Geoffrey 2 C. Gurtner, Peter C. Neligan, Daniel Z. Liu – Plastic Surgery Principles. 2-Elsevier (2018)

608
SECTION II
CHAPTER 24 • Lipoabdominoplasty
Fig. 24.13  Elevation up to 2 cm and fixation of the umbilical pedicle to the
aponeurosis.
Fig. 24.14  (A) Marking and (B) incision: the “star technique” omphaloplasty.
A
B
Fig. 24.15  Final appearance of umbilicus.
A
B
Fig. 24.11  Resection of the infraumbilical fuse.
Fig. 24.12  Plication.

609
Outcomes
Intermittent pneumatic pressure of the legs, adjusted
between 30 and 40 mm Hg, is used throughout the procedure
and in the immediate postoperative period, until the patient
is able to mobilize actively.
Dressings and postoperative care
The dressing consists of paper surgical tape on the suture line.
These tapes are changed on the third postoperative day and
again on the eighth day, when the stitches are removed. The
patient is instructed to use a compressive garment for 15–20
days after surgery.
In addition, patients can benefit from lymphatic drainage,
which is started on the seventh day of the postoperative
period. Patients who undergo lipoabdominoplasty present an
intermediary recovery between an abdominoplasty and a
liposuction because the lipoabdominoplasty is less invasive,
causes little vascular and nerve trauma, and leaves a smaller
dead space. These factors combined result in less morbidity
and a faster return to social and professional activities than is
the case with traditional abdominoplasty.
Outcomes
In the first 10 years of the senior author’s series, there was an
increase of 100% in the abdominal procedures, before 2000,
averaging 35 patients per year, and in 2015, averaging 65
patients per year. In the same time period, there was a more
than 50% reduction in the need for surgical revisions. Late in
the series, there were two cases of traditional abdominoplasty,
chosen because the patients primarily had skin excess after
bariatric surgery.
There was a decrease in the final scar extension when
compared to the initial marking in 30% of patients. The initial
line always measured 28 cm in length – 12 cm horizontal and
8 cm oblique on each side. In 602 patients, 180 had a final scar
between 25 and 27 cm, with an average reduction of 2 cm
from the initial marking. This is due to the traction that the
Scarpa’s fascia makes on the skin. The graceful shape of the
umbilicus scar was independently evaluated and rated as
good or excellent (Figs. 24.17–24.21
).
Fig. 24.16  Suture of the layers and lowering the scar.
Fig. 24.17  Scar 6–8 cm from the vulvar commissure and aspiration drain.
Fig. 24.18  Case 1: pre- and postoperative views.
Figs. 24.19–24.21 appear online only.
On the 7th or 14th day after surgery, the operated area is
edematous, including the abdomen and other aspirated areas;
however, after 1–2 months, the edema recedes.
The overall results were rated as good to excellent in almost
all cases, with better body contour and a decrease in the
abdominal measurements. Lipoabdominoplasty achieves the
results possible with both traditional abdominoplasty and

609.e1
Outcomes
Fig. 24.19  Case 2: pre- and postoperative views.
Fig. 24.20  Case 3: pre- and postoperative views.

609.e2
SECTION II
CHAPTER 24 • Lipoabdominoplasty
Fig. 24.21  Case 4: pre- and postoperative views.

610
SECTION II
CHAPTER 24 • Lipoabdominoplasty
embolism remained the same (0.2%), the small numbers
involved are not statistically significant.
Fig. 24.22 shows the 14-year statistics in the performance
of lipoabdominoplasty with selective undermining, com-
pared to the percentage of complications with traditional
abdominoplasty.
Comments
A review performed by Levesque et al. in 2013 searched for
PubMed/MEDLINE using the search terms lipoabdomino-
plasty and abdominoplasty since 2000. The titles and abstracts
were reviewed for relevance, and the list was reduced to a
total of 26 relevant articles accounting for 1316 lipoabdomino-
plasty patients. Of these patients, 21 of 1316 (1.6%) developed
seroma, 5 of 1032 (0.5%) experienced hematoma, 6 of 1032
(0.6%) had venous thromboembolism (VTE), and 3 of 1032
(0.3%) developed pulmonary embolism. In their case series, all
patients were women with an average age of 48 years (range,
27–70 years), average body mass index of 25.2 (17.7–35.5),
average follow-up of 8 months (range, 1–54 months), average
lipoaspirate of 1605 mL (range, 150–5350 mL), and average
weight of resected tissue of 1039 g (range, 128–4838 g). The
average operative time was 225 min (range, 88–435 min),
and average time in recovery prior to discharge was 124
min (range, 33–270 min). On their case series in the same
article, Levesque et al. had the following complication rates:
seroma in 20 from 85 patients, one patient developed deep
venous thrombosis (DVT), one patient developed cellulitis,
and one patient developed an abscess. This review concluded
that lipoabdominoplasty is a safe and effective procedure in
appropriately selected patients.27
liposuction. The combined procedure achieves a better body
contour with reduced morbidity. For most surgeons, there is
a fast learning curve because they will be familiar with tradi-
tional abdominoplasty and liposuction techniques when done
independently.
Complications
In the senior author’s series, the complication rate for tradi-
tional abdominoplasty was compared to that with lipoab-
dominoplasty. From 1979 to 2000 there were 496 traditional
abdominoplasty surgeries, and from the year 2000 to 2015
there were 996 cases of lipoabdominoplasty, as shown in Table
24.1. The lipoabdominoplasty cases consisted of 15 males and
981 females, with an average age of 34.
Table 24.2 shows the percentage of surgical revisions in
lipoabdominoplasty. This decreased from 20% with traditional
abdominoplasty to less than 7% with lipoabdominoplasty.
The cases of surgical revision due to complementary liposuc-
tion and postoperative skin flaccidity (2.5%) corresponded to
patients who had undergone previous bariatric surgery and
presented a great amount of flaccidity. There was a need for
surgical revision of scars in 4.1%, which represents 62% of all
surgical revisions for lipoabdominoplasty.
A reduced incidence of seroma (from 60% to 0.5%, P <
0.0001), epitheliolysis (3.8% to 0.2%, P = 0.0003), wound
dehiscence (5.1% to 0.5%, P < 0.0001), and necrosis (4% to
0.2%, P = 0.0002) has statistical significance. It is hypothesized
that the reduction in flap necrosis may be due to improved
vascularity on the arterial side, or possibly due to better
venous return.
Although the reduced incidence of hematoma (0.6–0.2%)
and the incidence of deep venous thrombosis/pulmonary
Fig. 24.22  Pre- and postoperative views.

611
Comments
Table 24.2  The author’s personal statistics for performing surgical revisions in abdominoplasty
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
TOTAL PROCEDURES = 996
15
45
55
64
62
65
68
71
75
82
85
79
83
56
59
32
Scars
3
5
4
3
4
3
3
4
2
1
2
1
2
1
1
1
Skin flaccidity
×
×
1
2
1
1
1
2
×
1
1
1
1
1
×
×
Insufficient liposuction
×
×
1
2
2
1
1
1
1
×
1
×
×
1
×
×
Excessive liposuction
×
×
×
×
×
×
×
×
×
×
×
×
×
×
×
×
Infection
×
×
×
×
×
×
×
×
×
×
×
×
×
×
×
×
Other causes
×
×
×
×
1
×
×
×
×
×
×
×
×
×
×
×
TOTAL REVISIONS = 63
3
5
6
7
8
5
5
7
3
2
4
2
3
3
1
1
Percentage (%)
4.5
8
9
11
12
8
8
11
4.5
3
6
3
4.5
4.5
1.5
1.5
Table 24.1  The author’s personal statistics for performing abdominoplasty vs. lipoabdominoplasty
1979–1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Abdominoplasty
469
25
Lipoabdominoplasty
15
45
55
64
62
65
68
71
75
82
85
79
83
56
59
32

612
SECTION II
CHAPTER 24 • Lipoabdominoplasty
Further reading
Saldanha OR, de Souza Pinto EB, Matos W, et al. Lipoabdominoplasty
with selective and safe undermining. Aesthetic Plast Surg.
2003;22:322–327. The aesthetic treatment of the abdominal region using
the principles of liposuction associated with traditional abdominoplasty.
Lipoabdominoplasty is different from other techniques because it has the
advantages of conserving perforator vessels of the abdominal wall.
Bonus images for this chapter can be found online at

Fig. 24.19 Case 2: pre- and postoperative views.
Fig. 24.20 Case 3: pre- and postoperative views.
Fig. 24.21 Case 4: pre- and postoperative views.
7. Callia WEP. Dermolipectomia Abdominal (Operação de Callia). São
Paulo: Carlos Erba; 1963.
8. Pitanguy I. Abdominoplasty: classification and surgical techniques.
Rev Bras Cir. 1995;85:23–44.
13. Illouz YG. A new safe and aesthetic approach to suction
abdominoplasty. Aesthetic Plast Surg. 1992;16:237–245.
14. Lockwood T. High-latera-tension abdominoplasty with superficial
fascial system suspension. Plast Reconstr Surg. 1995;96:603–608.
18. Saldanha OR, de Souza Pinto EB, Matos W, et al.
Lipoabdominoplasty without undermining. Aesthet Surg J.
2001;21:518–526. In 2001, using the term “lipoabdominoplasty” for the
first time and with the publication of this technique, Saldanha
standardized a selective undermining along the internal borders of the
rectus abdominal muscles, corresponding to 30% of the traditional
undermining, thus preserving the abdominal perforating vessels,
performing liposuction and abdominolipoplasty in the same surgical time,
safely.
21. Taylor GI, Watterson PA, Zelt RG. The vascular anatomy of the
anterior abdominal wall: the basis for flap design. Perspect Plast
Surg. 1991;5:1–30.
Access the complete reference list online at

Saldanha OR. Lipoabdominoplasty. Rio de Janeiro: Di-Livros; 2006. In this
book the author describes the anatomical concepts, history, and evolution
of the technique of lipoabdominoplasty. Saldanha describes each detail of
this surgery.
Saldanha OR, Azevedo SF, Delboni PS, et al. Lipoabdominoplasty: the
Saldanha technique. Clin Plast Surg. 2010;37:469–481. The incidence
of complications was compared in traditional abdominoplasty to that in
lipoabdominoplasty. From 1979 to 2000 the author performed 496
traditional abdominoplasty surgeries, and from the year 2000 to the
present date lipoabdominoplasty was performed on 602 patients.
De Souza Pinto EB. Superficial Liposuction. Rio de Janeiro: Revinter;
1999:1–4. Superficial liposuction, introduced by de Souza Pinto, was one
of the fundamental principles of lipoabdominoplasty because it made its
performance possible and easier. This procedure gives more mobility to the
abdominal flap so that it can slide down easily and reach the suprapubic
region.

612.e1
References
References
1. Illouz YG. Une nouvelle technique pour les lipodystrophies
localisés. Es Rev Chir Esth France. 1980;9:6.
2. Friedland JA, Maffi TR. MOC-PS CME article: abdominoplasty. J
Plast Reconstr Aesthet Surg. 2008;121:1–11.
3. Saldanha OR. Avaliação estética dos resultados da lipoabdominoplastia
em pacientes com sobrepeso. Estudo comparativo. Universidade de
São Paulo: Doctorate thesis; 2013.
4. Voloir P. Operation Plastiques Sus-Aponévrotiques sur la Paroi
Abdominale Antérieure. Paris: These; 1960.
5. Kelly HA. Report of gynecological cases. Johns Hopkins Med J.
1899;10:197.
6. Vernon S. Umbilical transplantation upward and abdominal
contouring in lipectomy. Am J Surg. 1957;94:490–492.
7. Callia WEP. Dermolipectomia Abdominal (Operação de Callia). São
Paulo: Carlos Erba; 1963.
8. Pitanguy I. Abdominoplasty: classification and surgical techniques.
Rev Bras Cir. 1995;85:23–44.
9. De Souza Pinto EB. Our experience in liposuction. Ann Cong Bras
Plast Surg. 1983;1:9.
10. Hakme F. Technical details in the lipoaspiration associated with
liposuction. Rev Bras Cir. 1985;75:331–337.
11. Matarasso A. Abdominoplasty: a system of classification and
treatment for combined abdominoplasty and suction-assisted
lipectomy. Aesthetic Plast Surg. 1991;15:111–121.
12. Matarasso A. Liposuction as an adjunct to full abdominoplasty.
Plast Reconstr Surg. 1995;95:829–836.
13. Illouz YG. A new safe and aesthetic approach to suction
abdominoplasty. Aesthetic Plast Surg. 1992;16:237–245.
14. Lockwood T. High-lateral-tension abdominoplasty with superficial
fascial system suspension. Plast Reconstr Surg. 1995;96:603–608.
15. Lockwood T. The role of excisional lifting in body contour surgery.
Clin Plast Surg. 1996;23:695–712.
16. Shestak KC. Marriage abdominoplasty expands the mini-
abdominoplasty concept. Plast Reconstr Surg. 1999;103:1020–1031.
17. Avelar JM. Abdominoplasty: a new technique without undermining
and fat layer removal. Arq Catarinense Med. 2000;291:147–149.
18. Saldanha OR, de Souza Pinto EB, Matos W, et al.
Lipoabdominoplasty without undermining. Aesthet Surg J.
2001;21:518–526. In 2001, using the term “lipoabdominoplasty” for the
first time and with the publication of this technique, Saldanha
standardized a selective undermining along the internal borders of the
rectus abdominal muscles, corresponding to 30% of the traditional
undermining, thus preserving the abdominal perforating vessels,
performing liposuction and abdominolipoplasty in the same surgical time,
safely.
19. Vila-Rovira R. Liposucción en Cirugía Plástica y Estética. Espafía:
Salvat; 1988:81–85.
20. El-Mrakby HH, Milner RH. The vascular anatomy of the lower
anterior abdominal wall: a microdissection study on the deep
inferior epigastric vessels and the perforator branches. Plast
Reconstr Surg. 2002;109:539–543, discussion 544–547.
21. Taylor GI, Watterson PA, Zelt RG. The vascular anatomy of the
anterior abdominal wall: the basis for flap design. Perspect Plast
Surg. 1991;5:1–30.
22. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am
Surg. 1979;45:612–617.
23. Graf R. Lipoabdominoplasty: fluxmetry study and technical
variation. In: Saldanha O, ed. Lipoabdominoplasty. Rio de Janeiro:
Di-Livros; 2006.
24. Munhoz AM, Ishida LH, Sturtz G, et al. Importance of the lateral
row perforator vessels in deep inferior epigastric perforator flap
harvesting. Plast Reconstr Surg. 2004;113:517–524.
25. De Frene B, Van Landuyt K, Hamdi M, et al. Free DIEAP and SGAP
flap breast reconstruction after abdominal/gluteal liposuction. J
Plast Reconstr Aesthet Surg. 2006;59:1031–1036.
26. Boyd JB, Taylor CI, Corlett R. The vascular territories of the
superior epigastric and the deep inferior epigastric systems. Plast
Reconstr Surg. 1984;73:1–16.
27. Levesque AY, Daniels MA, Polynice A. Outpatient
lipoabdominoplasty: review of the literature and practical
considerations for safe practice. Aesthet Surg J. 2013;33:1021–1029.
Uebel CO. Lipoabdominoplasty: revisiting the superior pull-down
abdominal flap and new approaches. J Plast Reconstr Aesthet Surg.
2009;33:366–376.
Samya S, Sawh-Martinez R, Barry O, Persing JA. Complication rates of
lipoabdominoplasty versus traditional abdominoplasty in high-risk
patients. J Plast Reconstr Aesthet Surg. 2010;125:683–690.
Le Louam C, Pascal JF. The high-superior-tension technique: evolution
of lipoabdominoplasty. Aesthetic Plast Surg. 2010;34:773–781.
Weiler J, Taggart P, Khoobehi K. A case for the safety and efficacy of
lipoabdominoplasty: a single surgeon retrospective review of 173
consecutive cases. Aesthet Surg J. 2010;30:702–713.
Saldanha, et al. Lipoabdominoplasty. Abdominal surgeries
complications reduction. Rev Bras Cir Plást. 2011;26:275–279.
Epstein S, Epstein MA, Gutowski KA. Lipoabdominoplasty without
drains or progressive tension sutures: an analysis of 100
consecutive patients. J Plast Reconstr Aesthet Surg. 2013;35:434–440.
Pollock TA, Pollock H. Commentary on: Lipoabdominoplasty without
drains or progressive tension sutures: an analysis of 100
consecutive patients. J Plast Reconstr Aesthet Surg. 2013;35:441–442.
Cardoso de Castro C, Salema R, Atias P, et al. Abdominoplasty to
remove multiple scars from the abdomen. Ann Plast Surg.
1984;12:369–373.
Willkinson TS, Swartz BE. Individual modifications in body contour
surgery: the “limited” abdominoplasty. Plast Reconstr Surg.
1986;77:779–784.
Saldanha OR, de Souza Pinto EB, Matos W, et al. Lipoabdominoplasty
with selective and safe undermining. Aesthetic Plast Surg.
2003;22:322–327. The aesthetic treatment of the abdominal region using
the principles of liposuction associated with traditional abdominoplasty.
Lipoabdominoplasty is different from other techniques because it has the
advantages of conserving perforator vessels of the abdominal wall.
Saldanha OR. Lipoabdominoplasty. Rio de Janeiro: Di-Livros; 2006.
In this book the author describes the anatomical concepts, history, and
evolution of the technique of lipoabdominoplasty. Saldanha describes each
detail of this surgery.
Saldanha OR, Azevedo SF, Delboni PS, et al. Lipoabdominoplasty: the
Saldanha technique. Clin Plast Surg. 2010;37:469–481. The incidence
of complications was compared in traditional abdominoplasty to that in
lipoabdominoplasty. From 1979 to 2000 the author performed 496
traditional abdominoplasty surgeries, and from the year 2000 to the
present date lipoabdominoplasty was performed on 602 patients.
Saldanha OR. Lipoabdominoplasty. Plast Reconstr Surg.
2009;124:934–942.
Aly A. Discussion. Lipoabdominoplasty. Plast Reconstr Surg.
2009;124:943–945.
De Souza Pinto EB. Superficial Liposuction. Rio de Janeiro: Revinter;
1999:1–4. Superficial liposuction, introduced by de Souza Pinto, was one
of the fundamental principles of lipoabdominoplasty because it made its
performance possible and easier. This procedure gives more mobility to the
abdominal flap so that it can slide down easily and reach the suprapubic
region.

