• Plans for future pregnancy
• A history of thromboembolic disease
are particularly concerning, and many of these patients are not
optimal candidates for a traditional abdominoplasty.


Patients with a disposition to formation or have to be
accepting of the poor scarring associated with these conditions.

satisfaction.
• Most massive-weight-loss patients are not candidates for abdominoplasty alone and
will require circumferential procedures.
can lead to serious problems postoperatively,
possibly resulting in abdominal compartment syndrome.
• In cases of elevated intraabdominal pressure, the abdominal wall elevates above a
line between the costal margin and iliac crest in the supine position.
• Abdominoplasty procedures with or without rectus plication have to be performed
cautiously in the nonscaphoid abdomen.

842
Body Contouring
PREOPERATIVE EVALUATION

• Prior cesarean section or other abdominal surgeries
• Pregnancy history

• Prior liposuction in the abdominal area
• Thromboembolic risk
• Smoking status
• Hormone use
• History of postoperative nausea and vomiting (PONV)
TIP: Abdominoplasty is an enormous stressor in terms of blood supply to the
abdominal wall. To minimize complications, avoid operating on active smokers. If
a patient has a history of smoking, insist that the patient quit smoking prior to the
procedure. A thorough discussion of the increased risk of complications associated
with smoking must occur. In certain cases, a urine nicotine test may be warranted
preoperatively and postoperatively should complications occur.
Other patient factors to consider include:

• Exercise routine
• Gastrointestinal history including irritable bowel syndrome or constipation
• Cardiac and pulmonary history (including obstructive sleep apnea)
• Desire for future pregnancy (patients should be encouraged to wait)
Physical examination must explore the existence and localization of vertical and
horizontal abdominal tissue excess and its relation to the underlying abdominal wall;

TIP: If the patient is examined only in the standing or supine positions, one may be
fooled into thinking there is little to no excess skin. The patient must be examined while
standing, sitting, and supine.
Musculofascial laxity must be thoroughly assessed (Fig. 60-5).
• A

60-5).
• The

• Midline must be assessed by palpation of a tensed abdominal wall
in the supine position.
TIP: Nearly all patients who have been pregnant have some degree of musculofascial
laxity of the abdominal wall in addition to excess skin.

843
Chapter 60 Abdominoplasty
The classic “diver’s test” demonstrating the extent of abdominal wall laxity.
or is imperative.
Examination should include evaluation for incisional, epigastric, periumbilical, and
inguinal hernias—especially in patients with prior abdominal surgeries and massive
weight loss.
TIP: The importance of a thorough hernia examination cannot be overstated.
Preoperative knowledge of hernias can help the surgeon avoid bowel injury during
dissection. Depending on the site of the hernia and the comfort level of the plastic
surgeon, preoperative knowledge of a hernia may allow repair to be coordinated with a
general surgeon. In cases of uncertainty, a computed tomography (CT) scan is indicated.
• The presence of represents alterations to the blood supply of the abdominal
wall and must be thoroughly assessed.
may limit the inferior movement of the abdominal skin

represent an interruption of the superolateral blood supply that

risk of complications).
CAUTION:



• Examine for or on the abdominal wall, especially under the
pannus in obese and massive-weight-loss patients.
• Photographic documentation consisting of eight views should be obtained
preoperatively and postoperatively: anterior, oblique anterior, side, oblique
posterior, posterior, anterior sitting position, bending position (both front and side
views) (see Chapter 3).



central and waist areas may also prove useful.

844
Body Contouring
INFORMED CONSENT
In addition to the standard risks of surgery, the surgeon must discuss the location and
length of with the patient. Considerations include:
• Standard lower abdominal transverse scar
• Standard circumumbilical scar
• Potential need for a midline vertical scar
• Potential for cutaneous deformities or “dog-ears” at the lateral ends of the
abdominoplasty incision
Abdominal located inferior to the umbilicus may be removed as part of the
abdominoplasty. Above the umbilicus, striae will not be removed and
as a result of abdominoplasty.
Wound-healing complications must be discussed as both the transverse incision at the
waist and the umbilicus are at risk due to the blood supply to these regions following
the abdominoplasty procedure.
must be discussed; patient should be reminded
that the structure is truly midline in only of patients.2,7
Risk of postoperative formation should be discussed; the need and purpose for
postoperative drains should be thoroughly explained (if used).
Comprehensive postoperative care instructions should be fully discussed. The use of
any additional recommended materials such as compression garments or specialized
dressings and the associated costs should be fully disclosed.
Potential need for secondary revision surgeries or additional procedures must be
discussed.
TIP: Most patients requesting abdominoplasty have at least some degree of fat excess

The patient should be made aware of this and should be encouraged to consider
concomitant or staged liposuction procedures. Failure to disclose this preoperatively
will result in an unhappy patient with a less than optimal result.
Financial arrangements and the patient’s responsibilities for procedures should be
explained and agreed upon preoperatively. The discussion should include fee structures
for secondary procedures.
Patients must understand that they may not be able to walk fully erect for several

minimum of 6 weeks without strenuous exercise or lifting.
The patient must be warned of the risk and life-threatening nature of venous
thromboembolism. Fully detail strategies utilized to minimize this risk (e.g., early
ambulation, pneumatic compression devices, chemoprophylaxis)
8 (see Chapter 11).
TIP: SCD must be applied and started prior to induction of anesthesia.

