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

694.e1
Historical perspective
Historical perspective
Prior to the year 2000, brachioplasty procedures were rarely
performed by most plastic surgeons. The earliest descriptions
of brachioplasty were relatively simple techniques involving
the removal of an ellipse of soft tissue. The axilla was not
addressed, and candidates for surgery were usually moder-
ately overweight individuals.2–4 In the 1970s, multiple articles
were published that described different patterns of arm soft-
tissue excision. Several of these publications included tech-
niques to avoid scar contracture at the arm/axilla transition.5–8
Pitanguy8 specifically described addressing deformities of the
axilla and lateral thoracic region along with the arm. The first
case report of a massive weight loss patient undergoing bra-
chioplasty was published in this period.9 In the 1980s, tech-
niques were described to perform brachioplasty as part of an
upper bodylift and near-total bodylift, and Goddio reported
on an innovative technique of burying soft-tissue excess.10–12
Brachioplasty continued to evolve in the 1990s.13,14 Liposuc-
tion became a more integral component of these procedures,
and Lockwood13 proposed that the posteromedial soft tissue
of the arm be suspended to the clavipectural periosteum by
means of the clavipectoral fascia and axillary fasciae. He
argued that when these structures loosen, they lead to a “loose
hammock” effect or arm ptosis. Lockwood’s technique for
brachioplasty described securing the arm flap to the axillary
fascia and the incorporation of a superficial fascial system
repair of incisions to help reduce the incidence of wide scars
and unnatural contours.
In the last decade, numerous articles have been written on
brachioplasty. In an effort to minimize scar length, several
authors have described excisional techniques limited to the
axilla and proximal arm in combination with liposuction.15–18
The majority of recent articles and symposia on brachioplasty
have involved almost exclusively the weight loss patient, and
the size of the series analyzed has increased considerably
from a decade ago.19–31 Much of the discussion today in the
literature is on scar position, the timing and use of liposuction,
and the incorporation of short scar techniques in the manage-
ment of the post-bariatric patient.
Our preference is to utilize a posteromedial approach with
extension to the medial epicondyle in combination with
liposuction in the vast majority of our weight loss patients. In
the first half of our series, our scars were placed along the
bicipital sulcus. We have not found an approach limited to the
axilla or proximal arm to be effective in a significant number
of individuals in this patient population.

695
Patient selection
Fig. 27.1  (A,B) Morbidly obese 69-year-old
woman. Fat deposits are most prominent along
axilla and posterior arm and, to a lesser degree,
anterior arm.
A
B
Fig. 27.2  (A,B) A 28-year-old woman, 6 years
following 185 lb (84 kg) weight loss. Her
current weight and body mass index are 188 lb
(85 kg) and 27, respectively. Note extreme
degree of soft-tissue excess.
A
B
an optimum result from a limited procedure in the proximal
arm is likely to be disappointed.
Patient selection
Candidates for brachioplasty should undergo a thorough
history and physical examination. Like all post-bariatric
patients, special attention should be directed towards weight
history. Critical information includes the patient’s height,
current weight, and maximum weight. The time interval
between their maximum and current weight and length of
time at the current weight should be documented. If weight
loss was achieved through bariatric surgery, the technique
and when it was performed should be noted. Other important
weight-related information includes whether the individual
is being followed by a bariatric surgeon, the time of the last
visit, and whether supplemental medication has been pre-
scribed and if it is being taken regularly. Problems potentially
related to bariatric surgery should be explored, i.e., frequent
vomiting, abdominal pain, weakness, light-headedness, and
frequent bowel movements. For patients who have lost weight
through lifestyle changes, some discussion should take place
as to how this was accomplished, i.e., exercise, diet and exer-
cise, or medication, and whether they are being supervised by
a professional.
Examination of the post-bariatric brachioplasty candidate
should be thorough, with particular attention directed towards

696
SECTION II
CHAPTER 27 • Upper limb contouring
Fig. 27.3  (A–C) A 37-year-old woman following 60 lb (27 kg) weight loss. Note relatively small amount of soft-tissue excess.
A
B
C
Fig. 27.4  (A,B) A 52-year-old woman
following 78 lb (35 kg) weight loss. Note degree
of soft-tissue excess despite relatively small
amount of weight loss.
A
B
the upper body. Along with the degree of soft-tissue excess
present along the forearm, arm, and axilla, an assessment
should be made of the breasts, lateral thoracic region, and
back. The fat content of all these areas should be noted. A
standardized exam form is helpful (Fig. 27.6). Notation is
made as to whether intertriginous dermatitis is present,
potentially along the axilla. Lymphedema and/or stigmata of
lymphedema should be documented, as should the presence
of arterial or vascular insufficiency. Existing scars, transverse
arm bands, and striae along the upper extremity should be
noted.
The best candidates for brachioplasty are healthy individu-
als who have achieved a stable weight, have a BMI less than
28, and who have lost substantial weight, generally over 50 lb
(23 kg). Individuals with a BMI greater than 28 can obtain
dramatic results; however, the final aesthetic result is less
likely to be ideal. The value of performing a brachioplasty
depends greatly on the extent of the deformity to be corrected,
which in turn usually depends primarily on the degree of
weight loss. Variables representing relative contraindications
to brachioplasty are high patient BMI and small BMI change
from highest weight, significant patient reservations regard-
ing arm scars, a history of hypertrophic or hyperpigmented
scars, and unrealistic patient expectations, particularly with
regard to short scar versions of brachioplasty. Absolute con-
traindications in our practice at this time are a history of
lymphedema and/or arterial or venous insufficiency of the
upper extremity. A related contraindication is a patient who