SECTION II • General Aesthetic Surgery
25.1 
Circumferential approaches to truncal
contouring: Introduction
J. Peter Rubin
Circumferential approaches to body contouring are a corner-
stone for reshaping of the trunk after pregnancy, weight loss,
or aging. Building upon a foundation laid by master body
contouring surgeons such as Ted Lockwood, two experts in
the field present chapters on the belt lipectomy and lower
bodylift, respectively.
These procedures differ in design and execution, and body
contouring surgeons should understand the fundamental
principles of each procedure and be able to apply these in
an individualized approach to meet each patient’s unique
anatomical features and aesthetic goals. In broad strokes, the
belt lipectomy, presented by Dr. Al Aly and colleagues, is a
powerful tool for refining the waistline. The lower bodylift,
presented by Dr. Dirk Richter and colleague, generally has a
more inferior zone of resection and effectively enhances lateral
thigh and buttock shape. Understanding how to apply the
principles of each operation enables the body contouring
surgeon to tackle a wide range of truncal contouring deformi-
ties with confidence. Moreover, elements of both operations
can be merged as needed.
Innovations in tissue repositioning during circumferential
bodylifting have enabled significant advances in buttock
shaping with local flaps. Two more experts in body contour-
ing present their approaches. Dr. Joe Hunstad and colleague
describe the purse string gluteoplasty technique, in which
islands of gluteal tissue are cleverly reshaped to simulate high
projection buttock implants. This technique can also be used
to enhance buttock shape without a full circumferential
procedure.
Dr. Robert Centeno and colleague describe the artistic
variations of gluteal flap transposition that can be applied to
achieve an aesthetic buttock contour with local tissues. Dr.
Centeno shows the full potential of this technique in his
elegant chapter.
These four chapters provide a comprehensive overview of
the state of the art techniques for circumferential truncal
contouring, and give the body contouring surgeon a number
of useful approaches for every body type that may be
encountered.

SECTION II • General Aesthetic Surgery
25.2 
Circumferential approaches to truncal
contouring: Belt lipectomy
Al S. Aly, Khalid Al-Zahrani, and Albert Cram
SYNOPSIS
■ The skin/fat envelope is tethered to the underlying musculoskeletal
anatomy in zones of adherence. These include the spine, the sternum,
the linea alba of the abdomen, the inguinal area, the suprapubic area
and the area between the hip and lateral thigh fat.
■ Massive weight loss patients make up the majority of patients who
undergo lower bodylift/belt lipectomy surgery. Second are females with
a body mass index (BMI) in the range of 26–28. Third are normal
weight females who wish a more dramatic improvement than an
abdominoplasty alone.
■ Three factors affect patient presentation: the BMI, the fat deposition
pattern, and the quality of the skin/fat envelope.
■ Bodylift/belt lipectomy procedures can be thought of as a circumferential
wedge excision of the lower trunk. One end of the spectrum of
procedures is the lower bodylift type II (Lockwood technique) and the
other end is the belt lipectomy/central bodylift (Aly and Cram technique).
■ Patients presenting for this surgery require a complete medical
assessment and a thorough physical examination.
■ In planning a bodylift/belt lipectomy, scar position can be approximated
by simulating the tissue dynamics at the time of closure. Anteriorly, the
inferior marks control the scar position, and posteriorly, the superior
marks control the scar position.
■ The operative sequence usually involves anterior surgery first, followed
by posterior surgery and closure.
■ Postoperative care requires hospital-level nursing with attention to
patient positioning, early ambulation, fluid infusion, and pain control.
■ While major complications are possible, the commonest problem is
seroma.
Access the Historical Perspective section online at

Introduction
Body contour deformities of the lower trunk can range
from “anterior only” to “circumferential” deformities. If the
problems are restricted to isolated moderate lipodystrophy
deposits, then liposuction may be the only treatment modal-
ity needed. Anteriorly, if skin laxity and/or abdominal wall
weakness are encountered, then abdominoplasty techniques
are needed to create the best contour. If the deformities involve
skin and subcutaneous laxity circumferentially, then bodylift/
belt lipectomy procedures are usually required to adequately
address the issues. Thus, in looking at the treatment of a large
range of patients presenting with lower truncal deformities,
there is a transition from liposuction only, to “anterior only”
excisional procedures, to “circumferential” excisional proce-
dures. This chapter addresses a circumferential lower truncal
excisional procedure, the “belt lipectomy”.
Basic science and disease process
Anatomy
It is important to have a clear understanding of the blood
supply of the abdomen, when contemplating circumferential
dermatolipectomy of the lower trunk. The anatomy of
abdominal wall blood supply is reviewed in Chapter 23.
The subcutaneous abdominal fat is divided into superficial
and deep layers by the superficial fascial system, which in this
region of the body is called Scarpa’s fascia. In thin patients,
the two layers are fairly close to each other in thickness. In
patients who have a high BMI, the superficial layer is often
much thicker than the deep layer.
There are areas within the trunk where the skin/fat enve-
lope is tethered to the underlying musculoskeletal anatomy,
restricting either descent or elevation, which can occur with
aging, weight fluctuation, or surgical manipulation. These
areas are called “zones of adherence” and act like “hooks” for
the skin/fat envelope to hang on to as it falls down, especially
after the skin has been stretched by excess weight and then
deflated by weight loss (Fig. 25.2.1). The zones of adherence
overlying the spine and the sternum are both strong areas
of adherence and are always present, while the zone of
  Access video lecture content for this chapter online at expertconsult.com

614.e1
Historical perspective
Historical perspective
Abdominal dermatolipectomy/abdominoplasty has a long
history, which is covered elsewhere in this book. Although
there were scattered reports of circumferential dermatolipec-
tomy in the literature in the 20th century, they were few and
that type of surgery was performed by very few surgeons.
Although bariatric surgery was pioneered in the 1960s and
1970s by Mason, from the University of Iowa, it did not
become popular until around the turn of the century. Around
the year 2000, bariatric surgery experienced a boom, which
has led to the onslaught of a new group of patients, collec-
tively referred to as “massive weight loss patients”. Because
of the circumferential nature of this group’s deformities, cir-
cumferential dermatolipectomy is fast becoming a mainstream
operation in plastic surgery. This chapter will discuss circum-
ferential dermatolipectomy in general, but especially in the
massive weight loss patient.

615
Basic science and disease process
The 20–30 pounds overweight group
Women who are 20–30 pounds overweight (BMI range of
26–28) who have never lost any significant weight despite rea-
sonable exercise and nutritional habits are the second group
that can potentially benefit from bodylift/belt lipectomy.
These patients present with lipodystrophy of the lower
trunk that is circumferential in nature, which leads to general-
ized lack of definition of the lower trunk (Fig. 25.2.3).
adherence overlying the midline linea alba of the abdomen is
often week to non-existent. There are strong zones of adher-
ence overlying the inguinal region bilaterally that play an
important role in controlling final scar position during
bodylift/belt lipectomy. A more variable zone of adherence is
located in the horizontal suprapubic area, which when present
leads to a suprapubic crease. This zone of adherence, along
with the inguinal zones of adherence, is responsible for a
panniculus hanging over the mons pubis.
Another important zone of adherence is located between
the hip and lateral thigh fat deposits and can prevent mobili-
zation of tissues during surgery. In some procedures, such a
“lower bodylift type II”, as described by Lockwood,1,2 this
zone of adherence is intentionally disrupted to allow for sig-
nificant elevation of the lateral thighs.
The disease process
There are three groups that can potentially benefit from
bodylift/belt lipectomy.3 Although all of these groups will
share some of the same indications and principles in design
of the operations, they differ and should be considered here.
Massive weight loss patients
Massive weight loss (MWL) patients make up the majority of
patients who undergo bodylift/belt lipectomy.3 The lower
trunk of MWL patients can be thought of as a balloon. As
patients gain weight and then lose it, the balloon is initially
stretched by the weight gain then deflated as weight loss
ensues. Like a balloon that has been inflated for a long time,
the intrinsic elasticity of the skin is irreversibly altered during
this process, leading to redundant lax skin, which is almost
always circumferential in nature. The usual pattern is of an
inverted cone (Fig. 25.2.2).
Fig. 25.2.1  The zones of adherence of the trunk. Note the inferomedial descent of tissues that occurs with aging and/or weight loss.
A
Strong adherence
Less adherant
Variable adherence
B
C
Fig. 25.2.2  The figure demonstrates the typical shape of the lower trunk after
massive weight loss; a three-dimensional “inverted cone”.

616
SECTION II
CHAPTER 25.2 • Circumferential approaches to truncal contouring: Belt lipectomy
when appropriate. Although MWL patients are grouped
together, they are quite variable in their presentation (Fig.
25.2.6). Three factors seem to affect the presentation: the BMI
at presentation, the fat deposition pattern, and the quality of
the skin/fat envelope.
BMI level at presentation
Massive weight loss patients will present to the plastic sur-
geons at different BMI levels. For some, this level is still very
high, BMIs of ≥35; for others, it may be intermediate, BMIs of
30–35; and for others, the BMI may drop to the mid- or low
20s (see Fig. 25.2.6).
Fat deposition pattern
The type of deformity that an MWL patient presents with also
depends on their particular fat deposition pattern. Humans
are born with a genetically controlled pattern of fat deposi-
tion, as well as a fat loss pattern. For example, females gener-
ally tend to store fat in the extraperitoneal space, the lower
abdomen, hips, and thighs – a pattern often referred to as
“pear-shaped” (Fig. 25.2.7). Males, on the other hand, tend to
Normal weight patients group
A third group that may benefit from bodylift/belt lipectomy
are normal weight patients who ordinarily would be consid-
ered candidates for an abdominoplasty but desire more dra-
matic improvements in lower truncal contour. These patients
often desire a remarkable improvement in their anterior
thighs, lateral thighs, buttocks, and lower back. In many
similar patients, liposuction can improve all of these areas
when combined with an abdominoplasty; however, if patients
desire significant lifting and contour delineation, then a cir-
cumferential excisional procedure is required (Fig. 25.2.4).
A subgroup of normal weight patients who can benefit
from a bodylift/belt lipectomy is made up of older patients
whose skin will not contract with liposuction due to skin
laxity and will require the pull created by the circumferential
excision (Fig. 25.2.5).
Diagnosis and patient presentation
Most of the subsequent discussions will be centered around
the MWL patients, and the other groups will be mentioned
Fig. 25.2.3  This patient is typical of the “20–30 pound overweight” group. Note the generalized circumferential lipodystrophy of the lower trunk.

617
Diagnosis and patient presentation
As a general rule, the greater the BMI drop, the more transla-
tion of pull will be present.
Commonalities of presentation
Almost all MWL patients present with a “hanging pannicu-
lus”. The size and shape of the panniculus will vary from one
patient to the other based on their intrinsic fat deposition
pattern (Fig. 25.2.9). Almost every MWL patient will present
with a “ptotic mons pubis”. The most obvious deformity is
vertical excess with varying degrees of horizontal excess.
The waist, which is the narrowest aspect of the lower trunk
between the ribs and the pelvic rim, can be blunted in many
MWL patients by the hanging skin/soft tissue envelope as it
drapes from the ribs to below the pelvic rim. The anterior and
lateral thighs are usually ptotic. In patients who belong to the
“20–30 pound overweight” group and “the normal weight”
group, the thighs are not as dramatically affected but are still
areas of concern.
As with the thighs, the buttocks in the MWL patient are
usually ptotic due to the effects of the weight gain/loss process.
store fat more centrally, in what is often referred to as an
“apple-shaped” configuration, where fat is deposited intra-
peritoneally and in the flanks (or “love handles”), and less fat
is deposited in the thighs (see Fig. 25.2.7).
The skin/fat envelope
The skin/fat envelope is what a plastic surgeon operates on,
and its intrinsic properties are especially important. Some
patients present with very pliable and thin skin/fat envelopes,
while others will present with very thick non-pliable tissues.
A concept that the authors have found very helpful in examin-
ing these patients is the “translation of pull” (Fig. 25.2.8). For
example, when examining the patient prior to surgery, the
lateral abdominal tissues are pinched, simulating the effects
of the lateral abdominal resection of a bodylift/belt lipectomy
on the distal thigh, which can be predictive of the final result
with a certain degree of accuracy. If the pinch demonstrates
very little translation of pull to these areas, as in the case of
patients who present with high BMIs and thick, non-pliable
skin/fat envelopes, this can be used to predict the final result.
Fig. 25.2.4  This patient presented in her mid-30s with a desire to improve her abdominal contour but also desired the best possible contour of her entire lower trunk
which included better waist definition, lifting of her anterior and lateral thighs, as well as a buttocks lift.