845
Chapter 60 Abdominoplasty
Risk in the literature is 0% to 0.8%. The Surgical Care Improvement Project

Box SCIP PROTOCOL
Shaving is not required. Do not use razors.
IV antibiotics given 30-59 minutes before the incision
24 hours of postoperative antibiotics
Elective surgery with Hgb A1C <7
Avoid intraoperative hypothermia
Foley catheter out within 24 hours
TECHNIQUE
TRADITIONAL ABDOMINOPLASTY

TIP: Patients should be encouraged to wear their undergarments of choice the day of
surgery to aid in planning of the incisions and scar placement.

superior iliac crest.
The planned incision should be marked transversely at the level of the pubic bone.
• At least must be left between this incision and the top of the vulval
commissure to prevent postoperative deformity.
The planned incision should extend laterally below the anterior superior iliac spine
(ASIS).
If possible, keep the incisions low in order to prevent visibility of the scar.
With the patient standing, the lateral aspects of the abdominal folds are marked. This is
a guide to the lateral extension of the incision.
A pinch test should be performed to determine how much skin could be comfortably
resected and a proposed upper incision is marked.
Areas for concomitant liposuction should be marked at this time.

Orientation of the umbilicus can be done with placement of two traction sutures
180 degrees apart.
The umbilicus is incised circularly, and dissecting scissors are used to separate the
umbilicus from the subcutaneous fat all the way down to the rectus sheath.
TIP:
stalk can lead to compromised vascularity of the umbilicus and postoperative necrosis.

846
Body Contouring
The inferior incision is carried out bilaterally and dissection is taken through Scarpa
fascia.
TIP:
prevent injury to the lateral femoral cutaneous nerve. Injury to this nerve can cause

known as ). van Uchelen et al found a 10% incidence of injury in
their review of abdominoplasty procedures9 (see Fig. 60-3, B).
The skin and fat of the abdominal wall is elevated from the underlying fascia in a loose
areolar plane up to the costal margins and the xiphoid process.

TIP: As dissection proceeds along the musculofascia centrally, be careful not to
transect the umbilical stalk. A number of periumbilical perforators present serve as
warning to the surgeon to slow dissection and preserve the umbilical stalk.

or hernia repair is performed (Fig. 60-6). Rectus plication
should be performed with

10
• A cotton-tipped applicator is used to apply methylene
blue to the rectus sheath in an elliptical area to be
imbricated.
• The rectus sheath is imbricated by placing
interrupted sutures along the borders of the
elliptical area.
• Reinforcing sutures should be run from the xiphoid
process to the umbilicus and from the umbilicus to
the pubis.
• Horizontal plication sutures are used if necessary.
TIP: It is vital to begin rectus plication at the level of the xiphoid process. Failure to do
so can result in a postoperative bulge in the epigastric area.
Surgical drains, if used, should be brought out through the lateral incision, thus

permanent suture.

30 degrees. The amount of skin and fat that can safely be removed and allow for a
tension-free closure is marked.
Excess skin and subcutaneous fat are resected.
Copiously irrigate the wound and temporarily tack the skin closed.
Plication sutures
of abdomen, including hor-
izontal sutures.

847
Chapter 60 Abdominoplasty
SENIOR AUTHOR TIP:
necessary, do not hesitate to extend the scar laterally

the abdominal wall (which may obviate drain placement).
The level of the umbilicus is transposed with a marking pen to the overlying skin of the
abdominal wall; the umbilicus is inset.

followed by closure of the deep dermal and subcuticular layers. Surgical cyanoacrylate
glue may also be applied.
TIP: If surgical cyanoacrylate glues are used, be sure to allow adequate drying time
prior to applying a gauze dressing.
A gauze dressing is placed and held in place with an abdominal binder. The patient is

PROGRESSIVE TENSION SUTURES

2-0 Vicryl or running continuous barbed suture.

the incision.
Decreased tension on the incision prevents necrosis and hypertrophic scars.
The dead space is closed, preventing hematoma and seroma formation.
Sutures can be used in lipoabdominoplasty, other forms of abdominoplasty, and body
contour surgery.
13
Progressive tension sutures.

848
Body Contouring
LIPOABDOMINOPLASTY14
The areas for liposuction are marked, usually avoiding liposuction of the upper midline.
Superwet technique is used.

A thin layer of fat is left on the abdominal wall to preserve lymphatic supply. At least
17% of lymphatics are preserved below Scarpa fascia.15

most commonly to the lateral border of the rectus3,16 (Fig. 60-8).
Area to be
loosened
Area to be
preserved
(neurovascular
bundle)
45-degree
angle
cannula

7.5 cm
15 cm

surgical
dissection

liposuction

The abdominal perforators at the lateral aspect of the rectus muscle are preserved.8
Progressive tension sutures (PTS) and/or drains can be used.
Saldanha et al14 theorized that 80% of blood supply, nerves, and lymphatics are
preserved with this technique, thus contributing to their low rate of seroma (0.4%),
dehiscence, necrosis, and hematoma. The incidence of DVT and PE remain the same.
Roostaeian et al17

lipoabdominoplasty was as safe as traditional abdominoplasty.
SENIOR AUTHOR TIP:
are followed. Flap perfusion is equivalent in traditional lipoabdominoplasty compared
to traditional abdominoplasty.
MINIABDOMINOPLASTY
The miniabdominoplasty is indicated in patients with primarily an excess of isolated
3,16 This is not a very common procedure.
A is planned than for traditional abdominoplasty; the scar should be
in length.