697
Patient selection
Fig. 27.5  (A,B) A 35-year-old man following
weight loss of 128 lb (58 kg). Note that the
contour deformity is primarily limited to the
axilla and proximal half of the arm.
A
B
is at high risk of developing one of these conditions. Examples
include patients who have undergone axillary lymph node
dissection or axillary radiation.
Plan formulation
The information gathered from the patient history and phys-
ical exam is instrumental in formulating a preliminary plan.
For patients expressing concerns only about their arms, the
plan is clear. For these patients, it is important to clarify the
importance of addressing the axilla in rejuvenating the arm.
Following massive weight loss, most patients express con-
cerns about more than just their arms; usually the breasts,
lateral thoracic region, back, abdomen, thighs, and buttocks
are of issue as well. The options available to the plastic surgeon
are multiple. Our preference is to perform a bodylift first, as
a single procedure, and then to follow with a combination
mastopexy/lateral thoracoplasty/brachioplasty not before 3
months.33 A medial thigh lift, if necessary, would take place at
least 3 months later. Our rationale for this sequence and
combination of procedures derives from the observation that
the bodylift procedure greatly affects the rolls frequently
present along the upper and lower back. In the vast majority
of patients, any remaining rolls along the back and flanks
following a bodylift can then be addressed by the combina-
tion mastopexy/lateral thoracoplasty/brachioplasty.
While the upper body procedures may be performed prior
to the bodylift, it is often difficult to estimate accurately the
appropriate amount of tissue to be excised at the lateral tho-
racic region. The vast majority of post-bariatric patients are
candidates for a bodylift; however, a discussion of the criteria
for this procedure is not within the scope of this chapter.
Before being considered for any procedure, certain criteria
must be met and issues addressed. The patient should be at
a stable weight for at least several months. This will vary
depending on bariatric procedure. Operating during a period
of active weight loss may result in an early recurrence of
soft-tissue laxity and, from a safety perspective, the patient is
unlikely to be nutritionally and metabolically optimized.
Patients with symptoms suggestive of problems related to
bariatric surgery should be evaluated by their surgeon. Indi-
viduals with a history of major mental illness or acute mental
illness are asked to be evaluated by an appropriate health
professional. Patients are advised to maintain the supplemen-
tal regimen prescribed by their bariatric surgeon. Individuals
with a history of tobacco consumption are urged to stop as
soon as possible. The risks of tobacco, including impaired
wound healing and thromboembolic phenomena, are clearly
established in the literature and are relayed to the patient.32,34
My preference is for patients who are on medications for
weight loss to stop them. All patients are referred for medical
clearance. While weight loss dramatically improves the health
of morbidly obese individuals, not all conditions are elimi-
nated.35 A careful medical evaluation of health is imperative.
After discussing a possible plan with the patient, I review
several topics. Many individuals are eager to lose more
weight prior to surgery, feeling that their surgery would be
safer and that more skin could be removed if they are at a
lower weight. My feeling is that most people whose weight
is stable at the time of consultation are at the weight they
are most likely to maintain over the long term. While many
post-bariatric patients can lose weight for relatively brief
periods of time, long-term additional weight loss following
bariatric surgery or through lifestyle change is difficult to
achieve. Individuals losing weight in a short period of time
can lead to several undesirable outcomes. First, they may
become nutritionally and metabolically unbalanced just at
the time surgery is to be performed. Secondly, weight gain
in the future will in most instances diminish the aesthetic
results of a procedure. I advise patients to eat a balanced
diet and maintain a stable weight. On the other hand, I do
explain that a certain amount of excess soft tissue will be
removed during surgery. Their new weight following surgery
should be their current weight minus the weight of the tissue

698
SECTION II
CHAPTER 27 • Upper limb contouring
Scars
Transverse bands Yes
No
Lymphedema Yes
No
Yes
Transverse bands Yes
No
Lymphedema Yes
No
No
Arms
Left: Striae
Yes
Skin excess None
Mild
Moderate
Severe
No
Lipodystrophy
None
Mild
Moderate
Severe
Intertriginous
dermatitis
Left None
Mild
Moderate
Severe
Right None
Mild
Moderate
Severe
Axilla/flank
Lipodystrophy
Left None
Mild
Moderate
Severe
Right None
Mild
Moderate
Severe
Skin excess
None
Mild
Moderate
Severe
Left
None
Mild
Moderate
Severe
Right
Breast
Current breast size
Desired breast size
Excess grams of breast tissue
Left
Right
Diameter of NAC
Left
Right
Distance from sternal notch to nipple (normal 23–25 cm)
Left
Right
Distance from IMF to nipple (10–12 cm)
Left
Right
Scars
Left
None
Biopsy
Inverted T
Vertical
Periareolar
Axillary
IM
Right
None
Biopsy
Inverted T
Vertical
Periareolar
Axillary
IM
Breast ptosis
Left
None
Grade I
Grade II
Grade III
Pseudoptosis
Right
None
Grade I
Grade II
Grade III
Pseudoptosis
Lymphadenopathy
Left
None
Grade I
Grade II
Grade III
Pseudoptosis
Palpable mass
Left
Yes
No
Right
Yes
No
Palpable mass
Left
Yes
No
Right
Yes
No
Nipple discharge
Left
Yes
No
Right
Yes
No
Right
None
Axillary
Supraclavicular
Distance from midline to nipple (10–12 cm)
Left
Right
Scars
Yes
No
Right:Striae
Yes
Skin excess None
Mild
Moderate
Severe
No
Lipodystrophy
None
Mild
Moderate
Severe
Fig. 27.6  Physical examination form.