618
SECTION II
CHAPTER 25.2 • Circumferential approaches to truncal contouring: Belt lipectomy
that one type of bodylift should be utilized over the other.
Rather, it is hoped that the surgeon would be familiar with
these techniques and be able to individualize the particular
procedure to the needs of their particular patient.
Belt lipectomy: a different procedure than the
lower bodylift type II (Lockwood technique)
In this type of bodylift, the overall circumferential wedge of
resection is located lower onto the lower trunk. The procedure
can be thought of as a truncal–thigh lift, not just a truncal
lift.5 This technique is discussed in more detail in Chapter
25.3. The bilateral zones of adherence located between the
hip and trochanteric fat deposits are intentionally destroyed
by discontinuous undermining or aggressive liposuction to
allow the surgeon to lift the lateral and anterior thighs very
aggressively.
The result of a lower bodylift type II are impressive in its
elevation of the thighs, and it creates a fairly low scar that
can be covered by most underwear or swimwear patterns (Fig.
25.2.12). There are disadvantages and limitations of lower
Many MWL patients also present with a lack of demarcation
between the lower back and buttocks (Fig. 25.2.10).
Many patients present with back rolls that are bothersome.
Some back rolls are located in the lower back and those are
generally amenable to improvement through bodylift/belt
lipectomy. Superior back rolls, usually contiguous with breast
rolls, or just below them, are not affected by bodylift/belt
lipectomy procedures and must be addressed through upper
bodylift procedures (Fig. 25.2.11).
Patient selection
Although a “bodylift/belt lipectomy” can be thought of as a
circumferential wedge excision of the lower trunk, there are
variations of the procedure.4 We have categorized what we
feel to be the ends of the spectrum of bodylifts and will go
over the differences so that the reader may understand what
each can accomplish. At one end is the “lower bodylift type
II”, as originally described by Lockwood.1,2 At the other end,
there is the “belt lipectomy”, as described by the authors,
originally in Iowa.3 It is not the intent of the authors to suggest
Fig. 25.2.5  A patient in her 60s is shown before and after a belt lipectomy. Patients in this age group often do not attain enough skin retraction through liposuction and
may require an excisional procedure to attain the best possible contour.

619
Patient selection
Fig. 25.2.6  Six massive weight loss patients are shown at presentation after weight stabilization. Note the significant amount of variability in BMI, fat deposition pattern,
and quality of the skin/fat envelope.
bodylift type II. Since the final scar is intentionally created
below the widest aspect of the pelvic rim, the waist is not
narrowed as much as it would if the final scar is created above.
The authors call this the “sundress effect” because it pulls
down the upper truncal tissues across the narrowest aspect, the
waist, onto the widest aspect, the pelvic rim, leading to blunt-
ing of the waist, rather than narrowing. Anteriorly, the scar is
considerably lower than the anterior superior iliac spine (ASIS),
which poses no significant problem if the abdominal flap that
is brought down to the level of the scar is thin. However, if the
abdominal flap is thick, as in higher BMI patients, it will add
to the prominence of the ASIS region, which should be flat, not
convex. A disadvantage of a posterior low scar in a lower
bodylift type II is that it violates the aesthetic unit principle.
This is not problematic in patients who value hiding the scar
within low underwear lines and do not require demarcation
between the lower back and buttocks, i.e., a male patient. On
the other hand, most female patients desire as much buttocks
definition as possible and demarcation between the lower back
and buttocks. Box 25.2.1 shows the main advantages and dis-
advantages of the lower bodylift type II.
BOX 25.2.1  Lower bodylift type II
Advantages
• Lifts the trunk
• Very aggressive thigh lift
• Reduces the amount of surgery that maybe subsequently
needed on the thighs
• Low scar position to be covered by low-lying swim/underwear
Disadvantages
• Blunts the waist in most patients
• Scar violates the buttocks unit posteriorly
• Lack of demarcation between lower back and buttocks
• Bulge over the anterior superior iliac spine in patients with thick
panniculi

620
SECTION II
CHAPTER 25.2 • Circumferential approaches to truncal contouring: Belt lipectomy
Fig. 25.2.7  Two patients demonstrating the two
most common fat deposition patterns. On the left,
the “apple” shape is shown, most often
encountered in males, although demonstrated in a
female here. On the right, the typical “pear”-
shaped female pattern of fat deposition is shown.
Fig. 25.2.8  The “translation of pull” is demonstrated in this figure. The patient in the middle picture is demonstrating the potential distant effects of the proposed
resection, simulated by the pinching hands. Note the postoperative anterior thigh contour is fairly similar to the preoperative pinch.

621
Patient selection
Fashions at the time of writing cover a lower position on the
torso than most belt lipectomy/central bodylift scars, espe-
cially the posterior aspect. Although this may change with
fashion trends, it is a legitimate problem, especially in male
patients who generally do not care for waist narrowing or
buttocks definition. Another disadvantage of this technique is
that the extent of thigh elevation is not as great as that attained
with a lower bodylift type II technique. Thus, the extent of
thigh reduction that may need to be performed after the belt
lipectomy/central bodylift is usually more extensive than
after a lower bodylift type II.
It is important to note that a plastic surgeon who treats
MWL patients on a regular basis should be familiar with both
the lower bodylift type II and belt lipectomy/central bodylift,
so that they may mix and match these techniques to create the
best possible outcome for a particular patient. Box 25.2.2 sets
out the main advantages and disadvantages of belt lipectomy/
central bodylift.
Selection criteria
Significant cardiopulmonary disease is a contraindication for
bodylift/belt lipectomy procedures. Smoking is considered a
Characteristics of the belt
lipectomy/central bodylift
Belt lipectomy/central bodylift procedures overall have a
more superiorly based wedge of excision when compared
with a lower bodylift type II.6 There is some weakening of the
zone of adherence between the hip and lateral thighs, but no
attempt is made to completely destroy them, as in a lower
bodylift type II. These differences lead to a more superiorly
positioned scar, circumferentially around the lower trunk.
Posteriorly, the scar is ideally positioned at the natural junc-
tion between the lower back and buttocks, which promotes
more attractive buttocks, demarcates the lower back from the
buttocks, and in most patients creates a narrower waist. Ante-
riorly, the scar positioning above the ASIS further promotes
narrowing of the waist by “cinching” above the widest aspect
of the pelvic rim. This is especially helpful in patients who
present with thick abdominal flaps, which will fit in a depres-
sion above the ASIS, rather than over it. Because the zones of
adherence are only weakened during this technique, the thighs
are not as aggressively lifted as in a lower bodylift type II.
There are disadvantages of belt lipectomy/central bodylift,
with the superiorly positioned scar being the primary one.
Fig. 25.2.9  Six massive weight loss patients demonstrating the variety in shape and size of their presenting panniculi.

622
SECTION II
CHAPTER 25.2 • Circumferential approaches to truncal contouring: Belt lipectomy
The BMI at presentation should be a very important factor
in determining whether a plastic surgeon should operate. As
will be discussed later in this chapter, complications increase
with increasing BMIs.7 Many plastic surgeons do not operate
on patients who present with a BMI >32. This is a reasonable
level, especially for those surgeons who are new to MWL
body contouring surgery and/or circumferential procedures.
The authors of this chapter routinely operate on patients in
higher BMI ranges, but they accept a much higher complica-
tion rate, especially if the BMI is >35, where the complication
rate is around 100%.
Ideally, it is best to delay body contouring procedures until
patients have stabilized their weight loss. The weight loss
process in many patients will often have “false plateaus”
where the patient will stabilize, but then start to drop again.
Most surgeons feel that a minimum of 3 months of stabiliza-
tion is required. For lap-bands, the average time to weight
stability is around 2 years. For gastric bypass and gastric
sleeve procedures, the average is around 18 months. And for
duodenal switch procedures, the average is 12–14 months.
These numbers are not absolute and may vary considerably
from individual to individual.
contraindication by most surgeons. Some surgeons operate on
smokers and accept a higher complication rate. Patients with
collagen vascular disease should also be approached with
extreme caution. The authors have operated on a few and
have had difficulty with healing and infection.
BOX 25.2.2  Belt lipectomy/central bodylift
Advantages
• Lifts the trunk
• Leads to waist narrowing
• Improves buttocks contour
• Demarcates the lower back from buttocks
Disadvantages
• High position of scar outside of normal swim/underwear
• Thigh reduction is not as aggressive as other technique
• May result in more extensive thigh reduction surgery than other
technique
Fig. 25.2.10  The variety in shape and size of the buttocks is demonstrated in these six massive weight loss patients. The accompanying lipodystrophy of the hip region, as
well as the descent of the buttocks, often contribute to a lack of buttocks definition and demarcation from the lower back.

623
Patient selection
include aging, child birth, skin laxity due to sun exposure, and
MWL. If the main cause is weight loss, then the following
questions should be answered:
■ What was their greatest weight?
■ How did they lose weight?
■ What was their lowest weight?
■ How long have they been at their present weight?
■ Do they think they are going to lose more weight?
■ Are they prone to “heroic methods” of weight loss?
If a patient presents with too much intra-abdominal content
to allow flattening of abdominal contour by muscle wall plica-
tion, then the result of a circumferential procedure is very
similar to that attainable by panniculectomy.8 It would thus
be prudent to avoid the increased risk of the circumferential
excision and limit the procedure to a panniculectomy.
The recovery period after a circumferential dermatolipec-
tomy can be quite challenging, both physically and psycho-
logically. Choosing a patient with unstable psychological
problems to go through the prolonged and arduous recovery
can result in disastrous consequences. Criteria for patient
selection are given in Box. 25.2.3.
Preoperative evaluation
Massive weight loss patients will present with multiple areas
of deformity, which include arms, breasts, upper back rolls,
thighs, and face. The lower trunk and hanging panniculus is
usually the primary complaint.
A detailed weight history is essential in patients who
present for lower truncal contouring. It is important to ascer-
tain the etiology of their lower trunk abnormalities, which
Fig. 25.2.11  Six different massive weight loss patients demonstrating the variety of back roll presentations. The mid to lower back rolls are often reduced or eliminated
after bodylift/belt lipectomy, but the upper back rolls are not.
BOX 25.2.3  Patient selection
• Medical stability
• Psychiatric stability
• Non-smoker (most surgeons but not all)
• Low intra-abdominal content
• Weight stability

624
SECTION II
CHAPTER 25.2 • Circumferential approaches to truncal contouring: Belt lipectomy
Fig. 25.2.12  Overall, the scar in a lower bodylift type II is
more inferiorly placed than in a belt lipectomy. Anteriorly,
the final scar is below the anterior superior iliac spine in a
lower bodylift type II (A, left), and above it in a belt
lipectomy (A, right). Laterally and posteriorly, the scar is
below the natural junction of the lower back with the
buttocks (B,C left), whereas it is located at, or just above,
the natural junction in a belt lipectomy (B,C right).
Scar below ASIS
Scar above ASIS
ASIS
A
Scar below natural
lower back/buttocks
junction
Scar at natural
lower back/buttocks
junction
B
Buttock unit
Buttock unit
C
A careful history of all significant medical problems should
be ascertained. A history of nutritional habits should be col-
lected. Post-bariatric surgery patients who are not on vitamins
indicate a lack of appropriate follow-up and probable nutri-
tional deficits. This should alert the plastic surgeon to pursue
their laboratory examinations very carefully.
Many MWL patients have extensive psychiatric histories.
The authors have found it necessary to obtain psychiatric
clearance for each belt lipectomy/bodylift patient. This is
done to emphasize the extensive nature of the surgery to the
patient as well as alerting the mental healthcare provider that
their services may be required in the postoperative period.

625
Treatment/surgical techniques
patients, many 20–30 pound overweight patients, and some
normal weight patients there is a need for significant improve-
ments above and below the level of excision circumferentially
around the entire lower trunk (Fig. 25.2.14). Thus, with the
tension maintained circumferentially, the improvement is also
maintained circumferentially above and below the excision.
If the concept of maintaining tension around the trunk is
ignored in patients who need improvements circumferentially,
either by doing an abdominoplasty or a T-type (fleur-de-lis)
resection, the results are less than ideal with the lateral and
posterior aspects of the lower trunk remaining unchanged
after surgery (Fig. 25.2.15).
Belt lipectomy
What will be described here is a belt lipectomy or central
bodylift technique because it is what the authors perform
most often, based on the fact that most of their patients are
female.
Goals
Overall, a bodylift/belt lipectomy procedure treats the lower
trunk as a unit and should address most of the patient’s
concerns in this region. Box 25.2.4 shows the general goals
that should be sought after.
Markings
The markings in bodylift/belt lipectomy surgery are the “road
map” to success. Although there are decisions to be made
The following points should be carefully noted on physical
examination:
■ The degree of skin laxity
■ The amount of subcutaneous fat
■ The translation of pull, as described above
■ The presence of scars: subcostal cholecystectomy scars
may jeopardize the flap vascularity, and vertical midline
scars may limit abdominal flap inferior mobility
■ Waist definition
■ The presence of abdominal or back rolls
■ The degree of rectus diastasis and/or the presence of
hernias
■ The amount of intra-abdominal content must be noted.
The traditional “diver’s test” is not effective in most
MWL patients because of the thickness and laxity of the
abdominal wall fat. The authors utilize the more effective
method of laying the patient in the supine position and
evaluating their abdominal contours. If the contour is
scaphoid and the abdominal wall falls below the rib cage,
then it would be expected that rectus fascia plication will
be effective in flattening the contour.9 If the abdominal
tissues are above the level of the ribs, then it can be
presumed that intra-abdominal contents are large enough
to prevent effective plication (see Fig. 25.2.7)
■ The degree of buttocks projection and ptosis
■ The degree of anterior and lateral thigh lipodystrophy
and ptosis.
In the MWL patient, the altered absorption or restriction of
food can create significant abnormalities of laboratory values,
leading to potential problems at surgery.10 Thus an extensive
set of labs should be obtained as early as possible in the care
of the patient because it may take some time to correct abnor-
malities. Those labs include complete blood count (CBC),
blood urea nitrogen, creatinine, electrolytes, glucose, urinaly-
sis, liver function tests, iron, calcium, albumin, pre-albumin,
total protein, vitamin B, magnesium, and thiamine. Chest
X-ray and electrocardiogram are obtained if indicated.
Treatment/surgical techniques
Rationale for circumferential excisional
procedures
A basic tenet of plastic surgery is that “Tension is bad”. It is
true that tension is bad for scarring and blood supply, but it
is essential for improving body contour in excisional proce-
dures. In abdominoplasty, the elliptical excision creates the
greatest amount of tension in the central zone of the abdomen.
The areas above and below this region, superiorly the epigas-
tric region and inferiorly the mons pubis, demonstrate the
greatest amount of improvement. As the elliptical excision is
followed laterally, the amount of tension decreases, reaching
zero at its lateral edges (Fig. 25.2.13). Thus the improvements
above and below the excision, the anterior thighs and the
lateral abdomen, also decrease in magnitude as the elliptical
excision is traversed from medial to lateral. In an ordinary low
BMI patient with “anterior only” deformities, there is little
need for improvement above and below the excision, outside
of the anterior abdomen. However, in most massive weight
Fig. 25.2.13  The black arrows indicate the amount of tension that will be created
at closure after the proposed resection of the abdominoplasty ellipse. The greatest
amount of tension is central and trails off to zero at the lateral edge of the elliptical
closure. The extent of body contour improvement above and below the resection is
directly related to the amount of tension. Thus the extent of improvement, light
blue, above and below the final scar will also be greatest centrally and fizzle to
zero, laterally. This patient does not need improvement laterally, above and below
the proposed excision, thus is an ideal candidate for an abdominoplasty.