849
Chapter 60 Abdominoplasty

is transected at the level of the anterior rectus sheath.
• The fascial defect created by umbilical transection be repaired.
Rectus diastasis, if present, is repaired using or

Excess skin and fat is resected; this is a much more conservative resection than
performed for traditional abdominoplasty (Fig. 60-9).
• The umbilicus will generally move using this technique.

abdominal contour, especially in the supraumbilical region.
A
B
C
Miniabdominoplasty. A, Skin elevated and skin cut out. B, Musculofascial repair. C, Scar.


skin infraumbilically that is primarily in nature and excess skin in the epigastric
region that is primarily in nature.
18


the skin.
• During the procedure, less skin is taken centrally and more is resected laterally,
resulting in an of pull.
• Undermining is only performed centrally in an area that allows for rectus plication.
The procedure also has the advantage of performing a lift of the anterior and lateral
thighs; it also allows for liposculpture of the abdominal wall.
Patients must be aware the scars are typically longer and higher in this procedure.

• Marking begins with a suprapubic mark 7.0 cm superior to the vulvar commissure or
base of the penis.
• The ASIS is marked bilaterally and connected to the suprapubic mark.
• The vertical excess of infraumbilical skin is then pulled taut and the edge of the skin
meeting the inferior incision line is marked.
• Excess skin laterally is tested using a pinch test and marked; this is then connected
to the inferior edge of the vertical excess.

850
Body Contouring
• The proposed incision should lie below the level of the umbilicus centrally and above
the level of the umbilicus laterally.
• Proposed areas of liposuction are then marked both centrally and laterally.


centrally just enough to allow for rectus plication; rectus plication is performed.

fascia but is loosened by discontinuous undermining using vertical spreading with

Underminer.

using a pinch test.
TIP: Remember, the more skin and fat should be resected laterally than centrally when
utilizing this technique.

place. Alternatively, it can also be excised and translocated as in a traditional
abdominoplasty procedure.
• The wound is temporarily tacked closed and then liposuction is performed.
• Drains are placed and secured.

sutures, followed by closure of the deep dermis and the skin.

The technique allows for excision of both lower abdominal skin and fat and
supraumbilical horizontal excess skin through a transverse incision.19
The vertical midline incision can be taken as high as the xiphoid process and as low as
the mons pubis, depending upon the areas of skin laxity.
TIP:
3
This procedure can cause powerful changes to the abdominal contour not available
with other techniques. The resulting scars must be discussed with the patient because

Before
After
Fleur-de-lis
abdominoplasty.

851
Chapter 60 Abdominoplasty
REVERSE ABDOMINOPLASTY
A transverse upper abdominal incision is made roughly at the level of the inframam-
mary fold, and redundant superior abdominal tissue is pulled up to meet this incision
and excised.
20
The principal indication for this procedure is the correction of redundant tissue left
superiorly after lower abdominoplasty; rarely a patient will present with isolated excess
skin and abdominal protuberance in the epigastric region of the abdomen.
The reverse abdominoplasty can be combined with breast procedures (e.g., a Wise-
pattern reduction of mastopexy) as the inframammary fold incision can be used for
both procedures.

Excised skin
Incision
Undermined skin
Muscle repair
Liposuction
Liposuction incisions
Reverse abdominoplasty.
POSTOPERATIVE CARE
Operations can be performed in either outpatient or inpatient setting.
• Miniabdominoplasty can easily be performed on an outpatient basis.
• Traditional abdominoplasty can be safely performed as an outpatient procedure in
healthy patients.
21
• Patients with preexisting scars should be observed for possible disturbances of
blood supply.
frequent breathing exercises and use of incentive
spirometer should be encouraged to prevent postoperative atelectasis.
Drains, if used, are left in place until discharge is <30 ml in two-consecutive 24-hour
periods; showering is permitted following drain removal.

hip joint) for 2-3 weeks postoperatively to ensure tension-free healing.
Postoperative follow-up examinations should evaluate for seroma formation.
Patients should be asked about bowel function; stool softeners should be provided to
avoid constipation and straining with defecation (especially when plication or hernia
repair has been performed).
Silicone sheeting or steroid impregnated tape may be applied to the incisions once
healed for a period of 3 months, which may improve the appearance of the scars.