699
Patient selection
corroborated by edema on physical exam. Protein-depleted
patients may demonstrate difficulty healing wounds. Severely
anemic patients with hemoglobin less than 10 g/dL are
referred to their primary physician and/or hematologist.
Patients with hemoglobin above 10 g/dL are advised to
continue on iron, folate, and B12 supplementation and to have
their blood cell count repeated in a week. Our preference is
for patients to have hemoglobin above 12 g/dL before surgery.
Patients are advised of the possible need for a blood transfu-
sion. My practice has not been to have patients bank their own
blood. In most institutions, blood can only be given within 1
month of surgery. One month may not be adequate time for
anemic patients to replenish their blood levels.
Preoperative visit
At the preoperative visit, usually 2 weeks before surgery, the
planned surgical procedure is reviewed in detail, as are the
potential complications. Requested consultations and recom-
mendations are discussed with the patient. Another critical
removed. A 3-month postoperative weight similar to their
weight at consultation suggests a significant weight gain. I
also explain that the long-term results of this surgery are best
maintained by weight stability, minimizing exposure to sun
(ultraviolet light), and no tobacco consumption.
Laboratory work-up
A patient history can often be suggestive of problems;
however, a thorough laboratory work-up is critical for identi-
fying existing deficiencies or abnormalities. It is not unusual
for menstruating women to have few, if any, symptoms
despite having severe anemia following bariatric surgery.
Along with a complete blood count and other studies, our
routine includes a complete metabolic panel. Abnormal labo-
ratory values are acted on as they are made available. Indi-
viduals found to be malnourished with a total protein less
than 6 g/dL and/or albumin less than 3 mg/dL may be
referred to their bariatric surgeon for re-evaluation and pos-
sible nutritional supplementation. Those findings may be
Abdomen
Tuberous breast
Left
None
Mild
Moderate
Severe
Right None
Mild
Moderate
Severe
Breast
Gynecomastia
Left
Type
I
II
III
IV
Hypertrophy
A
B
C
Right
Type
I
II
III
IV
Hypertrophy
A
B
C
Left
None
Mild
Moderate
Severe
Skin excess
Left
None
Mild
Moderate
Severe
Lipodystrophy
Left
None
Mild
Moderate
Severe
Fascial laxity
Yes
No
Intertriginous dermatitis
Hernia None
Ventral
Incisional
Umbilical
L. inguinal
R. inguinal
Pfannestiel
Abdominoplasty
Laparoscopic
Appendix
Chevron
L. paramedian
R. paramedian
L. inguinal
R. inguinal
Scars
None
Midline
Epigastric
Hypogastric
L. subcostal
R. subcostal
Striae
Yes
No
Left
None
Mild
Moderate
Severe
Right None
Mild
Moderate
Severe
Shoulder grooving
Left
Yes
No
Right
Yes
No
Baker capsular contracture
Fig. 27.6, cont’d

700
SECTION II
CHAPTER 27 • Upper limb contouring
of the arm. This condition is well tolerated by patients and
rarely noted. Liposuction prior to dissection of the medial
and posterior arm should provide an easily identifiable
plane immediately deep to the superficial fascial system and
superficial to the deep fascia of the arm. Along the entire arm
and elbow, vital structures remain deep to the deep fascia and
are unlikely to be injured. Along the proximal two-thirds of
the medial and posterior arm, superficial to the deep fascia,
are the medial and posterior brachial cutaneous nerves and
small superficial unnamed veins (Fig. 27.8). The cephalic vein
and anterior brachial cutaneous nerve should remain out of
the field of sharp dissection. Prior liposuction and careful
dissection should spare the medial and posterior brachial
cutaneous nerves. Injury to these nerves would result in cor-
responding numbness to these areas of the arm. Along the
distal one-third of the arm and in the region of the elbow,
the basilic vein and medial antebrachial cutaneous nerve
are superficial to the deep fascia and vulnerable to injury
(Fig. 27.9). Once again, liposuction prior to sharp dissection
in this area is helpful in visualizing these more important
structures. Zones of adherence along the arm are limited
primarily to the lateral arm and elbow region (Fig. 27.10). The
posteromedial approach does not involve sharp dissection
along the lateral arm, and fat deposits in this area are not
common. Liposuction along the medial and posterior arm
addresses fat deposits commonly encountered along the pos-
terior elbow and facilitates sharp dissection along the medial
elbow.
Marking
The goal of our technique is for the scar to lie along the
posteromedial arm, approximately at the level of the triceps
function of the preoperative visit is to review images taken at
the first consultation. Patients rarely have a completely accu-
rate sense of their deformities. Key elements of this discussion
are to highlight existing asymmetries and the presence of
bands, which in many cases cannot be completely corrected,
review the extent of their deformities, and explain the degree
to which the planned procedure or procedures will address
their deformities. I prefer not to do image morphing, but
rather show examples of individuals with similar body types
who have had the same procedures. Perhaps more than any
other post-bariatric body contouring procedure, candidates
for brachioplasty must have a very clear understanding of the
scar involved with the procedure.
The process of scar maturation must be discussed, as
should the potential risks for hypertrophic and hyperpig-
mented scars. A failure to discuss the full spectrum of scar
quality can lead to a disappointed patient despite an excellent
result in contour. Restrictions and recovery guidelines are
reviewed. Patients often have the sense that recovery from
surgery should involve significant bed rest. I emphasize the
importance of frequent ambulation. Medications that should
be avoided prior to surgery are reviewed; these include medi-
cations that increase the risk of bleeding (aspirin and non-
steroidal anti-inflammatory agents) and those that increase
the risk for deep vein thrombosis (oral contraceptives or
hormone replacement therapy). Patients are advised not to
take either for 2 weeks before or after surgery. I conclude with
a plan for deep vein thrombosis prophylaxis.
Thromboembolic disease prophylaxis
Thromboembolic disease has been very rare in our brachio-
plasty series. All patients undergoing brachioplasty have
activated lower extremity sequential compression devices in
place prior to surgery, during surgery, and until ambulation
is regular. Following surgery, patients are encouraged to
ambulate shortly after the conclusion of the procedure.
Patients with a BMI of greater than 32 are given 5000 units of
heparin subcutaneously prior to surgery. Individuals with
risk factors other than obesity are treated on a case-by-case
basis. Thromboembolic disease prophylaxis for patients
undergoing brachioplasty and additional procedures, particu-
larly abdominoplasty, is outside the scope of this chapter.
Treatment/surgical technique
Anatomy
When considering the posteromedial approach to brachio-
plasty, the identification of several superficial anatomic
landmarks is critical for consistent scar placement (Fig. 27.7).
Important surface anatomy includes the anterior and posterior
axillary folds, biceps and triceps muscles, medial epicondyle,
medial bicipital furrow, and medial cubital sulcus. A postero-
medial approach to brachioplasty in virtually all instances
involves the axillary dome. An incision in this region should
remain superficial, involving only skin and a small amount
of subcutaneous fat. Liposuction is not usually performed
in this region. The superficial-lying intercostobrachial nerve
can sometimes be encountered and inadvertently sacrificed.
The result is numbness along the proximal, medial aspect
Fig. 27.7  Arm surface anatomy. Medial arm perspective, highlighting location of
bicipital sulcus, medial cubital sulcus, medial epicondyle, and components of
axilla.
Medial
epicondyle
Medial cubital sulcus
Posterior axillary fold
Anterior axillary fold
Medial bicipital furrow
Vertical excess
Horizontal excess
Triceps brachii
Biceps brachii