626
SECTION II
CHAPTER 25.2 • Circumferential approaches to truncal contouring: Belt lipectomy
Marking the vertical midline
It is sometimes difficult to find the anterior midline. The
villous hair pattern in the epigastric region can be helpful to
delineate the midline. Inferiorly, the vaginal fourchette in the
female and the midline of the penis in males are helpful in
delineating the midline.
Horizontal mons pubis marking
Essentially all MWL patients have vertical excess of the mons
pubis and varying degrees of horizontal excess. Thus, it is
important to eliminate as much of the vertical excess as pos-
sible during bodylift/belt lipectomy. Since the mons pubis is
“V” shaped, a low resection well within the hair-bearing skin
will leave behind a much narrower final mons pubis, thus
eliminating both vertical and horizontal excess.
With the patient supine, the tissues are retracted superiorly
utilizing the non-dominant hand to create a pleasing appear-
ance of the mons. The midline bony prominence is palpated,
and 1–3 cm above it the horizontal mark is made from one
lateral edge of the mons to the other. This maneuver simulates
intraoperatively, the majority of planning and decision-
making should be done during the marking process. It is
important to photograph the markings and use them in two
ways. First, evaluate them prior to surgery and make needed
adjustments. Second, compare the patient’s final contour,
usually at 12 months after surgery, to the markings. It is the
only way to improve one’s technique.
The abdomen is the patient’s greatest concern, and the
surgeon should strive to attain the best possible abdominal
contour, not compromising that for lateral or posterior contour.
It should be remembered that there is a general inferomedial
rotation of tissues around the sacrum as a fulcrum, and to
reverse this deformity, fairly aggressive lateral resections are
required to attain harmonious truncal contour.
The marking instructions in this chapter are only guide-
lines. Although a lot of technical details will be dealt with
here, it is more important to learn the principles behind those
details so that they can be applied under varying conditions.
Controlling scar position is something that every surgeon
should aspire to attain. As a general principle, scar position can
be approximated by simulating the tissue dynamics at closure.
Fig. 25.2.14  In a patient with circumferential deformities above and below the proposed area of excision, there is a need to maintain excisional tension circumferentially, to
attain the appropriate improvements in all the involved areas.

627
Treatment/surgical techniques
tissue dynamics at the time of closure, the non-dominant hand
pushes the abdominal tissues superomedially in a fairly
aggressive manner to simulate the pull of the resected
abdominal flap on the closure in this area (Fig. 25.2.17). The
traction created by the hand is resisted by the zone of adher-
ence in the inguinal area. The mark is then made where the
surgeon desires the final scar to be. If the surgeon desires a
high “French bikini” angled scar, then the ASIS is palpated
and the mark is aimed just superior to it. This is the preference
of the authors because it creates a scar at the natural junction
between the abdominal and thigh units and it promotes a
narrower waist. If the surgeon prefers a lower scar, the same
maneuver is performed but the line is drawn in a lower
position.
Superior horizontal abdominal marks
With the patient in a semiflexed position, the superior pro-
posed line of excision is marked, usually a few centimeters
above the umbilicus in MWL patients and less so for patients
who are 20–30 pounds overweight or normal weight patients.
These marks, unlike the inferior marks described above, are
guidelines that are adjusted intraoperatively based on tissue
the dynamics at the time of closure. If measured, the distance
from the vaginal fourchette to the top of the proposed superior
aspect of the mons, under tension, is usually 6–8 cm (Fig.
25.2.16). The mark is measured on either side of the midline
to maintain symmetry.
Mark from lateral mons to ASIS
The horizontal mark from the mons pubis to the ASIS is done
with the patient in a slightly flexed position. To simulate
Fig. 25.2.15  Note in this massive weight loss patient, the improvements attained by a traditional abdominoplasty are limited to the central anterior abdomen, shown below.
Because there is no tension created by the abdominoplasty laterally and posteriorly, shown by the loss of light blue color, above, there is no improvement in these areas.
BOX 25.2.4  Goals
1. Elimination of the panniculus/flattening the abdomen
2. Elimination of mons pubis ptosis and redundancy
3. Creation of waist definition (usually a desire in females)
4. Lifting the anterior and lateral thighs
5. Elimination of lower back rolls and, in some patients, mid-back
rolls
6. Lifting the buttocks
7. Creation of better buttocks contour

628
SECTION II
CHAPTER 25.2 • Circumferential approaches to truncal contouring: Belt lipectomy
mobility and desired contour. Generally, the resection is fairly
aggressive in MWL patients because this will achieve the best
possible contour and because there is no need to temper the
vertical resection to prevent a lateral dog-ear. The circum-
ferential excision frees up the surgeon to be as aggressive
Fig. 25.2.16  The horizontal mark of the mons pubis. Note the mons pubis is
elevated to a pleasing appearance and the mark is made 1–3 cm above the pubic
bone.
Fig. 25.2.17  The mark from the lateral edge of the mons pubis to the anterior
superior iliac spine. The mark is made with the non-dominant hand pushing the
tissues superomedially to simulate the pull of the resected abdominal flap on the
inferior line of resection.
Fig. 25.2.18  The superior lateral mark should be marked without much angulation,
especially if the patient is marked in the supine position. A severely angulated
mark, shown in red, could lead to central abdominal flap necrosis due to a
significant reduction in the remaining blood supply.
as they need to be to attain the best possible contour. This is
one of the major advantages of circumferential excisions over
anterior-only procedures. The authors prefer to match the
distances of the upper marks to those of the lower marks to
help alignment at closure. Centrally, matching the mons pubis
horizontal mark, the superior marks are flat or slightly “V”
shaped, especially if one wants to avoid a “W” shape to the
final scar (Fig. 25.2.18).
To match the lower line from the mons pubis to the ASIS,
there is a tendency, especially in the supine position, to angu-
late the superior lateral mark when the surgeon prefers the
“French bikini” angle. This should be avoided because it leads
to less remaining intercostal, subcostal, and lumber vessels
reaching the inferior midline of the abdominal flap, resulting
in potential tissue necrosis centrally. When the patient stands
up, the superior lateral marks, which were made fairly flat in
the supine position, will become angulated because the pan-
niculus gravitationally descending more in the midline. Thus,
if the marks were to be angulated in the supine position they
will be even more dangerously angulated, leading to potential
complications.
It is important to note that anteriorly, the inferior marks
control scar position due to the fact that the inferior zones of
adherence are far less mobile and act to keep the scar closer
to them, rather than the fairly mobile abdominal flap.
The posterior vertical midline is marked
The posterior markings are performed with the patient
standing.
The posterior midline extent of resection is marked
Examination of the back on either side of the midline reveals
that in most MWL patients the lower back tissue is fairly

629
Treatment/surgical techniques
smooth and then it transitions to wrinkled skin, at varying
distances down the buttocks unit. Generally, the transition can
be thought of as the top of the buttocks, which has descended
secondary to the deflation of weight loss. The inferior point
of the midline extent of resection is marked close to this level,
especially if the midline buttocks crease is fairly low and
needs to be elevated. Once the inferior point is decided upon,
the tissue superior to it is pinched while the patient is flexed
at the waist, to simulate the position they will be in after
their abdominoplasty component is completed. The superior
midline mark is then made (Fig. 25.2.19). This maneuver is
essential to reduce the risk of dehiscence.
At this point, the surgeon has to evaluate the level of the
lateral aspects of the anterior superior and anterior inferior
marks and compare them to the position of the midline back
marks. Obviously, the anterior superior lateral mark will
eventually have to connect to the superior midline mark while
the lateral aspect of the anterior inferior marks will have to
connect to the inferior midline mark. If there are great discrep-
ancies, adjustments can be made at this point.
The inferior back marks
The inferior back marks, from the midline of the back to the
lateral extent of the anterior marks, are made in a smooth
shallow “S” fashion (Fig. 25.2.20). This mark is made first by
the authors rather than the superior mark because it is helpful
in creating the shape of the resection, which is important in
controlling contour. The lowest aspect of the “S” should be
located at the posterior axillary line because that is the area
of greatest vertical descent of the lower trunk due to aging
and/or weight loss.
The superior back marks
To create the superior back mark, from the midline of the back
to the lateral extent of the anterior markings, the inferior mark
is pinched, bringing the buttocks and lateral thigh tissues up
Fig. 25.2.20  The inferior posterior mark is made in a smooth shallow “S”-shaped
fashion. Because the greatest descent occurs out laterally, at the posterior axillary
line, this shape of excision allows for the greatest resection at this level.
Fig. 25.2.19  Marking the extent of central midline of the back excision is done
with the patient in the flexed position to simulate the position that the patient will
be in after their abdominoplasty component is completed. This will reduce the risk
of dehiscence because it accounts for the competing anterior and posterior tensions
at the end of the entire procedure.
as high as needed to create the desired lateral buttocks/thigh
contour (Fig. 25.2.21). The top of the pinch is marked at a
number of points, which are then connected to each other,
from the midline to the lateral aspects of the anterior mark.
The authors prefer the final midline scar to have a “V” shape
to create the scar at a natural junction between the lower back,
sacrum, and buttocks. Others prefer a straight line closure,
while very few surgeons prefer an inverted “V” pattern.
The superior marks of the back control scar position in a belt
lipectomy because the superior back tissues are much less mobile
than the buttocks tissues below.
Thus, if the markings are performed for a belt lipectomy/
central bodylift, with an intended scar at or just above the
widest aspect of the pelvic rim, the final scar is usually within
2–3 cm of the superior mark. If a lower bodylift is being
performed, this rule may not apply because the area of resec-
tion is farther away from the zones of adherence in the lower
back and the final scar position may be more than 3 cm
inferior to the original superior mark. Prior to surgery, the
authors evaluate and adjust the position of the posterior
superior mark and determine if it is in the correct place,
based on the knowledge of how far the final scar tends to be
from it.
Vertical alignment marks
Vertical alignment marks are made circumferentially. The
authors like marks to be made on the lateral aspects of the
mons pubis and at the level of the ASIS. The remaining marks’
positions are determined based on the size of the patient and
should be left up to the desire of the operating surgeon. It is
important to note that in most patients, there is a significant
diameter mismatch between the superior and inferior circum-
ferential marks. The inferior marks are almost always longer

630
SECTION II
CHAPTER 25.2 • Circumferential approaches to truncal contouring: Belt lipectomy
Fig. 25.2.21  The posterior superior mark is made by lifting the inferior mark at a
number of points, noting the appropriate buttock contour created by the lift, and
then connecting these points. It is important to note that the superior mark is what
controls final scar position because it is located in a less mobile area than the
highly mobile buttocks.
Posteriorly superior
mark controls scar
position
Low mobility
High mobility
in diameter, up to 15 cm per side in larger patients, than
the superior mark, necessitating adjustments, or “cheating”
during the closure. This can often lead to little puckers that
almost always resolve in the long term.
Positioning sequence
There are many potential positioning sequences that can be
utilized to perform a bodylift/belt lipectomy. As long as the
desired contour is attained, it matters little what sequence is
utilized.
Prone/supine positioning is the most commonly utilized
sequence. This sequence has the advantage of one turn and
an ability to judge symmetry of the back excision, and it
allows for augmenting the buttocks in a natural position. Its
disadvantages include more risk of positioning injuries, espe-
cially if operative times are prolonged in this position, which
include potential respiratory difficulties, shoulder injuries,
ulnar nerve injuries, and increased potential for eye injury.
Supine/prone positioning is also a single-turn sequence with
the added advantage of making sure that the highest priority
of contour is the anterior resection. Its increased disadvantage
over the above-mentioned sequence is that turning the patient
to the prone position after the anterior resection is completed
is more difficult because of the risk of dehiscing the anterior
closure during the turn.
Supine/lateral decubitus/lateral decubitus positioning is the
preferred sequence of the authors because of the need to
create the best possible anterior contour and then adjust the
remainder of the resection to it. Other advantages include the
ability to abduct the legs in the lateral decubitus position
and to allow for greater lateral resection of excess tissue.
Disadvantages include an inability to visualize the entire
back/buttocks during the resection, potentially leading to a
greater chance for asymmetry. Augmenting the buttocks in
the lateral position is more challenging and harder to judge.
Another potential disadvantage is that there are two turns
required, with an added turn at the end prior to transferring
the patient to the hospital bed. Although the authors are able
to accomplish these turns very efficiently and without over-
exposure and heat loss, they have a very well-trained team
with extensive experience. Less ideal situations may not
produce such ideal conditions.
Anesthesia and deep vein thrombosis/pulmonary
embolism prophylaxis
The majority of surgeons performing bodylift/belt lipectomy
utilize a general anesthetic. The authors of this chapter utilize
a general anesthetic with a thoracic epidural placed prior to
surgery, which has been found to be very effective in decreas-
ing postoperative discomfort.11 At the time of writing of this
chapter, the authors are compiling data that point towards a
significant reduction in deep vein thrombosis/pulmonary
embolism (DVT/PE) when an epidural is utilized. Although
the orthopedic and anesthesia literature is supportive of the
notion that epidural use reduces the risk of DVT/PE, it is too
early to definitively claim that in the field of plastic surgery.
If an epidural is not utilized, the reader has to make a decision
as to whether they should add chemoprophylaxis to the
routine of lower extremity alternating compression stockings
and early ambulation. It is not clear at this point what is the
best chemoprophylaxis regimen if it is to be utilized.
Surgical technique
The technique that is described here is a belt lipectomy pro-
cedure as performed by the authors.
In the operating room, the patient is put in the supine
position on a bean bag, arms are abducted at 90°. The mark-
ings are reinforced and methylene blue tattooed to prevent
fading with the prepping of the patient. After insertion of an
indwelling urinary catheter and application of sequential
compression boots, the patient is prepped and draped.
Traction sutures are placed at the 6 and 12 o’clock positions,
at the appropriate depth within the umbilicus, to facilitate a
circumumbilical incision. The umbilicus is incised, and the
umbilical stalk is freed from surrounding tissues using scis-
sors. Some patients may have an undetected periumbilical
hernia, so care must be taken while dissecting the stalk.
The inferior lower abdominal mark is then incised and the
dissection is taken down to, or just deep to, Scarpa’s fascia.
Some patients have very well-defined Scarpa’s fascia, while
others have a less distinct layer. Scarpa’s fascia is preserved
from the incision line and upward toward the umbilicus (Fig.
25.2.22). The authors believe that leaving some fatty tissue on
top of the rectus fascia reduces the risk of seroma.
The type of supraumbilical dissection performed is depen-
dent on the thickness of the presenting abdominal flap. If the
flap is thin, then a more traditional elevation towards the
costal margins and xiphoid is performed. The authors try to
leave a very thin layer of fat on the rectus fascia to help reduce
seroma. The extent of abdominal flap elevation should be just
enough to attain the proper advancement of the flap, create

631
Treatment/surgical techniques
the best possible contour, and preserve as many vascular
perforators as possible. If the abdominal flap is thick, then a
very limited dissection tunnel, up to the xiphoid, is performed
to expose the medial edges of the rectus muscle, and concomi-
tant liposuction of the flap is performed to thin the flap (see
Fig. 25.2.22).
Abdominal wall vertical plication is then performed from
xiphoid to pubis. The authors utilize long-lasting, non-
permanent, barbed, running sutures. Horizontal plications are
performed if deemed necessary.
In order to achieve maximum flap advancement, the patient
is flexed at the waist, and the flap is advanced inferiorly. The
flap is then tailored with the upper mark used as a guide.
When resecting the excess flap, it is often necessary to bevel
the resection if the flap is thick.
If the mons pubis is deemed too thick, it can either be
reduced by liposuction or by direct excision of sub-Scarpal fat.
Direct excision usually requires tacking down of the mons
Scarpa’s fascia to the underlying rectus fascia at the appropri-
ate level.
With the abdominal flap tailored and temporarily tacked
in place, a 1.5–2 cm vertical incision is made in the midline
overlying the umbilical stalk. A path for the umbilical stalk
to be brought through is created by blunt dissection, with
no fat removal. The authors feel that fat resection in the
neoumbilical region may lead to vascular compromise of
the flap. The desired inversion of the umbilicus is attained
through “three-point fixation sutures”, placed at 3, 6, and 9
o’clock. These are inverted 3-0 non-permanent monofilament
sutures that are placed through the abdominal wall fascia, the
subcuticular layer of the abdominal flap, and the subcuticular
layer of the umbilicus (Fig. 25.2.23). When these sutures are
tied, they will create as much, or as little, inversion as the
surgeon desires, as well as pulling the scar inside the umbili-
cal depression. The remainder of the umbilicus is sutured to
the surrounding abdominal flap with interrupted inverted
Fig. 25.2.23  Three-point fixation sutures that are utilized to create inversion of the
umbilicus and a final periumbilical scar that is located internally to avoid external
scar prominence. Note the authors do not defat the umbilical defect because it is
felt that this may lead to an increased risk of flap necrosis.
Fig. 25.2.24  The figure demonstrates the pattern of quilting sutures utilized by the
authors.
subcuticular sutures. No external sutures are utilized, to
avoid suture marks. The scar should also be located on the
inner aspect of the umbilical depression so that it is well
hidden.
Quilting sutures, placed between the abdominal flap and
the underlying abdominal wall, are utilized by some surgeons,
including the authors, to obliterate potential dead space in the
hope of reducing the risk of seroma formation.12 Other names
utilized for these sutures are progressive tension sutures as
well as Baroudi stitches. Fig. 25.2.24 shows the pattern of
quilting sutures utilized by the authors when combined with
a limited supraumbilical dissection.
Abdominal closure is usually accomplished over one
closed suction drain. The authors prefer to bring out this
drain laterally, at about the lateral level of the ASIS, because
pubic area drains tend to become quite uncomfortable if left in
place for longer than a week, which is not an infrequent occur-
rence in MWL patients. Closure involves reapproximation
Fig. 25.2.22  All infraumbilical elevations are performed at, or just deep to,
Scarpa’s fascia level. This figure demonstrates flap elevation in a “thick panniculus”
patient, where the authors routinely liposuction the supraumbilical flap. To avoid
vascular supply issues, this type of patient has a very limited supraumbilical
elevation, just to the medial edges of the rectus muscle, to allow for a full
complement of rectus perforators to remain intact.
Medial edges
of rectus muscles
Elevation at
Scarpa's fascia level