852
Body Contouring
Strenuous activities should be avoided for a minimum of 6 weeks postoperatively
(8 weeks in the case of hernia repair or plication).
An abdominal binder is worn until the drains are removed. At this time the patient is
switched to compression garments. Often times, patients enjoy the compression and
security of the garments and elect to wear them a few months after surgery.
Patients should be advised to avoid sunbathing or tanning beds for 1 year
postoperatively to avoid pigment changes in the remodeling scar. Sunblock should be
liberally applied when sun avoidance is not possible.
Any complaint of shortness of breath should be taken seriously and venous duplex
ultrasound should be considered on stable patients.
COMPLICATIONS
Patients can routinely expect postoperative pain and soreness, numbness of the

tension for weeks following the procedure.
22-25:
• Hematoma (0.6%-1.3%)
• Seroma (5.0%-15.4%)
• Wound infection (0.3%-3.5%)
• Fat necrosis (2.0%)
• Wound dehiscence (2%)


necrosis
• Paresthesias and persistent numbness
22-25:
(0.3%-0.8%) (see Chapter 11)
• The Caprini risk assessment model is a helpful tool to determine a patient’s risk for
deep vein thrombosis (Fig. 60-12).
• Respiratory compromise and abdominal compartment syndrome
• Systemic infections
Surgeons should be aware that abdominoplasty, especially when combined with other
procedures such as liposuction, has a higher systemic complication rate than any other
type of routine aesthetic surgical procedure.
If chemoprophylaxis used, administer for 7 days postoperative.
Any patient with complaints of postoperative shortness of breath should have a venous
ultrasound.
PE is evaluated with CT scan.
Future studies still needed to determine indications, dosage, timing and length of
prophylaxis

853
Chapter 60 Abdominoplasty














(<1 month)



Caprini risk assessment model.











If yes:

















(<1 month)


therapy



premature birth with toxemia or growth-
restricted infant
Continued
TOP TAKEAWAYS

An abdominoplasty is considered a major surgical procedure and must be
approached systematically to avoid complications.

It is mandatory to analyze any suspected skin tumor in the area of excised
tissues.

Be precise in determining the best procedure for the patient based on
preoperative expectations and physical examination.


possible.

Examine abdominal wall for scars, rashes, and hernias.

854
Body Contouring

Consider CT scan of abdominal wall if ventral hernias are suspected.

Examine abdominal wall in a supine position to measure if it is scaphoid and
amenable to plication.

To get best results, encourage liposuction of lower back and mons pubis if
needed.

Preoperative medical evaluation is imperative before operating.

Have policies for operating on smokers and diabetics.

Address constipation and consider a laxative, such as polyethylene glycol 3350,
preoperatively and postoperatively.

Have patients clean umbilicus daily starting the week before surgery.

Determine history of postoperative nausea and vomiting and be proactive to
prevent this complication.

DVT risk assessment for all patients and strategy for high-risk patients

Consider using the SCIP protocol to decrease surgical site infections (SSIs).

Try to keep incisions low.

Intraoperative photos to document results and tissue resected

Extend the incision to get rid of “dog-ears.”

Try to achieve an aesthetic umbilicus and mons pubis.

Do not overuse antibiotics. Get cultures of wounds to guide treatment.

Any postoperative patient with shortness of breath gets evaluated for venous
thromboembolism.
REFERENCES
1. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am Surg 45:612, 1979.
2. Rohrich RJ, Sorokin ES, Brown SA, et al. Is the umbilicus truly midline? Clinical and medicolegal
implications. Plast Reconstr Surg 112:259, 2003.

2005.
-
noplasty. Aesthet Surg J 35:972, 2015
5. Hunstad JP, Repta R. Atlas of Abdominoplasty. Philadelphia: Elsevier Health Sciences, 2008.
6. Rohrich RJ, Beran SJ, Kenkel JM, et al. Extending the role of liposuction in body contouring with
ultrasound-assisted liposuction. Plast Reconstr Surg 101:1090, 1998.

Reconstr Surg 113:1089, 2004.

2008.
9. van Uchelen JH, Kon M, Werker PM. The long-term durability of plication of the anterior rectus
sheath assessed by ultrasonography. Plast Reconstr Surg 107:1578, 2001.

Plast Reconstr Surg 115:1736, 2005.
11. Pollock H, Pollock T. Progressive tension sutures: a technique to reduce local complications in
abdominoplasty. Plast Reconstr Surg 105:2583, 2000.
12. Pollock T, Pollock H. Progressive tension sutures in abdominoplasty: a review of 597 consecu-
tive cases. Aesthet Surg J 32:729, 2012.

855
Chapter 60 Abdominoplasty
13. Rosen A. Use of absorbable barbed suture and progressive tension technique in abdomino-
plasty: a novel approach. Plast Reconstr Surg 125:1024, 2010.

2009.

abdominal wall: an anatomical study. Plast Reconstr Surg 135:1027, 2015.


17. Roostaeian J, Harris R, Farkas JP, et al. Comparison of limited-undermining lipoabdominoplasty


Plast Reconstr Surg 96:603, 1995.

20. Baroudi R, Keppke EM, Carvalho CG. Mammary reduction combined with reverse abdomino-
plasty. Ann Plast Surg 2:368, 1979.


Plast Reconstr Surgery 118:517, 2006.
22. Stewart KJ, Stewart DA, Coghlan B, et al. Complications of 278 consecutive abdominoplasties.
J Plast Reconstr Aesthet Surg 59:1152, 2006.
23. Alderman AK, Collins ED, Steu R, et al. Benchmarking outcomes in plastic surgery: national
complication rates for abdominoplasty and breast augmentation. Plast Reconstr Surg
124:2127, 2009.
24. Winocour J, Gupta V, Ramirez JR, et al. Abdominoplasty: risk factors, complication rates, and
safety of combined procedures. Plast Reconstr Surg 136:597e, 2015.
25. Neaman KC, Armstrong SH, Baca ME, et al. Outcomes of traditional cosmetic abdomino-
plasty in a community setting: a retrospective analysis of 1008 patients. Plast Reconstr Surg
131:403e, 2013.