701
Treatment/surgical technique
steps determine the soft-tissue excess to be excised from the
axillary dome. A dotted line is then drawn from the medial
epicondyle, point E, to the lateral aspect of the axillary dome
over the triceps muscle, point F. In heavier individuals, the
posterior portion of the arm may need to be grasped to
determine the location of the triceps muscle. Finally, an area
G above the dotted line E–F is identified corresponding to
the region of maximum soft-tissue excess on the posterior
aspect of the arm. Moderate downward traction is placed
on the area using multiple digits, typically the index, long,
ring, and small finger to identify a level H, which descends
to the height of point E or the medial epicondyle. A line is
then drawn from point E through H and on to the lateral
aspect of the ellipse, point I. The line from E through level
H–I should mirror the corresponding soft-tissue excess of the
posterior arm in that region. Typically the line rises gradually
over the distal arm and more so as it reaches the proximal
one-third of the arm and descends slightly towards the
axilla.
Operative technique (Videos 27.1 and 27.2 )
Sterile drapes are placed on the operative table and arm
boards. With the patient in the supine position, a sequential
compression device is placed on one leg and a blood pressure
cuff on the other. An intravenous catheter is placed in the
dorsal aspect of the hand or wrist. Intravenous antibiotics
are given, typically a first-generation cephalosporin. A pulse
oximeter device is placed on the ear. Following general
anesthesia, often with a laryngeal mask, the forearm, arm,
axilla, flank, and chest are prepped with Betadine. A sterile
towel is wrapped around each hand and proximal forearm
muscle. At the axilla, the scar should lie within the axillary
dome. Marking begins with the patient standing and the arm
extended perpendicularly from the body (Fig. 27.11). A line
is drawn along the lateral inferior border of the pectoralis
major muscle from point A, the superior portion of the axil-
lary dome, to point B, the inferior portion of the dome. A
point C is found, usually at the level of triceps muscle that
can be advanced easily to a point D at the most superior
portion of the axillary dome. The points at A, B, and C are
connected to complete the ellipse at the axilla. The preceding
Fig. 27.8  Sagittal view of arm anatomy. Sagittal view of midportion of arm,
highlighting nerves, arteries, veins, and fascial planes at this level.
Cephalic vein
Superficial fascia
Superficial fascia
Brachialis
Biceps brachii
Radial nerve
Triceps brachii
Lateral
Medial
Medial
brachial
cutaneous
nerve
Posterior brachial cutaneous nerve
Medial
antebrachial
cutaneous
nerve
Brachial artery
Anterior brachial cutaneous nerve
Median nerve
Ulnar nerve
Deep fascia
Basilic vein
Fig. 27.9  Sagittal view of arm anatomy. Sagittal view of distal portion of arm,
highlighting nerves, arteries, veins, and fascial planes at this level.
Cephalic vein
Superficial fascia
Superficial fascia
Brachialis
Brachioradialis
Biceps brachii
Radial nerve
Triceps brachii
Lateral
Medial
Medial
antebrachial
cutaneous
nerve
Brachial artery
Median nerve
Ulnar nerve
Deep fascia
Basilic vein
Fig. 27.10  Zones of adherence. Medial and lateral view of arm surface,
highlighting with shading areas of greatest tissue adherence: medial, lateral, and
posterior elbow region and lateral and anterior arm.
Some
liposuction
More
liposuction
Zone of adherence