632
SECTION II
CHAPTER 25.2 • Circumferential approaches to truncal contouring: Belt lipectomy
of Scarpa’s fascia and one to two superficial layers for skin
closure. The lateral dog-ears created by the anterior resec-
tion are temporarily closed with staples to allow for the
upcoming turns.
Turning of the patient to the lateral decubitus position
should be accomplished by the coordinated effort of the
anesthetist and at least four other operating room personnel.
It is very important to keep the waist flexed at all times during
the turning process to prevent dehiscence of the abdominal
closure. The best way to ensure this is to assign one person to
this task. All pressure points need to be padded, including an
axillary roll. The hips are abducted to allow for the maximum
excision of the lateral tissues, which can be accomplished with
pillows placed between the knees (Fig. 25.2.25).
With the patient re-prepped and draped, the back excision
from the lateral dog-ear to the midline of the back is under-
taken. Most patients will undergo liposuction of the lateral
thighs, which is performed at this juncture.
The authors prefer to make the superior mark incision first.
The level to which the dissection is deepened is dependent on
the desired amount of fat to be left in the buttocks. In patients
with overprojected buttocks, the desired goal is to reduce the
projection and create a depression at the waist by cinching
above the hip. This is best accomplished by dissecting down
to just above the muscle fascia and then elevating an inferiorly
based flap down to the level of the proposed excision line (Fig.
25.2.26). When tailoring the flap, the resection is beveled to
further create narrowing of the waist.
In patients who have normal or deficient buttocks projec-
tion, the goal of surgery is to maintain as much projection as
possible. Thus, the superior mark incision is deepened to the
superficial fascia level, and the flap is dissected inferiorly to
the level of the proposed excision at this level (see Fig. 25.2.26).
During the tailoring process, the inferior flap is not beveled.
The inferior dissection of the lateral thigh region of this
segment of the procedure is usually limited to the proposed
inferior excision line. After tailoring the inferiorly based flap,
closure is performed in a similar manner to the anterior
closure. A drain is inserted prior to closure. Closing one side
will lead to a midline dog-ear, which is temporarily closed
with staples to allow for the next turn. The patient is then
turned and the same steps are repeated for the other side.
The patient is then turned to the supine position while
making sure they are maintained in the flexed position and
Fig. 25.2.25  The authors prefer the lateral decubitus
position to excise the tissues from the lateral dog-ear created
by the anterior resection to the midline of the back. This
position allows for maximal hip abduction and easy access
for lateral thigh liposuction. It is essential that the patient is
appropriately padded, including an axillary roll.
Axillary roll
Fig. 25.2.26  The level of elevation of the inferiorly based flap during the back
resection is dependent on the presenting anatomy and the desired goals of the
patient. In patients with high BMIs and/or overprojected buttocks at presentation,
the dissection is deepened to the just above the muscle fascia to allow for
narrowing of the waist and reduction of buttocks projection (A). In patients with low
BMIs and/or underprojected buttocks at presentation, the dissection is deepened to
the superficial fascial system level to maintain fullness and increase final projection
(B).
A
Skin
Deep muscular fascia
Deep fat layer
Muscle
Superficial fascial system
(Scarpa’s fascia anteriorly)
Superficial fat layer
B
transferred to a flexed hospital bed under the supervision of
the operating surgeon.
Autoaugmentation of the buttocks for patients who present
with underprojected buttocks is advocated by some investiga-
tors. In these procedures, the proposed tissue to be excised
from the back is de-epithelialized and rotated into the but-
tocks region to create bulk. The authors do not utilize these
flaps for a variety of reasons. First, these flaps can augment
the buttocks in the wrong position, lead to malposition of the
back scar, and most often are not needed at all. The authors
are a referral center for complications associated with body
contouring after MWL, and some very difficult problems have
been encountered with these flaps. These include fat necrosis,
major skin necrosis, chronic pain, chronic seromas, major

633
Outcomes/prognosis/complications
Outcomes/prognosis/complications
As with the patient presentation, the prognosis after belt lipec-
tomy depends on the patient’s BMI, fat deposition pattern,
and the quality of their skin/fat envelope. Of these factors,
the patient’s BMI is the most important. As a general rule, the
lower the BMI at presentation, the better the result and the
lower the complication rate. Conversely, the higher the BMI,
the less attractive the result, and the higher the complication
rate. In MWL patients, the authors have categorized patients
by BMI level: group I, BMI ≥36; group II, BMI 30–35; and
group III, BMI ≤29. Although the cut-offs between groups
are arbitrary, the intent of the categorization is to help the
surgeon and patient predict, in a general manner, the expected
results. Thus group I patients (Figs. 25.2.27 & 25.2.28) will
demonstrate less improvement and more complications
after bodylift/belt lipectomy than those in group II. Group
II (Figs. 25.2.29 & 25.2.30) will demonstrate less improve-
ment and more complications than those in group III (Figs.
25.2.31 & 25.2.32). This rule holds as long as one compares
these patients in groups. Within each of these arbitrarily
chosen BMI ranges, patients do not necessarily follow the
rule that a lower BMI automatically guarantees better results
or lower complication rates because other factors such as
fat deposition pattern and the amount of skin laxity also
play a role.
It is important to explain to patients, prior to surgery, that
their contour is improved significantly after bodylift/belt
lipectomy but their skin quality is unchanged. Thus, once the
swelling associated with surgery is resolved, skin elasticity on
palpation is unchanged from its preoperative characteristics,
especially in the epigastric region. Both the inexperienced
surgeon and the patient may desire more tissue excision, but
this will lead to failure.
A subject that has not been addressed in the literature is
the sensory loss associated with circumferential dermatoli-
pectomy procedures. Traditional abdominoplasty sensory
loss is usually located inferior to the neo-umbilicus in
a triangular pattern, with the base straddling the midline
at the abdominal scar and the apex at the neo-umbilicus.
Over a 1- to 2-year period, sensation tends to return to this
area with the apex descending and the base becoming nar-
rower. What has been observed by the authors is that the
area of sensory loss is usually circumferential, with varying
and sometimes asymmetric patterns, and that it improves
from 6 months to 1 year. It is also important to warn the
patients prior to surgery that should they gain significant
weight, most or all of their body contour improvement can be
reversed.
Complications
Circumferential bodylift/belt lipectomy procedures per-
formed on normal weight patients tend to have similar com-
plication profiles to their abdominoplasty counterparts. On
the other hand, MWL patients who undergo bodylift/belt
lipectomy have significant risk of complications, more so than
in any other area of aesthetic surgery. This is especially true
if the surgeon chooses to operate on patients presenting in the
higher BMI ranges. As a general rule, the higher the BMI, the
higher the complication rate.
dehiscence, and sepsis. The added time in the operating room
to autoaugment the buttocks also increases the time of a
procedure that is already long, worsening the potential for
complications. It is the authors’ opinion that these flaps should
not be attempted by the novice body contouring surgeon
because even very experienced surgeons who perform these
techniques are selective in whom they choose to perform
them on.
Postoperative care
A sign is placed on the patient’s bed which reads “Patient
is not to be moved in any way till completely awake and
alert”. While the patient is drowsy from anesthesia, simple
body position movements by the nursing staff can lead to
dehiscence. Once the patient is awake and alert, they can
sense tension and will be able to prevent dehiscence on
their own. The patient is educated prior to surgery about
the ability to sense tension and how they are to help the
nursing staff with this aspect of their postoperative care.
It is a standing order for the authors that all patients are
walked the same day of surgery, with assistance, even if it
is just a few steps. The epidural catheter anesthetic infusion
is managed by the anesthesiologist and is left running until
the morning of the second postoperative day. The infusion
is then discontinued, but the catheter is left in place. If the
patient is unable to tolerate discomfort without the epidural
infusion, then it is restarted, but in the majority of cases, the
epidural catheter is removed. The urinary catheter is removed
4–6 h after the epidural infusion is discontinued. The authors
recommend a 2-day stay in the hospital because almost
all major problems tend to occur within this time period.
Most patients are able to go home between the second and
third day.
For the first week, the patient is ambulated bent at the waist
and then allowed to slowly straighten up over a couple of
days. Activity is slowly increased as tolerated over the first
3–4 weeks, with most patients being able to return to non-
physical work in 4 weeks. A compression garment is worn by
the patient starting a few days after surgery when the surgeon
feels comfortable that it will not compromise blood supply of
the abdominal flap. Subsequently, the patient is asked to wear
the garment for as long as they can tolerate it. Drain removal
is based on ≤40 cc/day, with most drains removed at 2 weeks,
even if this criterion is not met. A postoperative care summary
is given in Box 25.2.5.
Most patients will not attain their final contour for at least
1 year, with a few patients continuing to improve for up to 2
years.
BOX 25.2.5  Postoperative care summary
• “Patient is not to be moved in any way till completely awake and
alert” should be posted on the patient’s bed
• Ambulate the same day of surgery with assistance
• Do not allow patient to straighten up for 1 week postoperatively
• A 1- to 2-day monitoring period is highly recommended
• Garments should be worn for extended periods of time
• Maturation of results take at least 1 year

634
SECTION II
CHAPTER 25.2 • Circumferential approaches to truncal contouring: Belt lipectomy
eventually resolve on its own. Thus, the authors will watch a
small fluid collection, rather than aspirate it.
If a seroma should become infected, it usually requires
incision and drainage, antibiotic coverage, and making sure
the pocket closes from deep to superficial by the use of a
“wick”-type dressing.
Wound separation
The long incisions in circumferential dermatolipectomy com-
bined with the high-level tension created by the procedure
very often lead to small wound separations. Most often they
will heal without much difficulty or negative sequelae, but
they can be bothersome to the patient. Thus, it is best to warn
patients about these areas prior to surgery. Treatment is
usually conservative, allowing secondary intention healing to
occur.
Seromas
The most common complication of bodylift/belt lipectomy,
outside of small non-healing areas along the incision line, is
seroma. As a matter of fact, if the surgeon elects to operate on
patients presenting with BMIs >35, they should expect a
seroma in almost all cases. Currently, the authors leave a layer
of fat on the rectus fascia in the infraumbilical dissection of
the abdominal flap and utilize quilting sutures in the hope of
reducing seroma frequency. When a seroma is encountered,
the authors serially aspirate it, and if that is not successful,
they will inject the pocket with a sclerosing agent, doxycycline,
in the hopes of closing down the pocket. It has become appar-
ent that the presence of a seroma capsule is not an indication
for operating on a seroma, as is traditionally believed. It has
also become apparent that if a fluid-filled pocket is small and
non-expanding, it does not need treatment, because it will
Fig. 25.2.27  This figure demonstrates preoperative (above) and postoperative (below) photographs of a patient who presented with a BMI >35, a group I patient, who
underwent a belt lipectomy/bodylift. Because the abdominal flap at presentation was thick and required thinning, the supraumbilical tissues, shown above the proposed
superior marks, were liposuctioned and a limited central flap dissection was performed to maintain the rectus perforators blood supply. Note there were two proposed lines
of excision marked in the hopes of reaching the more superior one, but if not then a more inferior one would have been utilized. The scar was intentionally kept high in
order that a “cinching” at the waist could be accomplished. Posteriorly the inferiorly based buttocks flap was elevated at the level of the underlying muscle fascia, in order
to “cinch” around the waist and create a depression above the buttocks proper, which increases the apparent projection of the buttocks. Note that group I, when compared
with groups II and III, demonstrates less overall improvement in lower truncal contour.

635
Outcomes/prognosis/complications
tension” and avoiding body positions that strain the closures.
It is important to advise patients that all their movements, for
the first 3 months after surgery, should be slow and deliberate,
which will lead to a sense of tension before the tension reaches
the level required to dehisce. Early dehiscence can be treated
by a return to the operating room for attempted closure,
closure in the emergency room, or the application of a wound-
vac. The area involved may require a scar revision in the long
run.
Infection
The most common cause for infections after a bodylift/belt
lipectomy is undetected seromas. It is wise to see these patients
for at least a year after surgery to make sure that there are no
undetected seromas. As mentioned earlier, the authors do not
treat small non-expanding fluid collections but they do keep
a close watch on them in case they become infected. The
treatment of an infected seroma is described above. Occasion-
ally a patient will develop a skin cellulitis, which is unrelated
Dehiscence
A dehiscence is defined as a wound separation at the super-
ficial fascial system level or deeper. Circumferential proce-
dures are more prone to dehiscence because of the competing
tensions, especially the anterior and posterior closures. Fortu-
nately, dehiscences are fairly rare if a number of issues are
addressed. Dehiscence may occur within the immediate
postoperative period or a few weeks after surgery when the
patient has presumably healed. Three strategies will help
reduce the risk of dehiscing in the early postoperative period.
First, the extent of the back midline resection is preoperatively
marked with the patient in the flexed waist position attained
after the anterior resection is completed. Second, the sign
placed on the patient’s bed that warns all healthcare person-
nel to avoid manipulating the patient until they are awake
and alert is essential because “an awake patient can sense
tension and protect themselves”. Third, preoperatively,
patients and nursing staff are coached on how a patient is
be “rolled out of bed” with the aid of the patient “sensing
Fig. 25.2.28  The figure demonstrates pre- (above) and postoperative photographs (below) of another group I patient who presented in the high BMI range, >35. She
previously underwent an unsuccessful “anterior only” abdominoplasty to treat her circumferential lower truncal excess. A belt lipectomy/bodylift was performed on this
patient, which required a complete redo of the abdominal region.