856
ANATOMY
The medial thigh has a relatively thin outer layer of epidermis and dermis.

system.
Deep to the subcutaneous fat lies the strong, thick .1-4
• Attaches to the ischiopubic rami of the bony pelvis, to Scarpa fascia of the
abdominal wall, and to the posterior border of the urogenital diaphragm
• Has an especially strong area at the junction of the perineum and the medial thigh

• Best found intraoperatively by dissecting at the origin of the adductor muscles on the


5
The lies lateral to the Colle fascia dissection (Fig. 61-1).
• Midinguinal point between the pubic symphysis and anterior superior iliac spine
• Borders



NOTE:

Inguinal ligament
Femoral nerve
Femoral artery
Femoral vein
Adductor longus
muscle
Inguinal ligament
Femoral nerve
Femoral artery
Femoral vein
Adductor
longus muscle
Sartorius muscle
Femoral triangle
Femoral triangle.

857
Chapter 61
INDICATIONS AND CONTRAINDICATIONS
INDICATIONS
The indication for a medial thigh lift is the presence of Without skin laxity,
thigh contouring may be achieved with liposuction alone.
Accurately classifying the deformity is critical for guiding treatment (see Tables 61-1
through 61-3).
CONTRAINDICATIONS
Contraindications for performing a medial thigh lift are similar to those for any elective
or aesthetic procedure and include the following:

• Unresolved depression
• Unrealistic expectations
• Unwillingness to accept a lengthy scar or likelihood of common complications

disease, postphlebitic syndrome, or lymphedema
PREOPERATIVE EVALUATION: HISTORY AND PHYSICAL
EXAMINATION
A complete history is obtained, with special attention to the following:
• Smoking status
• Nutrition status, with adequate protein and vitamin supplementation in bariatric
patients
• Weight history, especially weight stability
• Surgical history, i.e., previous body contouring procedures
• Psychiatric evaluation
• Plans for other body contouring procedures and priority problem areas for the
patient
A complete physical examination is performed, with special attention to the following:
• Presence, location, and degree of skin ptosis—drape, bulges, tension, the pattern of
sagging (i.e., proximal versus distal)
• Skin tone and the relationship of skin to the underlying adipose
• Context of the remaining thigh and lower body deformity

lower body, which may be addressed with liposuction during surgery
Standardized photographs should be taken (see Chapter 3).

858
Body Contouring
CLASSIFICATION SYSTEMS


Patients



Type I


Type II

to the upper third of the thigh

incision in the medial thigh
Type III

that extends beyond the upper third of
the thigh
Both liposuction and horizontal and
vertical skin excision in the medial
thigh
Type IV
Moderate skin laxity that extends the
length of the thigh

Type V
Severe medial thigh skin laxity with
lipodystrophy
Staged procedure:
First stage: Aggressive liposuction
Second stage: Excisional medial thigh lift





Type I


Horizontal vector thigh lift
Type II

lipodystrophy
Staged suction lipectomy and
horizontally based medial thigh lift

Pittsburgh Rating Scale



0
Normal
None
1
Excessive adiposity

2
Severe adiposity and/or
severe cellulite

3
Skin folds
Excisional lifting procedure
Suction-assisted liposuction; ultrasound-assisted liposuction.

859
Chapter 61
TIP: Careful evaluation of each patient’s deformity is needed to determine the best
treatment.
SENIOR AUTHOR TIP: Careful evaluation of the lower leg preoperatively is
essential. Many patients after weight loss will present with which should
be differentiated from preexisting lymphedema. The feet and ankles should be
photographed preoperatively so that patient concerns of postoperative swelling can
be assessed in comparison with the baseline examination.
The thigh can be addressed in thirds, regardless of whether patients have had massive
weight loss. Skin laxity in the upper third can be treated by a medial thighplasty


the knee and encompassing the entire thigh can be treated with a full-length vertical
thighplasty. Global thigh adiposity is best treated with staged procedures: debulking



relax in a medioinferior direction; thus a staged medial thigh lift can help to correct any
of the residual laxity after the initial body lift. If a patient had a prior abdominoplasty
or panniculectomy, medial thighplasty can be combined with a lower body lift in a

INFORMED CONSENT
The informed consent should include the likely possibility of wound complications and
the possibility for extension of the incision/scar.
SENIOR AUTHOR TIP: Thighplasty can have most of the complications seen in body
contouring. Because the rate of minor wound-healing complications is very high
with this procedure, they should be discussed in detail with patients before surgery
to prevent postoperative dissatisfaction. Complications include seroma, hematoma,
delayed wound healing, scar migration, prolonged pain, swelling or change in the
shape of the genital region, tissue relaxation, leg swelling (which may be permanent
and require chronic care [lymphedema]), unsatisfactory thigh contour and shape,
incomplete correction of loose skin at the knee, and risk of deep vein thrombosis (DVT)
or pulmonary embolism.
EQUIPMENT
The medial thigh lift is a procedure with various methods of patient positioning and
can be combined with other body contouring procedures, requiring lengthy operating
times.