702
SECTION II
CHAPTER 27 • Upper limb contouring
proximal to the medial epicondyle; (3) in the proximal and
mid posterior arm; and (4) in the distal lateral arm. Via these
stab wounds tumescent fluid (1 L of saline, 1 cc of 1/1000
epinephrine, 50 cc of 1% lidocaine) is injected into the sub-
cutaneous tissues of the medial and posterior arm. If fatty
deposits are to be addressed along the anterior and lateral
arm, fluid should be injected into these areas as well. Our
preference is to inject at a 1 : 1 ratio of fluid injected to the
volume of aspirate removed. Excessive fluid injection may
compromise control over excision.
While the tumescent fluid is setting, the ellipse at the axilla
is excised. Only a small amount of subcutaneous fat is removed
with the skin to avoid any deeper structures. Liposuction is
then performed with a 3–4-mm cannula beginning through
the stab wound along the proximal medial forearm. Via this
approach, the medial arm is suctioned with particular atten-
tion directed towards the distal medial arm where the skin is
more firmly adherent to the underlying fascia. The arm is
typically resting on the arm board during this maneuver.
Suction is then performed along the posterior and posterolat-
eral arm via the stab wound along the distal lateral arm. The
surgeon is standing and the forearm is elevated off the arm
board by an assistant.
Finally, liposuction is performed to the entire posterior
arm via the posterior stab wounds. The surgeon is standing
and the arm medially rotated over the patient’s chest. With
the arm resting on the arm board, the skin from point E
through H–I at the axilla wound is incised. The subcutane-
ous tissues are divided to reach the “honeycomb”-appearing
plane produced by the liposuction. Dissection is easily
performed in this plane to the posterolateral aspect of the
arm (Fig. 27.13). The supporting ligaments to the skin in the
and secured to itself and the patient with staples. A drape
is stapled to the patient along the upper chest and over the
midclavicular portion of the shoulders. Drapes are placed
over the patient’s body from the lower chest and inferiorly
(Fig. 27.12). The previously made markings along the axilla,
points A to B and back to A through C are scored with a knife
blade. Similarly, the line from E through H and on to the
lateral limb of the axillary ellipse is scored. Beginning with
the right arm and using a No.15 blade, four stab wounds
are made: (1) along the proximal medial forearm; (2) just
Fig. 27.11  Markings for brachioplasty.
A
B
E
A
C
B
D
I
F
Area G
Level H
Fig. 27.12  Draping for bilateral brachioplasty. In this case, brachioplasty is being
performed along with lateral thoracoplasty and mastopexy.

703
Treatment/surgical technique
of the axilla and arm, followed by a loosely applied elastic
wrap to the arm. To support the dressings at the axilla, an
upper pole breast binder is placed or, if breast surgery is being
performed concomitantly, a bra is placed.
In our practice, the lateral thoracic region is often addressed
in combination with a brachioplasty and mastopexy. The
sequence of procedures in these cases is for the mastopexy to
be performed first. From the lateral extent of the inframam-
mary wound closure, the tailor-tack technique is then utilized
to assess the excess skin and soft tissue along the lateral tho-
racic region and to the dome of the axilla. Once this assessment
has been made, the excess skin and a small amount of subcu-
taneous fat from the lateral thoracic region and axilla are
removed. The arm portion of the brachioplasty procedure can
then begin as described above from the step where liposuction
is performed. The remainder of the procedure is the same,
except for the final wound closure which will extend inferiorly
from the axilla to the lateral thoracic region and terminate at
the lateral extent of the mastopexy inframammary wound
closure. In cases where large areas of skin and soft tissue have
been removed from the lateral thoracic region, the dermal
sutures can placed to incorporate a superficial bite of the
tissues at the base of the wound or a drain can be left in place
for several days (Fig. 27.15). These efforts may diminish the
likelihood of a seroma or persistent fluid drainage from the
axilla.
In addition to the arm, the proximal forearm may be a
concern for some patients, particularly women in their fifth
decade and beyond. Management of the proximal forearm
begins with the routine brachioplasty as described above, up
to the point just before the final intracuticular layer of 3-0
Monocryl is placed. With the 2-0 Vicryl suture in place, the
tailor-tack technique is used to assess the excess skin and soft
tissue along the proximal forearm beyond the medial epicon-
dyle. The skin and a small amount of subcutaneous fat from
the pattern created along the proximal medial forearm are
removed. The final closure begins with 2-0 Vicryl in the
forearm and is then followed by the 3-0 Monocryl along the
forearm, arm, and axilla.
region of the elbow are thicker and slighter more difficult to
divide.
With the dissection complete, a towel clamp or Adair
is used to approximate the lateral skin edge of the axil-
lary ellipse, point I, to a point directly across the wound
along the skin edge A–B. Point C or a point either slightly
above or below C along the lateral aspect of the ellipse is
found which, when attached to the medial skin edge A–B,
immediately below where point I has been attached to the
skin edge A–B, creates the desired contour of the proximal
arm and axilla. Additional towel clamps are then used to
approximate the lateral and medial skin edges of the axillary
ellipse.
Once the desired points along the axillary ellipse have been
approximated, attention is directed towards the arm. Towel
clamps are placed along the upper divided skin edge, E
through H–I. Beginning in the region of greatest tissue excess
of the arm, typically slightly proximal to the midarm, a Pitan-
guy long skin demarcator is secured to a towel clip. The
surgeon and assistant then apply upward traction on the
entire lower skin flap edge. Advancement of the demarcator
posteriorly towards the lower flap will cause it to glide pos-
teriorly for 1 cm or more before stopping. The lower flap is
drawn into the jaws of the demarcator under moderate
tension. Once mild resistance is reached, the lower flap is
released by approximately 1 cm. This point is then marked
(Fig. 27.14).
The same technique is repeated along the arm three or four
times to develop an outline of the flap to be excised. The dots
are connected and the flap excised. Careful hemostasis is
gained. No drain is placed. Towel claps are used to approxi-
mate the flap edges along the axilla and arm. At the axilla, 2-0
Vicryl interrupted sutures are used to approximate the super-
ficial fascial system and deep dermis, approximately 0.5 cm
from the flap edge. Incorporated in this approximation is a
superficial bite of the deeper tissues to help eliminate dead
space. A 3-0 Monocryl intracuticular suture is then placed. A
similar closure of 2-0 Vicryl and 3-0 Monocryl is used along
the arm; however, the deeper tissues are not incorporated in
the closure. Sterile abdominal pads are placed on the wounds
Fig. 27.13  Appearance of subcutaneous tissues following liposuction to medial
and posterior arm. Plane of dissection readily visible.
Fig. 27.14  Use of Pitanguy large-skin demarcator to determine amount of
soft-tissue excess.