636
SECTION II
CHAPTER 25.2 • Circumferential approaches to truncal contouring: Belt lipectomy
these feeding vessels and thus may lead to necrosis of the
midline inferior flap. Since the inferior line marks are what
controls final scar position, not the superior line marks, there
is no need to angulate sharply, which avoids this potential
complication.
As in traditional abdominoplasty, subcostal scars can and
will interfere with the remaining blood supply of the flap
after a traditional elevation. There are a number of strate-
gies that can be employed to decrease the risk of necrosis.
In some MWL patients, their subcostal scar is so low that
it can be used as the upper limit of the resection, thus
eliminating any tissue that may be compromised. Another
strategy is to perform a T-type resection with the subcostal
scar used as one of the vertical limbs brought together in the
midline. The authors have no experience with this option.
The most common way for the authors to handle subcostal
scars is to alter the sequence of surgical steps, by making
the superior mark incision first and conservatively elevating
the supraumbilical flap, while evaluating the blood supply
of the tissue at risk, which is immediately inferomedial to
the scar (Fig. 25.2.33). If those tissues are deemed ischemic,
to a seroma. Those are treated as in any other cellulitis
encountered after a surgical procedure, usually with appro-
priate antibiotic coverage.
Tissue necrosis
Tissue necrosis can occur after bodylift/belt lipectomy, espe-
cially in the anterior midline of the inferior aspect of the
abdominal flap, due to a variety of factors, which include
smoking, excessive tension on the closure, acute angulation
of the superolateral excision line of the abdominal flap, and
old abdominal scars interfering with the normal blood supply.
The authors avoid operating on smokers. Quilting sutures can
help reduce tension on the closure but it is best to avoid too
much tension in the first place.
There is a tendency to over-angulate tailoring of the lateral
abdominal flap in an attempt to match the inferior incision
line, especially if it is angulated sharply, as in a “French bikini”
line (see Fig. 25.2.18). Since the main blood supply of the
abdominal flap is the intercostals, subcostal, and lumbar
vessels, sharp angulation of the superior incision will violate
Fig. 25.2.29  This figure demonstrates a patient who belongs to group II, who present with a BMI between 30 and 35. The patient is shown prior to surgery (above) and
after belt lipectomy/bodylift (below). Patients in this group will generally demonstrate more improvement than group I, but less than group III.

637
Outcomes/prognosis/complications
Fig. 25.2.30  This figure demonstrates another group II patient, BMI 30–35, before (above) and after belt lipectomy/bodylift (below). Note the patient subsequently also
underwent an upper bodylift.
discussions are centered around adding chemoprophylaxis to
the standard regimen, as discussed earlier. More randomized
trials need to be conducted on chemoprophylaxis, as well
as epidural analgesia, before definitive recommendations can
be made.
Psychological difficulties
Massive weight loss patients often have psychological
issues that either result from their obesity or helped cause
the obesity.13 The postoperative recovery from a bodylift/
belt lipectomy can be quite stressful psychologically, and
MWL patients may deteriorate after their bodylift/belt
lipectomy. The authors obtain psychiatric clearance on all
bodylift/belt lipectomy patients and have found this to be
very helpful in reducing the rate of psychological problems
postoperatively.
they are resected and the inferior flap is advanced superiorly,
as in a reverse abdominoplasty. Obviously, this will lead to
a fairly high final scar position, which the patient should
be warned about prior to surgery. On the other hand, if
the sub-scar tissues are found to have an adequate blood
supply, then the supraumbilical flap is advanced inferiorly
to the proposed inferior mark and the inferior flap is tailored
accordingly.
Deep vein thrombosis and pulmonary embolism
Patients undergoing bodylift/belt lipectomy have multiple
factors that increase the risk of DVT/PE. To prevent DVT/
PE, standard prophylaxis includes early mobilization and
the use of sequential compression stockings. At the time of
writing, there is a significant amount of discussion about
other means of reducing DVT/PE. The majority of these

638
SECTION II
CHAPTER 25.2 • Circumferential approaches to truncal contouring: Belt lipectomy
Fig. 25.2.31  This figure demonstrates a group III patient, BMI <30, before (above) and after belt lipectomy/bodylift (below). Note that group III patients, overall
demonstrate a greater degree of body contour improvement than either group I or II patients.

639
Outcomes/prognosis/complications
Fig. 25.2.32  This figure demonstrates another group III patient, BMI <30, before (above) and after belt lipectomy/bodylift (below). Note the greater overall improvement
over group I or II patients.

640
SECTION II
CHAPTER 25.2 • Circumferential approaches to truncal contouring: Belt lipectomy
1. Lockwood T. Lower bodylift with superficial fascial system
suspension. Plast Reconstr Surg. 1993;92:1112–1122.
2. Lockwood T. Lower bodylift. Oper Tech Plast Reconstr Surg.
1996;3:132–144.
3. Aly A, Cram AE, Chao BS, et al. Belt lipectomy for circumferential
truncal excess: the University of Iowa experience. Plast Reconstr
Surg. 2003;111:398–413. This is the first article ever published that
describes the use of circumferential lower truncal lipectomy/belt lipectomy
in the treatment of massive weight loss patients. It also describes four
groups, including the massive weight loss group, where circumferential
procedures can be utilized.
4. Aly AS. Option in lower truncal surgery. In: Aly AS, ed. Body
Contouring after Massive Weight Loss. St Louis, MO: Quality Medical
Publishing; 2006:59. This chapter describes the differences between the
different types of circumferential procedures both in technique and
philosophy.
5. Lockwood TE. Lower bodylift and medial thigh lift. In: Aly AS, ed.
Body Contouring after Massive Weight Loss. St Louis, MO: Quality
Medical Publishing; 2006:147. This chapter describes Lockwood’s
original technique, which differs significantly from belt lipectomy. It
describes the use of the superficial fascial system in excisional truncal
contouring as well as describing his technique for medial thigh lifting.
6. Aly AS, Cram AE. The Iowa belt lipectomy technique. Plast Reconstr
Surg. 2008;122:959–960.
7. Aly AS, Capella JE. Staging, reoperation and treatment of
complications after body contouring in the massive weight loss
patient. In: Grotting JC, ed. Reoperative Aesthetic and Reconstructive
Plastic Surgery. St Louis, MO: Quality Medical Publishing;
2007:1701.
8. Aly AS. Belt lipectomy. In: Aly AS, ed. Body Contouring after Massive
Weight Loss. St Louis, MO: Quality Medical Publishing; 2006:83. This
chapter goes in detail over the author’s approach to contouring the lower
truncal area. It covers patient presentation, physical examination,
markings, operative technique, results, and complications.
9. Aly AS. Belt lipectomy. In: Aly AS, ed. Body Contouring after Massive
Weight Loss. St Louis: Quality Medical; 2006:86.
11. Michaud AP, Rosenquist RW, Cram AE, et al. An evaluation of
epidural analgesia following circumferential belt lipectomy. Plast
Reconstr Surg. 2007;120:538–544. The article describes the authors’
regimen for epidural anesthesia, which the authors believe to be essential,
not only alleviating postoperative pain, but also in reducing the risk of
VTE/PE.
Access the complete reference list online at

Fig. 25.2.33  This figure demonstrates the most common approach that the authors utilize when a “chevron” cholecystectomy scar is encountered. The superior proposed
line of excision is incised first. The supraumbilical elevation is limited to the medial edges of the rectus muscles. The shaded area, inferior to the chevron scar, is then
evaluated at this point and if it is found to be vascularly compromised, the superior flap is tailored at the level of the old scar. The inferior flap is then elevated and tailored
to that resection line. On the other hand, if the shaded area demonstrates good vascularity, which fortunately occurs in most situations, then the superior flap is advanced
inferiorly in the usual manner and the inferior flap is tailored accordingly, resulting in a scar located in the usual position.
A
Old scar
Initial incision used to test
the vascular supply of the
abdominal flap
Area of potential necrosis
B
Superior flap is elevated first,
the inferior flap is adjusted

640.e1
References
References
1. Lockwood T. Lower bodylift with superficial fascial system
suspension. Plast Reconstr Surg. 1993;92:1112–1122.
2. Lockwood T. Lower bodylift. Oper Tech Plast Reconstr Surg.
1996;3:132–144.
3. Aly A, Cram AE, Chao BS, et al. Belt lipectomy for circumferential
truncal excess: the University of Iowa experience. Plast Reconstr
Surg. 2003;111:398–413. This is the first article ever published that
describes the use of circumferential lower truncal lipectomy/belt lipectomy
in the treatment of massive weight loss patients. It also describes four
groups, including the massive weight loss group, where circumferential
procedures can be utilized.
4. Aly AS. Option in lower truncal surgery. In: Aly AS, ed. Body
Contouring after Massive Weight Loss. St Louis, MO: Quality Medical
Publishing; 2006:59. This chapter describes the differences between the
different types of circumferential procedures both in technique and
philosophy.
5. Lockwood TE. Lower bodylift and medial thigh lift. In: Aly AS, ed.
Body Contouring after Massive Weight Loss. St Louis, MO: Quality
Medical Publishing; 2006:147. This chapter describes Lockwood’s
original technique, which differs significantly from belt lipectomy. It
describes the use of the superficial fascial system in excisional truncal
contouring as well as describing his technique for medial thigh lifting.
6. Aly AS, Cram AE. The Iowa belt lipectomy technique. Plast Reconstr
Surg. 2008;122:959–960.
7. Aly AS, Capella JE. Staging, reoperation and treatment of
complications after body contouring in the massive weight loss
patient. In: Grotting JC, ed. Reoperative Aesthetic and Reconstructive
Plastic Surgery. St Louis, MO: Quality Medical Publishing;
2007:1701.
8. Aly AS. Belt lipectomy. In: Aly AS, ed. Body Contouring after Massive
Weight Loss. St Louis, MO: Quality Medical Publishing; 2006:83. This
chapter goes in detail over the author’s approach to contouring the lower
truncal area. It covers patient presentation, physical examination,
markings, operative technique, results, and complications.
9. Aly AS. Belt lipectomy. In: Aly AS, ed. Body Contouring after Massive
Weight Loss. St Louis: Quality Medical; 2006:86.
10. Sebastian JL. Bariatric surgery and work-up of the massive weight
loss patient. Clin Plast Surg. 2008;35:11–26.
11. Michaud AP, Rosenquist RW, Cram AE, et al. An evaluation of
epidural analgesia following circumferential belt lipectomy. Plast
Reconstr Surg. 2007;120:538–544. The article describes the authors’
regimen for epidural anesthesia, which the authors believe to be essential,
not only alleviating postoperative pain, but also in reducing the risk of
VTE/PE.
12. Pollock TA, Pollock H. No-drain abdominoplasty with progressive
tensions sutures. Clin Plast Surg. 2010;37:515–524.
13. Sarwer DB, Fabricatore AN. Psychiatric considerations of the
massive weight loss patient. Clin Plast Surg. 2008;35:1–10.

SECTION II • General Aesthetic Surgery
25.3 
Circumferential approaches to truncal
contouring: The lower lipo-bodylift
Dirk F. Richter and Nina Schwaiger
SYNOPSIS
■ A two-position circumferential approach for body contouring of the
lower trunk is presented as an alternative technique to the belt
lipectomy described by Aly.
■ Mostly indicated in patients after massive weight loss, this procedure
arose from the original lower bodylift from Ted Lockwood.
■ It allows the simultaneous skin resection and reshaping in the
abdominal, flank, lateral thigh, back, and gluteal regions in the same
operation with only two position changes.
■ Besides the reconstruction of the abdominal wall, the gluteal
restoration presents a major aspect of this procedure, allowing a
volume and shape enhancement with autologous tissue
transpositioning.
■ This technique requires precise patient selection, discussion of the
desired result with the patient and clarification of realistic expectations.
■ The lipo-bodylift is the ideal procedure for skin laxity around the trunk
after weight loss, aging, or liposuction-induced deformities.
■ Focus more on the gluteal area and add gluteal reconstruction to the
technique.
■ Do NOT perform a bodylift procedure on patients with BMI >32.
■ Divide weight loss patients in three groups: large buttocks with excess
adipose tissue; normal-sized buttocks with ptosis and skin
redundancy; flattened, hypoplastic buttocks with ptosis and skin
redundancy.
Introduction
With the success and increasing number of bariatric proce-
dures, the authors have registered a yearly increase of body
contouring procedures. Additionally, due to increasing expe-
rience in this field of plastic surgery, these procedures have a
wider range of indications, including patients after massive
weight loss, patients with primarily cosmetic indications
(aging process), and patients who seek for correction of
contour deformities after previous liposuction. Coincidently,
the requirements and demands for such operations are
continually increasing. In addition to the typical problem
areas such as the abdomen, the mons pubis, and hip regions,
patients frequently present with a growing attention to the
aesthetic restoration of the gluteal area.
The variety of gluteal deformities after weight loss result
in a range of patient complaints and discomfort. Some patients
complain of an enlarged buttock, some of deficient gluteal
volume with gluteal flattening (platypygia), and yet others
suffer from cellulite or a lengthening of the infragluteal fold.
However, patients primarily seek for an enhancement of the
gluteal shape and projection. According to the statistics of the
International Society of Aesthetic Plastic Surgery (ISAPS), this
is the current fastest growing field.
A well-shaped buttock is characterized by several factors:
it is more rounded than angular, the intergluteal fold is rather
short than long, and the feminine gluteal cleavage has a
superior and inferior buttock separation. Dividing the but-
tocks into an upper, middle, and lower section, the ideal
maximum projection should be between the upper and middle
third.
The infragluteal fold should run in a round rather than
horizontal curve with a minimal crease, ideally without any
droop. Patients’ side view should illustrate an S-shaped
contour in relation to the back and thigh, as a smooth inward
sweep of the inferior back and waist area.1 To meet these ideal
characteristics, several techniques are available to plastic
surgeons. In the late 1960s, surgeons performed gluteal aug-
mentation with existing breast implants. Currently, various
gluteal implants are available, which can be implanted epifas-
cially, subfascially, or submuscularly. Nowadays, gluteal
contouring is most frequently performed through liposuction,
particularly by sculpturing the adjoining regions such as the
hips, flanks, and saddlebag deformities, achieving excellent
results without any direct buttock approach.
During the past decade, buttock augmentation by autolo-
gous fat grafting has gained wider acceptance and success.
Many different techniques such as macro- or micrografting
are available for contour improvement of the gluteal region,
solely or in combination with liposculpturing.2
  Access video lecture content for this chapter online at expertconsult.com