860
Body Contouring
In addition to liposuction equipment, sequential compression devices for venous
thromboembolism (VTE) prophylaxis, drains, warming blankets, and compression
garments, surgeons also require equipment for appropriate patient positioning and
padding.
TECHNIQUES
The preoperative marking process helps to reinforce and inform patients regarding scar
length and expectations. Markings may be made on the same day or the night before
surgery.
Given the biomechanics of skin excess, this procedure may also be combined with
lower body lift and abdominoplasty.
CLASSIC MEDIAL THIGH LIFT WITH TRANSVERSE SKIN EXCISION/UPPER
THIGH CRESCENT EXCISION

• The patient is in a standing position with knees apart.
• Skin is retracted medially and posteriorly and marked for excision.
• Areas of excess fat are marked for liposuction.
• The femoral triangle is marked to prevent damage to neurovascular and lymphatic
structures.
• The incision is marked from the level of the ischium along the inner surface of the
buttock’s fold medially and inferiorly to the labia majora (female).
• Skin laxity beyond the upper third of the thigh is examined (pinch test) for the need
to add a vertical component to the incision (Fig. 61-2).
• Patients may also be in a recumbent position for marking (Fig. 61-3).
B, Vertical incision thighplasty. (Dark gray
shading indicates liposuction; red shading indicates resection; arrows indicate vectors of pull.)
Liposuction
Resection
A
B

861
Chapter 61
Upper medial thighplasty. A, The

an assistant pushes the loose thigh skin toward
the knee, the superior incision is drawn between
the labia majora and thigh. B, The point of
maximal resection along the mid-medial thigh is

C, As the thigh is again abducted, the crescent-
shaped inferior incision line is extended from
this inferior resection mark anterior to the outer
mons pubis line and posterior to the buttock-
thigh junction line.
Superior incision line
A
Point of maximal
resection
B
Inferior incision line
C
SENIOR AUTHOR TIP: Patients should be marked while they are in a frog-leg position.
This will allow surgeons to determine a safe amount of tissue to resect to prevent
labial distortion postoperatively when the patients spread their legs. Overestimating
a resection when patients are standing can lead to overresection and labial distortion
when the legs are spread.
All medial thighplasty scars are placed close in the pubic region to frame it and to
prevent visible scars on the thighs, which can migrate inferiorly over time. I typically
mark patients 4 cm lateral to the vulval commissure to keep the scar in close.

• The surgery begins with the patient in the prone position; liposuction of the hip and
thighs is performed, followed by excision of the posterior portion of skin and fat.
This wound is closed in layers.
• The patient is then placed in a supine position; further liposuction is performed.
• The legs are placed in a frog-leg position. The proximal incision is made, with care
to not violate the femoral triangle, followed by undermining down to the caudal
incision.

862
Body Contouring

ramus.


and femoral triangle are preserved, to prevent lymphatic complications.

fascial system of the medial thigh skin.
• Drains are placed, and the skin is closed with deep dermal and subcuticular layers.
Skin glue and Steri-Strips may also be used.
SENIOR AUTHOR TIP:
Some evidence shows that liposuction outside the zone of resection can lead to an
increase in infection postoperatively. Care should be taken to avoid liposuction in the
banana roll of the buttocks to prevent contour deformity.
Dissection is superficial in the femoral region to the adductor longus tendon.
All anchoring sutures are placed distal to the adductor longus to prevent injury to
lymphatics and other structures in the femoral region. Three 2-0 absorbable braided

the groin to prevent labial distortion. These sutures are placed when the patient is in
a frog-legged position and tied when the leg is adducted into a supine position. Care
should be taken to not grab any of the thigh muscle or muscle fascia when placing these
sutures, because movement after surgery can cause them to tear and lead to bleeding.
MEDIAL THIGH LIFT FOR MASSIVE
EIGHT OSS PATIENTS
and
increased risk for recurrent ptosis seen in these patients.
• Compared to the classic method, this is achieved by a
incision that accomplishes the thigh lift through a horizontal vector.

SENIOR AUTHOR TIP: All thighplasty procedures have Colles fascia sutures placed to
prevent scar migration and labial distortion.
The transverse excision in the groin crease is usually not very robust and acts to remove
the dog-ears at the end of the large, full-length vertical thighplasty excision.

• The patient is standing with knees apart.
• Areas of excess fat in the distal third of the thigh are marked for liposuction.
• The desired placement of the vertical incision is marked at the medial thigh.

anteriorly, to determine the amount of skin to be resected. This wedge is marked for
resection (Fig. 61-4, B).
• Patient may also be marked while they are in a recumbent position (Fig. 61-4).

863
Chapter 61
Vertical band excision.
A, With the leg on the bed, and superior and
medial drag on the anterior thigh skin, the
anterior excision line is drawn. B, The width of
maximal resection at the mid-thigh is gathered
and marked. C, From this mid-thigh mark,
a widening posterior incision line is drawn
from below knee to the ischial tuberosity. The
angle between this vertical limb and the upper
crescent excision is widened by edging the
superior portion of the anterior line posteriorly.
After marking, the patient stands. Adjustments
are made as needed.
Anterior incision line
A
Mid-thigh incision line
B
Posterior incision line
C


being aggressive liposuction. Resection is performed 3-6 months later.
• The patient is positioned supine, with legs in a frog-leg position.