704
SECTION II
CHAPTER 27 • Upper limb contouring
Outcomes, prognosis, and
complications
The vast majority of patients following brachioplasty are very
pleased with their results when proper screening and preop-
erative education have been performed. Patients most likely
to approach an aesthetic ideal and to have a high level of
satisfaction are those with a presenting BMI of less than 28
and those who have had a preoperative BMI change of greater
than 20. Patients presenting at a higher BMI, greater than 28
and who have also experienced very substantial weight loss
prior to surgery are also very likely to be satisfied but are less
likely to achieve an aesthetic ideal (Fig. 27.16). Candidates for
surgery presenting a higher BMI, greater than 32, and who
have had relatively little weight loss prior to surgery, and
patients with a BMI change of less than 5 are usually the least
satisfied and have small aesthetic improvement (Fig. 27.17).
Critical to achieving the best results with arm contouring
surgery is addressing the upper body as a whole. Patients are
unlikely to be satisfied with their arms if their forearms,
axillae, or lateral thoracic region have not been addressed and
are contributing to their upper body concerns.
Major complications from brachioplasty were few (Table
27.1). In our review of 600 brachioplasty cases (1200 arms),
skin dehiscence was the most frequent complication, at 26%.
Few of the dehiscences occurred acutely (within the first
24–48 h of the procedure), but rather became evident approxi-
mately 2 weeks following the procedure. Of the dehiscences,
95% occurred at the intersection of the closure of the dome
and the arm. Like any triangular-shaped skin flap, the tip of
the flap has compromised blood supply. The typical course is
for the tip of the flap to take on a dusky appearance in the
first few days following the procedure, and by about 2 weeks,
wound separation occurs. The majority of skin dehiscences
are less than 2 cm in size. Avoiding this complication is chal-
lenging because some form of Z-plasty must be present for
the closure to extend from the axilla to the arm and prevent
scar contracture. While advising the patient to limit extension
of the arm may be helpful, it is unlikely to prevent this
problem entirely.
The dehiscences are treated with dressing changes. In some
instances, hypergranulation tissue may arise in the area of
skin dehiscence. Nitrate application is an effective treatment
for this. In our series, seromas are the second most frequent
problem, occurring in 10% of cases. The vast majority,
approximately 90%, occur along the distal medial one-third
Fig. 27.15  (A) Markings for planned combination mastopexy, lateral thoracoplasty,
and brachioplasty. (B) Final closure of combination mastopexy, lateral
thoracoplasty, and brachioplasty.
A
B
Postoperative care
Ambulation is encouraged as soon as possible after surgery.
Brachioplasty is nearly always performed in an ambulatory
setting, particularly if it is the only operation being performed.
Discharge home is usually within several hours of the conclu-
sion of the procedure. Dressings are removed 2 days postop-
eratively. Showering is permitted at this time. Patients are
advised to keep their axillae dry at all times when not shower-
ing and to avoid perspiring excessively or lifting their arms
(not forearms) above shoulder level for 2 weeks following
surgery. This still allows the forearms and hands to be used
for grooming. No garments are required to be worn. Lower
body vigorous activities may be resumed 2 weeks following
surgery. Upper body vigorous activities, including arms, may
be resumed at 6 weeks. Patients are encouraged to take nar-
cotics as needed but to minimize them as soon as possible.
Routine follow-up is at 1 week, 6 weeks, 3 and 6 months, and
yearly thereafter. Images are usually taken at the 3-month
follow-up.
Table 27.1  Complication rates associated with brachioplasty
Brachioplasty complication rates n = 600
cases (1200 arms)
Percentage
Skin dehiscence
26%
Seroma
10%
Infection
2.5%
Hematoma
0.5%
Skin necrosis
0.5%
Deep vein thrombosis
0.2%

705
Secondary procedures
Doppler study revealed involvement of the deep system of the
arm. There have been no instances of pulmonary embolism.
Secondary procedures
Patients seeking improvement following brachioplasty
surgery typically have concerns about scar quality or location,
or overall upper limb contour. Complaints about scar quality
include wide, pigmented, or hypertrophic scars. Some
patients, concerned about scar perceptibility, may seek a more
posterior or more anterior position for their scars. Concerns
about contour include excess skin and/or fat and irregular
contour or the presence of transverse bands (Fig. 27.18). We
have found that the vast majority of brachioplasty arm scars
mature to become similar in color to the patient’s adjoining
skin.
As has been noted regarding scars in general, arm
scars of patients of a lower Fitzpatrick rating are likely to
have a quicker and more complete dissipation of pigment
than individuals higher on the scale. Aside from strongly
advising the avoidance of ultraviolet light to scars during
of the arm, immediately beneath the scar. Most become
evident at about 3 weeks postoperatively and range in diam-
eter from 1 to 4 cm.
Initially we manage seromas with needle aspiration. This
technique unfortunately has a very high recurrence rate. The
technique of marsupialization, incising the skin over the
seroma, draining the seroma, and suturing the seroma cavity
to the skin, is 100% effective but results in a scar that may be
wider than the adjoining scar and prolong the healing of the
wound. Our preference at this time is to drain the seroma
via the scar and place a secured Penrose-type drain into the
seroma cavity. Patients are maintained on antibiotics while
the Penrose is in place. This simple technique has proven to
be very effective. Infections have been very infrequent, as
have bleeding and hematomas. Complaints of dysesthesia
beyond 3 months have been few, and rare beyond 6 months.
Skin necrosis has also been very infrequent, despite liposuc-
tion being performed in virtually all cases. We have only one
documented instance of deep vein thrombosis in a patient
undergoing brachioplasty. The patient presented with a pal-
pable cord extending from the forearm to the arm, suggestive
of superficial thrombophlebitis. An upper extremity venous
Fig. 27.16  (A,C) A 27-year-old woman 3 years following weight loss
of 164 lb (75 kg). Current weight and body mass index (BMI): 202 lb
(92 kg) and 37, respectively. Highest weight and BMI: 366 lb (166 kg)
and 67. (B,D) At 6 months following brachioplasty with concomitant
liposuction and posteromedial scar placement.
A
B
C
D