642
SECTION II
CHAPTER 25.3 • Circumferential approaches to truncal contouring: The lower lipo-bodylift
■ Vitamin E
■ Vitamin D (25-hydroxyvitamin D)
■ Copper
■ Calcium
■ Magnesium
■ Phosphorous
■ Zinc
■ Folate
■ Prealbumin/total protein/albumin
■ Iron/total iron-binding capacity (TIBC), ferritin,
transferrin
■ CBC (complete blood count), hemoglobin and hematocrit
■ Chem. 7 (comprehensive metabolic panel)
■ Liver panel: serum glutamic-oxaloacetic transaminase
(SGOT)/serum glutamic-pyruvic transaminase (SGPT),
alkaline phosphatase, T/D bilirubin
■ Cholesterol/triglyceride levels
■ Hemoglobin A1C level (only if patient was diabetic
before surgery)
■ Dehydroepiandrosterone (DHEA)
■ Thyroid-stimulating hormone, T4 (required if patient has
thyroid disease)
■ PTH
Previous liposuction in the abdominal area has to be ascer-
tained and specifically enquired about since the patient might
conceal this prior treatment. Patients have to present a stable
weight for at least 6–12 months preoperatively; weight loss
should be completed prior to the surgery. As a guideline, we
do not operate on patients with a BMI above 32. This is
because local and general complications are at increased risk
and aesthetic outcomes disappointing. Those patients are
referred back to the bariatric surgeon to decide whether there
is an option of conversion.
The clinical examination is the essential part of every
medical history assessment. The examination of the lower
trunk should include an accurate palpation of the abdominal,
lateral thigh, and gluteal adipose tissue in patients upright,
prone, and supine, as well as lateral position. This enables the
examiner to assess the tissue conditions with regard to volume
and mobility by pinching and metric measurement. It is
crucial to consider the existent adipose tissue at the lateral and
posterior lower gluteal and proximal thigh region. Unfortu-
nately, untreated distinct masses of local adipose tissue in
these regions will assuredly limit the gluteal improvements,
since downward traction will displace gluteal tissue in a
caudal direction. Skin quality with the presence of striae has
to be evaluated, explaining to the patient that supraumbilical
striae will not be resected in abdominoplasty procedures
(except for fleur-de-lis procedures). Further, any existing
lower and upper abdominal pannus has to be assessed and
measured, documenting any existing eczema or consequent
hyperpigmentation. Any pre-existing scar (subcostal, midline,
horizontal) in the abdominal and gluteal area has to be docu-
mented in writing and photographically, since it can impair
the blood supply of the tissue flap. Further, the status of the
abdominal muscles has to be assessed, and any existing rectus
diastasis, incisional, epigastric, or umbilical hernia has to be
excluded, in specific cases by a supportive computed tomo-
gram or magnetic resonance imaging. In cases of elevated
intra-abdominal pressure, the abdominal wall extends above
These techniques, however, are not always suitable for
patients after massive weight loss (MWL). These specific
patients suffer from atonic skin quality with a high degree of
laxity and, consequently, with the indisputable requirement
of tissue resection. These severe deformities have caused a
continuous development of various lifting procedures, such
as the pioneering circumferential lower bodylift, described by
Ted Lockwood in 1993.3–6 Further developments of these
procedures in combination with autologous tissue augmenta-
tion, such as the de-epithelialized gluteal flaps for buttock
reshaping, enable an improvement of the postoperative
results. In 2005, Sozer et al. reported of a series of 20
de-epithelialized turnover dermal fat flaps for buttock aug-
mentation in bariatric and aesthetic patients undergoing
lower bodylifts.7 After more than 200 cases, the technique has
evolved to include a split portion of the gluteus maximus
muscle, resulting in a better blood supply to the flap, more
caudal reach, and dramatic decrease in fatty necrosis.8
In this context, we established a technique of gluteal fat
tissue transpositioning (transposition-gluteoplasty) during
our modification of the lower lipo-bodylift, which has shown
itself to be a reliable alternative for enhancement of the gluteal
projection and shape.
Patient selection and screening
A precise physical examination and assessment of patients’
medical history during the first consultation is mandatory in
every patient. We recommend a repeat of evaluation prior to
surgery, if it is performed with a delay from the time of the
first consultation. The assessment of medical history includes
the current weight; initial and current body mass index (BMI)
or in future the body shape index (BSI; a metric for assessing
the health implications of a given human body height, mass,
and waist circumference – the inclusion of the latter is believed
to make the BSI a better indicator of the health risks from
excess weight than the standard BMI); the weight history,
with weight fluctuations and constancy periods; the frequency
of exercising; former bariatric procedures; nutritional disor-
ders; medication; the number of pregnancies and children;
history of cesarean section; abdominal surgeries and abdomi-
nal hernias; gastrointestinal, cardiac, and pulmonary history;
and a smoking history. It is important to know which bariatric
procedure has been used. Look for the port, if a gastric banding
was performed, that may be in your area of undermining or
liposuction. Traction on your flap may result in a dislocation
of the band causing strangulation of the stomach. Some
anesthesiologists prefer to have the band deflated. Watch out
for a proper supplement of vitamin B12 in patients after bypass
and sleeve resection.
The routine blood tests after bariatric surgery are hemoglo-
bin, hematocrit, electrolytes, vitamin B1, B12, folic acid, iron/
ferritin, vitamin D3, glucose, transaminases, and albumin.
Total protein, total cholesterol, parathyroid hormone, A1C
(the latter only if patient was diabetic before surgery).
The recommended annual lab work for post-bariatric
patients:
■ Vitamin A
■ Vitamin B6
■ Vitamin B12

643
Patient selection and screening
informed about their postoperative care including their
expected level of activity, and they have to understand the
limitations of the surgical result in cases of existing variables
of bone structure, fat distribution, and any existing scars.9,12,13
Studies have evaluated differences in collagen and elastin
content in the abdominal skin of patients without weight loss
compared to those with bariatric weight loss, showing an
impairment in skin quality in the bariatric group.14 This fact
should be clarified to every single patient to limit their post-
operative expectations. Patients with multiple striae have to
be informed that secondary relaxation in their specific case
may require a repetitive skin-tightening procedure.
During clinical examination of the abdominal region, the
following parameters should be noted:
■ Abdominal tissue excess
■ Abdominal skin quality (striae?)
■ Umbilical stalk deformity
■ Number of skin folds and their continuity to the flanks
■ Skin quality
■ Adipose tissue volume and mobility
■ Abdominal muscle tone
■ Mons pubis region.
During clinical examination of the gluteal region, the follow-
ing parameters should be noted:
■ Gluteal height
■ Gluteal width
the costal margin and the level of the iliac crest in the supine
position. Abdominoplasty procedures with fascial tightening
have to be performed cautiously in such cases and are prone
to a higher recurrence rate.9,10
We recommend setting up a photographic documentation
of pre- and postoperative conditions, consisting of different
views (anterior, oblique, lateral, and posterior; Fig. 25.3.1).
Postoperative photo documentation can be made at 3, 9,
and 12 months. In individual cases, we recommend perform-
ing additional photo documentation of various arm and thigh
positions, tissue characteristics with relaxed and contracted
muscles, the patient in sitting position to demonstrate redun-
dant upper abdominal laxity and tissue excess, and additional
views with the patient holding up and pinching excess tissue
in the specific region. For a classification of the different
deformities, we found the Pittsburgh Rating Scale to be
helpful for patient demonstration and selection of the optimal
operative approach.11 However, we experienced a wider
indication for the combined technique of liposuction and
excisional procedures in all body regions.9,10
Patients’ detailed information on the operative procedure;
alternative techniques; and the general and operation-related
risks and benefits is an essential part of preoperative docu-
mentation. Besides standard and individualized consent
forms, which have to be reviewed and signed by the patient
at the earliest opportunity, we recommend an audiovisual
demonstration of intraoperative details, pre- and postopera-
tive results, and possible complications. Patients should to be
Fig. 25.3.1  Preoperative photo series of a
future bodylift patient.
A
B
C
D
E
F

644
SECTION II
CHAPTER 25.3 • Circumferential approaches to truncal contouring: The lower lipo-bodylift
Treatment goals and planned outcomes
Circumferential tightening procedures have the goal of restor-
ing and improving the body shape, including the abdominal,
flank, and gluteal regions. The abdominal region can be
reshaped through preparatory steps deriving from a stan-
dard abdominoplasty, a lipoabdominoplasty, or fleur-de-lis
abdominoplasty. The main goals are maximal skin and fat
tissue reduction with contouring of the abdominal wall. The
flanks are mainly restored by vertical tissue resection; addi-
tionally in fleur-de-lis procedures, the waist circumference
■ Maximum height of projection
■ Round shape versus rectangular shape
■ Skin quality
■ Adipose tissue volume and mobility
■ Gluteal muscle tone
■ Back folds
■ Vertebral status, e.g., scoliosis.
In our MWL patient group, we have established a classifica-
tion for surgical planning of the gluteal region, which can be
simply divided into three groups (Fig. 25.3.2):
1. Large buttocks with excess amount of gluteal adipose
tissue
2. Normal sized buttocks with ptosis and skin redundancy
3. Flattened, hypoplastic buttocks with ptosis and skin
redundancy.
The adipose tissue in the upper third of the gluteal region has
an excess lobular and lamellar structure with a ratio of 1 : 2 in
females and 1 : 1 in males, respectively, whereas the lower
third presents a 1 : 1 ratio in both sexes (Fig. 25.3.3).12
Patients who are in group 1 may present with residual
overweight. In order to reduce gluteal adipose tissue, a thor-
ough liposuction is performed between lobular and lamellar
adipose tissue and in all areas that are going to be resected.
As this will also be done in the front, we call this procedure
lipo-bodylift.
In patients with a group 2 deformity, we maintain an epi-
fascial preparation with preservation of the entire superficial
fascia. In this regard, we refrain from an extensive adipose
tissue resection, maintaining the lobular adipose tissue. In
cases of deflated and flattened buttocks of group 3 deformi-
ties, we stringently refrain from any adipose tissue reduction
and perform preparation at a superficial subcutaneous level.
In opposition to the technique of subfascial dissection
described by Lockwood, we generally remain above the
superficial fascia, which is a constant and strong structure,
separating the lamellar and lobular adipose tissue. The gluteal
superficial fascia provides comparable features such as
the fascial superficial musculo-aponeurotic system (SMAS)
during facelift surgery, e.g., the reduction of tension on skin
level and the opportunity to provide a multivectoral remodel-
ing on different tissue levels.12
Fig. 25.3.2  Patients with group 1 (A), group
2 (B), and group 3 (C) gluteal deformity
showing the three different types of gluteal
shape.
A
B
C
Fig. 25.3.3  Superficial lobular fat separated by the superficial fascia from the deep
lamellar fat.
Superficial
lobular fat
Deep
lamellar
fat
Fascia
superficialis

645
Markings
underwear so the borders can be marked and the future scar
line can be adjusted to the patient’s favored underwear. This
means, ideally, that the future scar can be hidden. As the next
step, the tissue should be pinched out to get an estimation of
the mobility and quality of the excess tissue. The future scar
line should be marked in red to get a better idea on where to
plan the upper incision line.
It is very important to discuss with the patient their desired
result and preferences. The main aim of the lower bodylift is
that the scar can be completely hidden by underwear. This
approach is different from the belt lipectomy, where the main
goal is to achieve the best possible waistline.
After marking the future scar line in red, we start the mark-
ings on the back with the very top of the intergluteal fold.
Then the excess tissue should be pulled down at the midaxil-
lary line to estimate the laxity from cranial of the future scar
line, so that, at the end of the surgery, the scar will end up
within the borders of the underwear.
In most patients, the laxity from above the scar line is about
3–4 finger-breadths. This point should be marked symmetri-
cally on both sides.
Now the point on top of the intergluteal fold is connected
with the point in the midaxillary line following the natural
contour in an arcuate manner. In such a manner, the upper
back incision line is finalized.
As a next step, the lower incision line is marked. The excess
skin should be pinched by pulling the tissue upwards at the
level of the midaxillary line while stabilizing the upper inci-
sion line with the index finger. Quite commonly, this point
of the lower incision line relates to the lateral zones of
adherence.
Depending on the type of deformity of the buttock, the
excess tissue is pinched again and either a curved or straight
line is drawn from the midaxillary line back to the intergluteal
fold. If gluteal augmentation is required – such as in deflated
buttocks – the lower incision line should be drawn a little
more cranially, since more tissue will be required to cover the
augmented area. Over-resection of skin should be strictly
avoided.
In the area of the rima ani, the incision line should end in
a pointed angle, since a straight incision line across the inter-
gluteal fold leads to an elongated intergluteal fold and an
enlarged buttock.
Now the front markings can be started. Most commonly in
MWL patients, an additional relaxation of the mons pubis is
found and should be included in the surgical plan.
First, the patient should be asked to lift up the excess tissue
of the abdomen so the vulva commissure or the root of the
penis is exposed. Then a distance of 7–8 cm is measured and
marked cranially from the vulva commissure/root of the
penis. This is the lower border of your incision line.
Now the line can be drawn laterally connecting the ventral
with the dorsal markings. The ventral incision line should be
planned a little bit below the natural tissue fold, since the
tissue quality within the folds is normally quite low. To make
sure that the angle of the incision is correct, make the patient
sit and double-check that your markings on the abdomen
relate to the natural folds.
To estimate the upper incision line, the patient should lay
down and bend the hips in about a 45° angle. After that, the
excess tissue is pinched and the upper incision line is marked
above the umbilicus if it allows a tension-free closure.
may be reduced by horizontal tissue resection. In the gluteal
region, there are different approaches available, depending
on the patients preoperative conditions. The available options
are gluteal tissue reduction by direct excision or gluteal auto-
augmentation in cases of volume and shape deficiency. In
both cases, the goal of the bodylift procedure is a restoration
of gluteal volume and gluteal reshaping in relation to the
surrounding regions.
Preoperative planning and preparation
Smokers are advised to quit smoking at least 6 weeks prior to
the surgery. Patients should take antiseptic showers in the
evening and morning prior to the surgery; the skin folds and
the umbilicus should be cleaned thoroughly with antiseptic
solutions.
Since postoperative blood transfusion may be necessary in
selected cases, patients have to be informed preoperatively, as
this requires a blood typing and additional informed consent.
Anticoagulant drugs and supplements must be avoided 14
days prior to surgery. In all cases, we advise patients for bowel
purgation the night before surgery. In patients with a large
hernia, they may be restricted to a fluid diet for 24 h prior to
surgery.
Patients have to be informed about the intraoperative
procedures including any change of position with the risks
of postoperative complications, antithrombotic precautions,
Foley catheter, drains and garment placement, as well as
patient-controlled analgesia. Moreover, they have to be
instructed about the postoperative course regarding thrombo-
embolism prevention, respiratory exercises, early mobiliza-
tion, avoidance of high abdominal pressure, the estimated
time point for drain and suture removal, as well as the
minimum time required off work and away from exercise.
Patients should avoid any skin irritation or inflammation
in the area of the abdominal fold and umbilicus. An inspection
of these areas during consultation as well as immediately
prior to the operation is strongly advisable. Prophylaxis for
pulmonary embolism and deep vein thrombosis is an essential
consideration, especially in smokers and patients taking birth
control medications or hormone replacement therapy.15 We
initialize heparin therapy in all patients the evening before
surgery or at latest 2 h prior to the surgical procedure. We
inform patients that this specific risk will be decreased if
hormonal therapy is discontinued 3–4 weeks prior to surgery.
In cases of a pre-existing diastasis or hernia, the reconstruc-
tion of the fascia results in an additional increase of intra-
abdominal pressure, which may be a source of respiratory
difficulties. Therefore, we advise preoperative breathing
exercises (utilizing an incentive spirometer) and the wearing
of a compression girdle beginning 1–2 weeks prior to the
surgery. A cold, dry cough, or any kind of respiratory infec-
tion should lead to postponement of surgery, since fits of
coughing may provoke a rupture of the fascial sutures with
consequent secondary bleeding.9,12,16
Markings
We recommend to start the markings in a standing position
(Fig. 25.3.4). The patient should be asked to bring their favorite

646
SECTION II
CHAPTER 25.3 • Circumferential approaches to truncal contouring: The lower lipo-bodylift
pressure-reduced, and symmetrical positioning. We drape the
entire region of the lower back, the hips, the gluteal, and the
dorsal thigh region with a sterile covering, ensuring a total
overview of the gluteal and the surrounding regions, includ-
ing the gluteal fold.
After final closure of the gluteal region, the lateral skin
excess is temporarily closed with staples, and a sterile dress-
ing is applied (Fig. 25.3.6). The primary covering is then
removed, and the patient is turned to a second operating table
back in the supine position and then transferred back to the
original table using a sterile cover. In this way, a change of
tables is avoidable.
Dressings and staples are removed after symmetrical
positioning, and the patient is draped and covered sterile.
Posterior drains may now be connected. Further, the anterior
part of resection is now continued, using either the standard
horizontal or fleur-de-lis excision pattern.9,12
Procedural approach
The lower bodylift is routinely performed by two surgeons
and optionally with one or two medical assistants. The leading
surgeon performs the initial markings and their intraoperative
verification and has to supervise the entire procedure. Tissue
preparation, dissection, and wound closure are performed
simultaneously on both sides. After surgical scrub and
Then a line is drawn between the point above the umbilicus
and the midaxillary line to connect the upper incision line
of the back with the upper incision line of the front. To be
safe, double-check your drawings by pinching the tissue
circumferentially.
Experience has shown us that the resection above the future
scar line can be estimated about a quarter of the excess tissue,
and the resection below the future scar line makes up about
three-quarters of the excess tissue, in general.
In the front, the excess tissue and amount of resection
varies a lot. After finalizing your drawings in the front, the
posterior vectors should be marked (Fig. 25.3.5) to get better
waist contouring. The idea is to rotate the tissue inwards to
get a rounder and fuller projection of the buttock and a more
defined waistline.
If additional liposuction is required, we recommend
marking the areas in a different color in concentric circles
while the patient is standing up.
Patient positioning
After orotracheal intubation and bladder catheterization, the
patient is transferred to the operating room in the supine
position. Here the patient is turned into the prone position,
ideally from the first operating table to a second. It is
advisable to use prepared soft cushions for a secure,
Fig. 25.3.4  Bodylift markings showing the future scar line in red.
A
B
C
D
E