• The anterior incision is made to the level of the deep fascia.

• The dissection is carried posteriorly to meet the posterior markings. The posterior
incision is then made.
• Skin is excised from distal to proximal, with segmental closure with staples to
minimize tension and edema and to optimize wound closure.

dermal, subcuticular). Cyanoacrylate skin glue and Steri-Strips may also be used.
SENIOR AUTHOR TIP:
system, thereby avoiding even seeing the great saphenous vein if possible.

Care should be taken to prevent injury to the saphenous vein, which is associated with
increased risk of lymphedema.

864
Body Contouring
FASCIOFASCIAL SUSPENSION TECHNIQUE IN MEDIAL THIGH LIFTS
Given the complications associated with medial thigh lifts, the goals of this technique
are to minimize subcutaneous undermining and maximize fascial suspension.
• These are achieved by placing
the tension of the thigh lift
on

rather than on the Colles


• The patient is in a standing
position when marked.
• The transverse incision is
medial to the groin crease.
Superiorly it extends
bilaterally on the pubis and
ends with a Burow triangle.
Inferiorly, the incision runs
along the perineal-thigh crease, extending posteriorly into the medial gluteal fold.

• Skin and fat are undermined to the fascia of the gracilis and adductor longus
muscles.
• The fasciae are horizontally incised and dissected from the underlying muscle.
• The fasciae are advanced with the skin and fat resection and secured cranially. As a

tension on the skin closure.
SPIRAL LIFT: MEDIAL AND LATERAL THIGH LIFT WITH BUTTOCK LIFT
OZER ET AL
Patients with a pear-shaped body contour deformity often have buttock ptosis and
posterior thigh laxity, which present a surgical challenge that cannot be corrected with
liposuction alone.

• With the patient in a prone position, legs are abducted to assess lateral resection.
• Symmetry is evaluated while the patient is standing.
• A line is drawn from the inferior gluteal fold medially toward the upper inner thigh,
to the pudendal region, along the inguinal line, through the anterior iliac spine to
the posterior iliac crest, above the buttocks, ending in a V at the sacrum to adjoin
with the marking from the contralateral side.
• Pinch test is used to assess the amount of skin resection.

• With the patient in a prone position with legs abducted, liposuction of the thighs


deepithelialized.


Fasciofascial suspension technique. Pre-
operative marking of skin incisions. A Burow triangle

865
Chapter 61
• A crescent of tissue joining the previous excision sites is resected at the superior
medial thigh.

of the perineum medially, to the inguinal ligament anteriorly, and the periosteum of
the anterior superior iliac spine laterally.
• The wound is closed in layers.
TIP: To prevent recurrence of thigh ptosis, anchor the closure to Colles fascia or use
fasciofascial suspension of the adductor and gracilis muscles.
Spiral lift. Excised tissue extends from the inner inside crease of the buttocks along the
inguinal crease and anterior iliac spine, spiraling above the buttocks and meeting the contralateral
incision at the sacrum.
SENIOR AUTHOR TIP: To help prevent delayed wound healing in the groin near the
T-point closure, permanent sutures are used from the T point distally. This aids in
preventing problems postoperatively when patients are in a sitting position either on a

POSTOPERATIVE CARE
Pain control with a multimodal analgesia
Early ambulation (POD 0)


has not occurred within 3 days, then oral diuretics should be prescribed.

POD 10).
Compression garments may be started immediately postoperatively or after 2 weeks,

incision line healing and hygiene.
Given the location of the wound and likelihood for wound complications, meticulous
hygiene and care of the suture line are important.
Patients are usually discharged from the hospital POD 1-4.

866
Body Contouring

a month to minimize swelling.

used within 2 weeks to minimize edema and improve skin quality.
SENIOR AUTHOR TIP: Patients are placed in ACE wraps postoperatively until the drains
are removed (POD 7-14). Patients are then encouraged to wear a compression garment

week after surgery when not ambulating. Swelling tends to increase 2-3 weeks after
surgery as patients become more active. If swelling in the feet is noted, wrapping should
start immediately. If edema persists, early referral to a physical therapist who specializes
in lymphedema management is encouraged. Patients are reassured that edema usually
is limited and resolves over time.
COMPLICATIONS
8 did not gain widespread acceptance because
of problems of inferior wound migration, widening of scars, lateral traction deformity
of vulva, early recurrence of ptosis.
In current practice, complication rates vary with technique, ranging from
9,10 Complications include the following:
• Seroma



9

recurrent cases, reinserting a drain may be necessary. If a scarred cavity has
formed, treatment may require sclerosing agents or surgical excision with
quilting.





during dissection of the femoral triangle.

11 have reported an incidence of 30.8% of abnormal
lymphoscintigraphy after medial thigh lift.