706
SECTION II
CHAPTER 27 • Upper limb contouring
we have found some improvement in scar quality with this
protocol. Our rationale for this approach is that tension
appears to be one of the most important variables affecting
scar quality. The wound tension at scar revision is likely to be
less than at the time of the approximation of the flaps at the
primary procedure. If at the time of the planned scar revision
minimal soft-tissue excess exists and remaining arm fat is
present, liposuction will be performed prior to scar revision
in an effort to diminish arm volume and minimize wound
tension at closure.
Patients and plastic surgeons have different opinions about
the ideal and least perceptible location for brachioplasty scars.
Regardless of preference, scar location can be adjusted as long
as some soft-tissue redundancy is present. Once again, as with
scar revisions, significant soft-tissue excess can be produced
with liposuction. Secondary procedures for complaints
regarding generalized soft excess are treated with an approach
similar to that described above for primary procedures, as are
generalized irregularities secondary to a primary liposuction,
the period of maturation, we have not required patients to
apply or consume any of the multitude of available prod-
ucts purporting to improve scar quality. We have not had
a positive experience with steroid injections for treatment
of hypertrophic scars. In most instances, steroid injection
has substituted the hypertrophic scar with an equally con-
spicuous area of abnormal-appearing, attenuated skin. Our
approach to wide, hypertrophic or hyperpigmented scars is
to encourage patients to allow time for the natural process
of scar maturation to take place. We have found that virtu-
ally all arm scars become increasingly less perceptible over
time, either through depigmentation or with the resolution
of hypertrophy. In instances where the patient is unwilling to
wait an extended period of time, we advise patients to wait
at least 8–10 months before seeking any kind of intervention.
Requiring that patients delay intervention allows for some
relaxation of skin and soft tissue to take place.
Our treatment of poor scars is to excise them and reap-
proximate the soft-tissue edges. In the vast majority of cases
Fig. 27.17  (A,C) A 37-year-old woman 7 years following weight
loss of 45 lb (20 kg). Current weight and body mass index (BMI):
220 lb (100 kg) and 37, respectively. Highest weight and BMI:
265 lb (120 kg) and 44. (B,D) At 6 months following
brachioplasty with concomitant liposuction and posteromedial scar
placement.
A
B
C
D

707
Secondary procedures
the anterior aspect of the arm, proximal to the elbow. In some
instances, the band appearance may be made more noticeable
by brachioplasty, particularly if the scars are hypertrophic (see
Fig. 27.18). Repeated flexion of the elbow over time appears to
produce a permanent band of scar tissue in the soft tissues of
the arm. While liposuction of the anterior aspect of the arm on
either side of the band significantly diminishes the percepti-
bility of the band, it does not address the band itself. Z-plasty
of the band has been suggested, but should be approached
cautiously because of the more anterior scar location.
non-excisional procedure. Secondary procedures for focal
irregularities following liposuction can be more challenging.
A common area for oversuctioning of fat is in the distal
one-third of the arm, just proximal to the elbow. Treatment
of this condition can involve liposuction alone or direct
excision of the surrounding areas of the arm. The presence
of transverse bands remains an occasional but recurrent
complaint for patients following brachioplasty. The bands are
usually evident prior to brachioplasty, are more noticeable
among higher-BMI individuals, and are typically found on
Fig. 27.18  (A) A 40-year-old woman following weight loss of
30 lb (17 kg). Current weight and body mass index (BMI): 150 lb
(68 kg) and 28, respectively. Highest weight and BMI: 180 lb
(82 kg) and 34. (B) At 3 months following brachioplasty with
concomitant liposuction and posteromedial scar placement. Note
hypertrophic scar and increased perceptibility of transverse band.
A
B
1. American Society of Plastic Surgeons. Cosmetic Surgery National
Data Bank Statistics. Available at: <
default/files/ASAPS-Stats2016.pdf>. 2016.
10. Hallock GG, Altobelli JA. Simultaneous brachioplasty, thoracoplasty
and mammoplasty. Aesthetic Plast Surg. 1985;9:233–235.
13. Lockwood T. Brachioplasty with superficial fascial system
suspension. Plast Reconstr Surg. 1995;96:912–920. Anatomic studies are
reported by the author that reveal that the posteromedial soft tissue of the
arm in youth is firmly suspended to the clavipectoral periosteum by means
of the clavipectoral and axillary fasciae. Loosening of these structures leads
to ptosis of the posteromedial arm. On the basis of this anatomic concept,
the brachioplasty technique proposed provides anchoring of the arm flap to
the axillary fascia and repair of the superficial fascial system to reduce the
risk of scar widening or migration and unnatural arm contours. The series
included five cases. While the series is small, the article highlights the
importance of the superficial fascia system in body contouring surgery.
17. Abramson DL. Minibrachioplasty: minimizing scars while
maximizing results. Plast Reconstr Surg. 2004;114:1631–1634. A
short-scar brachioplasty or minibrachioplasty technique is described by the
author that limits the scar to the axilla and proximal arm. Eight patients
were treated with the technique. Brachioplasty techniques with scars
limited to the proximal arm are likely to have a limited scope of utility in
the massive weight loss patient.
18. Reed LS. Brachioplasty with limited scar. Clin Plast Surg. 2014;41:
753–763.
21. Capella JF. Brachioplasty. Baker, Gordon Symposium. February 1,
2005, Miami, FL.
22. Pascal JP, Le Louarn C. Brachioplasty. Aesthetic Plast Surg.
2005;29:423–429. A technique for brachioplasty is described where the
scar is placed along the posteromedial arm and concomitant liposuction is
used to help preserve both deep and superficial lymphatics, reduce damage
to vessels and nerves, reduce volume, and allow for better tissue
mobilization. The series includes 21 patients. The concepts presented in
this article are similar to the techniques discussed in this chapter and
those I presented in February 2005 in Miami, Florida, at the Baker,
Gordon Conference. Liposuction is a particularly important component of
brachioplasty.
28. Gusenoff JA, Coon D, Rubin JP. Brachioplasty and concomitant
procedures after massive weight loss: a statistical analysis from a
prospective registry. Plast Reconstr Surg. 2008;122:595–603. The
authors analyze data from a prospective registry of massive weight loss
patients who underwent brachioplasty alone or with concomitant
operations to identify statistically significant complications. Outcome
measures included operative time, time since gastric bypass, need for
revision, arm liposuction, and complications such as seroma, dehiscence,
hematoma, infection, and nerve injury. Patients with a greater change in
Access the complete reference list online at