647
Procedural approach
Fig. 25.3.5  Marking of the posterior vectors is necessary to avoid a “tent-like” appearance of the back after the bodylift. Schematic (A) and intraoperative (B)
demonstration of posterior vector lines. Intraoperative lateral view after incision of vectors (C). (From Rubin P, Jewell M, Richter DF et al. (eds). Body Contouring and
Liposuction. St. Louis, MO: Elsevier Saunders; 2012:389–390.)
A
B
C
consequent draping, the area of resection and undermining is
infiltrated moderately with tumescent solution (1 L Ringer
solution including 1 ampule Suprarenin) until the desired
turgor is achieved. The solution is introduced in the entire
surgical field and the neighboring regions. It should be
ensured that the liquid is introduced only in the preparation
plane in order to cause a cooling effect and a hydrodissection.
An excessive swelling of the tissue and an associated hyper-
hydration should be avoided.
Type 1
In type 1 patients where a lipo-bodylift is planned, we start
with the liposuction of the area that is going to be resected
(Fig. 25.3.7). We reduce the volume below and above Scarpa’s
fascia and go very superficially until the tissue to be resected
gets paper-thin.
Then the lower incision line is infiltrated with local anes-
thetic to reduce postoperative pain and the consecutive risk
of blood pressure increase. The dissection goes easy and dry
through the empty network of tissue due to the liposuction
until the lower incision line.
Types 2 and 3
The initial skin incision (utilizing a cold blade or alternatively
the Colorado microdissection needle) is made along the
superior marking line and is continued down to the level of

648
SECTION II
CHAPTER 25.3 • Circumferential approaches to truncal contouring: The lower lipo-bodylift
The mobilization of the superior wound edges should be
avoided or, if necessary for wound closure, should be per-
formed cautiously, preserving any emerging perforators.
With completion of dissection, the waist and gluteal adipose
tissue should be widely mobilized and ideally covered by a
stable superficial fascia. For the purpose of autologous gluteal
augmentation, three 1-0 non-absorbable braided threads are
sutured from lateral to medial before knotting, ideally grasp-
ing stable fascia and consequently displacing the gluteal and
waist adipose tissue medially. For cranial repositioning,
another three to four 1-0 threads are sutured from caudal to
cranial at the medial to central aspect of the buttocks (Fig.
25.3.8). Hereby, it is crucial to avoid strangulation of adipose
tissue during fascial suturing in terms of avoidance of tissue
necrosis. By transpositioning and tightening of the gluteal
adipose tissue, the gluteal region is lifted cranially with a
consequent final skin closure under reduced tension. Further,
this maneuver is able to improve the shape of the waist by
mobilization of the waist adipose tissue and its medial
transpositioning.9,12
In severe or secondary cases of gluteal ptosis, it may be
advisable to strengthen the gluteal tissue reconstruction
with an additional mesh, either resorbable, semi-resorbable,
or non-resorbable. Studies with acellular dermis are under
conduction.
The stage of resection should always be supervised by the
“leading” surgeon to assure a symmetrical resection. We
advise the utilization of bullet forceps for determination of the
amount of resection. The marked vector lines are incised from
medial to lateral and incised under maximal tension. The
medial, central, and lateral gluteal flaps arising in this way
are measured precisely under tension for symmetrical resec-
tion, which is subsequently carried out between the clamps.
Following the vector lines, a moderate inward rotation is
achieved, and a temporary wound closure of the gluteal area
is performed with bullet forceps, followed by reconstruction
of the superficial fascia system (SFS) with absorbable stable
2-0 monofilament or braided sutures. A subcuticular multi-
layer wound closure is performed with absorbable 2-0 and 3-0
monofilament suture in an everting manner prior to intracu-
ticular suturing. Because of the wound length and resulting
tissue tension, absorbable 2-0 monofilament suture is advis-
able. Finally, Steri-Strips are applied in perpendicular direc-
tion for the initial 3 weeks postoperatively. Alternatively,
wound closure at all levels may be performed with a single
absorbable barbed suture (2-0) in running manner; this saves
a lot of time and provides stable results. Skin closure may
alternatively be performed with a two-component skin closure
system.17 Two suction drains are placed in each gluteal and
lateral thigh region. Before patients are turned into supine
position, we perform a temporary closure of the lateral skin
excess utilizing a stapler and an occlusive dressing.
Anterior preparation
The inferior incision is checked and remarked, adjusting the
initial inferior line to the laterally final ending gluteal incision
line. It always has to be ensured that the umbilical stalk is
thoroughly cleaned. Initially, the whole area of direct and
indirect undermining is infiltrated with the standard tumes-
cent solution, and a deep liposuction is performed in accor-
dance to the lipoabdominoplasty. This enables more flap
the underlying superficial fascia, which separates the super-
ficial lobular from the subfascial lamellar fat. Next, the dissec-
tion is continued caudally just above the robust white
superficial fascia. The preservation of fascia to the deep gluteal
fat as the “gluteal SMAS” is conceptually similar to the “facial
SMAS” used in facelifts or abdominal “Scarpa fascia”.
In all types of patients, the lateral gluteal half of the super-
ficial fascia is then incised at the height of the inferior resection
line before flap mobilization is continued caudally bluntly on
an epimuscular level down to the gluteal fold. The preserva-
tion of superficial fascia to the inferior skin flap allows a
reconstruction of the fascial continuity upon wound closure.
For this maneuver, it is essential to maximally release the
lateral gluteal tissue adhesions to the gluteal skin flap as far
anterior to the anterior axillary line and caudally to height of
the gluteal fold. Further dissection is then continued to the
lateral thigh, where the preparation level is above the aponeu-
rosis of the tensor fascia lata muscle. An extended distal
mobilization of the lateral thigh may be carried out bluntly
utilizing the Lockwood underminer or by additional liposuc-
tion with low pressure.
Fig. 25.3.7  Liposuction should only be performed within the area of resection to
avoid compromised blood supply.
Fig. 25.3.6  Temporary dressing of the lateral wounds with Opsite film allows an
easy turn-over of the patient from prone to supine position.

649
Procedural approach
Fig. 25.3.8  Schematic (above) and intraoperative (below) presentation of the gluteal auto-
augmentation (transposition-gluteopasty), which includes subfascial gluteal adipose tissue
preservation and entire epifascial mobilization (A), two-dimensional fascial and adipose tissue
transpositioning utilizing non-resorbable sutures in single-knot technique (B), and maximization of
tissue accumulation at the upper gluteal third (C). (From Rubin P, Jewell M, Richter DF et al. (eds).
Body Contouring and Liposuction. St. Louis, MO: Elsevier Saunders; 2012:397.)
A
B
C
mobility and thins out the fatty tissue, especially in type 1
patients with local fat deposits.
Then the lower incision line is infiltrated with local anes-
thetics to reduce postoperative pain and the consecutive risk
of blood pressure increase as in the back. After incision of the
lower incision line, preparation is performed down to Scarpa’s
fascia after ligation of any superficial epigastric vessels
(Fig. 25.3.9). For adequate preparation of Scarpa’s fascia, we
recommend the use of the Colorado MicroNeedle and to
ensure a sufficient upward pull of the abdominal flap. By

650
SECTION II
CHAPTER 25.3 • Circumferential approaches to truncal contouring: The lower lipo-bodylift
discontinuous separation of lateral adhesions using the Lock-
wood underminer or more liposuction may enable a further flap
mobilization.
Now, the patient is placed in the beach-chair position and
two to three progressive tension sutures with 2-0 Vicryl are
placed in the midline from cranial to caudal to seal the dead
space and to shift the tension caudally (also see Chapter 23).
Afterwards, Scarpa’s fascia is gripped below the umbilicus
with a powerful 1 Ethibond thread (Ethicon Inc., Somerville,
NJ) and pulled upward (Fig. 25.3.11). Due to this so-called
Scarpa lift, moderate tightening effects can be achieved in the
area of the inner thigh and the pubic area. In addition, you
achieve stability of the lower scar line to control the subse-
quent scar position.
If an infraumbilical rectus diastasis is found, either a fin-
gertip dissection or a direct excision of the overlying fat
should be performed to allow a fascia plication in that area.
Occasionally the fatty tissue below Scarpa’s fascia is so strong
that it should be thinned with additional liposuction. This is
rarely necessary, since the rotation and spreading of the tissue
leads to a flattening of the tissue.
Now the new position of the umbilicus is defined and a
V-shaped incision performed. Another quilting suture is made
from the tip of the V-incision down to the deep muscle fascia
superior to the umbilicus stalk. This gives a nice definition of
the midline and creates, in conjunction with the other progres-
sive tension sutures, a mild central groove. The umbilicus is
then pulled through and fixed.
More progressive tension sutures are then applied so the
cavity is closed completely and the tension is taken from the
wound edge. You can now start the resection. During tissue
resection, bullet forceps or a Pitanguy tissue demarcator can
support the estimation of the upper resection line. Further
evaluation of the amount of resection may be facilitated by
additional vertical flap incisions and temporary wound
closure utilizing bullet forceps. The upper incision line is then
marked and the resection is performed oblique to the wound
edge in a 45° angle to enable a more precise adaptation of
varyingly thick layers. In selected patients with a pronounced
abdominal fat layer, the fatty tissue beneath Scarpa’s fascia
should be resected in the entire mobilized area. This may
avoid postoperative complications due to superinfected fat
preservation of Scarpa’s fascia, the subjacent lymphatic vessels
are preserved. In general, we found a thin fat layer below
Scarpa’s fascia.
The dissection level is performed above Scarpa’s fascia
entailing a number of key advantages: long-lasting swell-
ings can be prevented because the underlying lymphatic
vessels are preserved and the tightening of the SFS cra-
niomedially provides an additional “inner traction” on the
deep penetrating fascial system of the thigh (Colles’ fascia).18
Approximately three finger-breadths below the umbilicus,
Scarpa’s fascia is dissected and further mobilization of the
abdominal flap is performed cranially above the anterior rectus
fascia.
At the height of the umbilicus, the abdominal flap is incised
in the midline and the umbilical stalk is transected square-
shaped or circularly and completely mobilized from the
abdominal flap without any remaining periumbilical fat
tissue. Especially in patients after massive weight loss, the
umbilical stalk has to be shortened and fixated to the anterior
rectus fascia at the height of the stalk’s basis, preferably with
stronger absorbable sutures at 3, 6, and 9 o’clock positions.
Further, dissection continues superior above the anterior
rectus fascia up to the xiphoid. The linea alba can easily be
identified as it is distinctively connected to Scarpa’s fascia.
Usually it is sufficient to dissect the tissue up to the lateral
border of the rectus muscles. In the area of the costal margin,
it is essential to restore the lateral perforators for sufficient
flap perfusion. At this time point, after finalization of the
abdominal flap mobilization, in cases of concomitant rectus
diastasis, the plication of the anterior rectus fascia from the
xiphoid to the symphysis is accomplished using non-
absorbable or absorbable suture material in preferred cross-
wise technique (Fig. 25.3.10). This takes care of the vertical
and horizontal excess of the muscle relaxation.
In cases of lower abdominal diastasis, Scarpa’s fascia
and underlying tissue may be bluntly mobilized to allow
for further midline fascial plication. For cases of an asym-
metrically located umbilical stalk or for further accentuation
of the waist with further waist tightening, an additional
paramedian plication of the anterior rectus sheath may
be facilitated. Since lateral dissection is avoided up to the
costal arch for preservation of the lateral perforators, a
Fig. 25.3.9  Preparation above Scarpa’s fascia on lower abdomen to preserve
lymphatic vessels.
Fig. 25.3.10  Rectus plication in a crosswise technique treating vertical and
horizontal muscle relaxation.

651
Potential complications and management
reduced by aligning the lower incision line at 7 cm above the
vulvar commissure. In severe cases, a central wedge excision
can be performed to reduce the horizontal tissue surplus.
Adjuvant liposuction
Adipose tissue surplus in the back or upper flank region,
which may be detected superior to the resulting scar line, can
be reduced by liposuction after wound closure. This adjuvant
procedure allows improvements of the gluteal and overall
body contour from different perspectives.
Male “love handles”
Male patients frequently present with local adipose tissue in
the posterior flank region, which may be reduced by liposuc-
tion after gluteal wound closure or superiorly excised in toto
during posterior preparation. We recommend cautious hemo-
stasis of this localized fat pad during extirpation, since blood
supply is ensured by 2–3 perforating vessels.10
Potential complications and
management
General symptoms after lower bodylift procedures include
postoperative pain or soreness, numbness of the skin flaps,
bruising, general fatigue, and discomfort due to increased
skin tension for a few weeks postoperatively.
Local complications in all regions include hematoma,
seroma, wound infection, fat necrosis, wound dehiscence,
paresthesias, and persisting numbness. Seromas are a very
common problem in the abdominal region and usually
handled with serial punctures and drainage. Persistent
seromas may require a secondary surgical procedure. In
general, seromas should be detected in time and treated by
simple aspiration to avoid a superinfection or any consequent
wound separation.
Minor wound dehiscences are common and mostly self-
limiting. In the intergluteal cleft region, patients frequently
have to deal with wound healing disorders and their conse-
quent conservative treatments. Wound closure in this specific
region is strengthened with non-resorbable simple interrupted
sutures to avoid wound separation due to shearing forces.
Due to the use of absorbable sutures for wound closure, we
regularly see single or multiple local wound healing disorders
throughout the entire wound; however, this spitting occurs
more often in the gluteal region. Since tension in this region
cannot be reduced as effectively as in the abdominal region,
a consequent wound separation in this area is of higher risk.
To improve wound healing, we routinely perform wound
closure in an everting manner, which reduces wound healing
disorders due to a reduced interference by suture material on
skin level.
Significant dehiscences may be caused by increased tension
or wound-edge necrosis. Appropriate treatment of wound
necrosis is initial conservative wound care, until the area of
necrosis has demarcated for surgical revision. Additional
flap advancement may allow optimal secondary wound
closure. Any impairment of the umbilical perfusion should
be treated conservatively, as long as the umbilical stalk is
adapted on skin level. Further local complications include
necrosis. In general, it is safely practicable to excise the sub-
Scarpa fat plane from the abdominal flap, especially in the
midline region for abdominal contour accentuation. After
meticulous coagulation, the wound is closed temporarily.
Temporary wound closure is performed with bullet forceps,
starting laterally to medial. In patients with massive weight
loss and extensive circular tissue excess in the thigh region,
we recommend maximally shifting the entire tissue medially.
This tissue excess can be pleated at the medial aspect of the
proximal thigh and removed at the time of the inner thigh lift
if planned.
After the placement of 2–3 drains in the abdominal region,
the final wound closure is performed for all layers as described
above. Again, for time reduction in wound closure, the use of
absorbable barbed sutures and a two-component skin closure
system is routinely advisable.17 After a final antiseptic wound
cleaning, Steri-Strips are applied as described before. These
supportive dressings should remain for 3 weeks postopera-
tively. Finally, a sterile wound dressing is applied and an
adjustable compression girdle is applied.
Mons pubis reconstruction
Primarily female patients ask for a reconstruction of the mons
pubis region. A tissue surplus in this region can be maximally
Fig. 25.3.11  The Scarpa lift: this can add extra contouring on the anterior and
lateral thigh when Scarpa’s fascia is strong enough and well preserved.
A
B