• Incision line wound complications, such as skin necrosis, suture line dehiscence

partial skin necrosis.
9

867
Chapter 61
• Cutaneous deformities (dog-ears), skin irregularities, and depressions
• Hypertrophic scars, scar migration (17% incidence9)
• Flattening of the buttocks from tension of wound closure
• Recurrence of thigh ptosis
• Prolonged nonlymphatic edema
• Contour deformity of the mons pubis; descent of labial thigh scars and distortion of
labii

placement of a Colles fascia stitch.

expansion.
TIP: Surgeons should carefully dissect and identify the femoral triangle to prevent
lymphedema.
TOP TAKEAWAYS

When I mark patients, they are placed in the frog-leg position. I estimate the
transverse excision component by pushing up on the thigh tissues to reach the
groin crease. A line is drawn from the palpated adductor longus tendon down
to the knee. Holding the marking pen on this line, the tissues are repeatedly
mobilized medially and laterally to mark the planned estimated area of
resection. I do this multiple times to verify the resection. Hash mark lines are
used as reference points to aligh the medial and lateral incisions. Symmetry is
checked between the thighs to make sure the estimates are appropriate.

A dilute epinephrine solution of 1:100,000 is injected. Excision is performed

estimated line of resection. No undermining is performed beyond this. A rat-
tooth pickup and pen are used to verify the estimated resections along the hash
marks. The tissues are serially resected to prevent overresection. The T point is


Closed suction drains are brought out in the pubic region to prevent additional
scars near the knee and for ease of maintenance.


are typically instructed to stay 2 nights in the hospital and are given a patient-



treated with marsupialization or negative-pressure wound therapy.

Medial thighplasty involves an extensive recovery, and appropriate postoperative
care at home is required for a successful outcome. Patients should arrange to

Continued

868
Body Contouring

Some surgeons advocate for excision site lipectomy, in which the area of
resection is defatted with liposuction before excision. This will decrease the
injury to lymphatics and prevent long-term complications. No prospective
randomized controlled trials have been conducted to prove this technique is

the zone of resection to prevent damage to the skin edges, which can lead to
wound-healing problems.

Judicious liposuction near the knees during thighplasty can aid in contouring


For patients with laxity of the skin in the lower leg, the medial thighplasty
incision can be carried further onto the leg; however, the scar appearance may
be suboptimal.


compression afterward to reduce edema. Standard ACE wraps may be

compression wraps may be required.
REFERENCES

1988.
-
constr Surg 87:1019, 1991.

92:1112; discussion 1123, 1993.

Plast Surg 31:523, 2004.
5. Mathes DW, Kenkel JM. Current concepts in medial thighplasty. Clin Plast Surg 35:151, 2008.

Aesthetic Plast Surg 19:137, 1995.
7. Sozer SO, Agullo FJ, Palladino H. Spiral lift: medial and lateral thigh lift with buttock lift and
augmentation. Aesthetic Plast Surg 32:120, 2008.

9. Bertheuil N, Thienot S, Huguier V, et al. Medial thighplasty after massive weight loss: are there
any risk factors for postoperative complications? Aesthetic Plast Surg 38:63, 2013.

outcomes and complications. Plast Reconstr Surg 135:98, 2015.
11. Moreno CH, Neto HJ, Junior AH, et al. Thighplasty after bariatric surgery: evaluation of lym-
phatic drainage in lower extremities. Obes Surg 18:1160, 2008.

869
CLASSIFICATION OF MORBID OBESITY1,2

2

2

2. Morbidly obese patients exceed their ideal body


2


2

Underweight
<18.5
Normal
18.6-24.9
Overweight
25.0-29.9
Obese
30.1-34.9

I
Severely obese
35.0-39-9

II
Extremely obese
40.0+

III
COMORBIDITIES OF MORBID OBESITY1,2
Osteoarthritis
Obstructive sleep apnea


Hypertension
Diabetes mellitus
Congestive heart failure
Asthma
SENIOR AUTHOR TIP: -

COMPLICATIONS OF SKIN REDUNDANCY
Intertriginous infections/rashes
Musculoskeletal pain
Functional impairment, especially with ambulation, urination, and sexual activity
Psychological issues such as depression and low self-esteem

870
Body Contouring
BARIATRIC SURGERY TECHNIQUES2
Performed through traditional open techniques or laparoscopic techniques.
substantially reduce the morbidity from postoperative
wound infections, dehiscence, and incisional hernias.
RESTRICTIVE PROCEDURES
Manipulate the
Reduce caloric intake by decreasing the quantity of food consumed at a single meal

unable to maintain weight loss
Achieves approximately 50%
reduction of excess weight



3
3
(Apollo Endosurgery)

COMBINATION RESTRICTIVE AND MALABSORPTIVE PROCEDURES
(Fig. 62-1)
Polycystic ovarian syndrome
79% resolution of hirsutism, 100%
resolution of menstrual dysfunction
Stress urinary incontinence
44%-88% resolved
GERD
72%-98% resolved
Hypertension
52%-92% resolved
Cardiovascular disease
82% risk reduction
Asthma
82% improved or resolved
Obstructive sleep apnea
74%-98% resolved
Depression
55% resolved
Degenerative joint disease
41%-76% resolved
Gout
77% resolved
Venous stasis disease
95% resolved
Type 2 diabetes mellitus
83% resolved
Metabolic syndrome
80% resolved
Nonalcoholic fatty liver disease
– 90% improved steatosis
– 37% resolution of inflammation
– 20% resolution of fibrosis
Dyslipidemia, hypercholesterolemia
63% resolved
Pseudotumor cerebri
96% resolved
Migraines
57% resolved
Mortality
89% reduction in 5-year mortality
Quality of life
improved in 95% of patients
Comorbidity reduction after bariatric surgery.