708
SECTION II
CHAPTER 27 • Upper limb contouring
body mass index had a higher chance of wound infection. Longer operative
time was associated with increased rates of surgical complications at the
operative site. There was a trend towards increased complications when
arm liposuction was combined with brachioplasty. The series included 101
cases. This article is particularly important in that it reviews a relatively
number of cases and makes conclusions based on data.
32. Nemerofsky RB, Oliak DA, Capella JF. Body lift: an account of 200
consecutive cases in the massive weight loss patient. Plast Reconstr
Surg. 2006;117:414–430.
33. Aly AS, Capella JF. Staging, reoperation and treatment of
complications after body contouring in the massive-weight-loss
patient. In: Grotting J, ed. Reoperative Aesthetic and Reconstructive
Surgery. 2nd ed. St. Louis, MO: Quality Medical Publishing;
2007:1701–1740.
34. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous
thromboembolism. Chest. 2001;119:132S–175S.

708.e1
References
References
1. American Society of Plastic Surgeons. Plastic Surgery Statistics.
Available at:<
Statistics/2016/2016-plastic-surgery-statistics-report.pdf.
2. Thorek M. Esthetic surgery of the pendulous breast, abdomen and
arms in the female. Ill Med J. 1930;3:48–57.
3. Posse RP. Cirugia Estetica. Buenos Aires, Argentina: 1946.
4. Correa-Iturraspe M, Fernandez JC. Dermolipectomia braquial.
Prensa Med Argent. 1954;34:2432–2436.
5. Baroudi R. Dermatolipectomy of the upper arm. Clin Plast Surg.
1975;2:485–494.
6. Guerrero-Santos J. Brachioplasty. Aesthetic Plast Surg. 1979;3:1–14.
7. Juri J, Juri C, Elias JC. Arm dermolipectomy with a quadrangular
flap and “T” closure. Plast Reconstr Surg. 1979;64:521–525.
8. Pitanguy I. Correction of lipodystrophy of the lateral thoracic
aspect and inner side of the arm and elbow dermosenescence. Clin
Plast Surg. 1975;2:477–483.
9. McCraw LH Jr. Surgical rehabilitation after massive weight: case
report. Plast Reconstr Surg. 1974;53:349–352.
10. Hallock GG, Altobelli JA. Simultaneous brachioplasty, thoracoplasty
and mammoplasty. Aesthetic Plast Surg. 1985;9:233–235.
11. Hauben DJ, Benmier P, Charuzi I. One-stage body contouring. Ann
Plast Surg. 1988;21:472–479.
12. Goddio AS. A new technique for brachioplasty. Plast Reconstr Surg.
1989;84:85–91.
13. Lockwood T. Brachioplasty with superficial fascial system
suspension. Plast Reconstr Surg. 1995;96:912–920. Anatomic studies are
reported by the author that reveal that the posteromedial soft tissue of the
arm in youth is firmly suspended to the clavipectoral periosteum by means
of the clavipectoral and axillary fasciae. Loosening of these structures leads
to ptosis of the posteromedial arm. On the basis of this anatomic concept,
the brachioplasty technique proposed provides anchoring of the arm flap to
the axillary fascia and repair of the superficial fascial system to reduce the
risk of scar widening or migration and unnatural arm contours. The series
included five cases. While the series is small, the article highlights the
importance of the superficial fascia system in body contouring surgery.
14. Temourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast
Reconstr Surg. 1998;102:545–551.
15. Richards MA. Minimal incision brachioplasty: a first choice option
in arm reduction surgery. Aesthet Surg J. 2001;21:301–310.
16. Vogt PA. Brachial suction-assisted lipoplasty and brachioplasty.
Aesthet Surg J. 2001;21:164–167.
17. Abramson DL. Minibrachioplasty: minimizing scars while
maximizing results. Plast Reconstr Surg. 2004;114:1631–1634. A
short-scar brachioplasty or minibrachioplasty technique is described by the
author that limits the scar to the axilla and proximal arm. Eight patients
were treated with the technique. Brachioplasty techniques with scars
limited to the proximal arm are likely to have a limited scope of utility in
the massive weight loss patient.
18. Reed LS. Brachioplasty with limited scar. Clin Plast Surg. 2014;41:
753–763.
19. Strauch B, Greenspun D, Levine J, et al. A technique of
brachioplasty. Plast Reconstr Surg. 2004;113:1044–1048.
20. Taylor J, Shermak M. Body contouring following massive weight
loss. Obes Surg. 2004;14:1080–1085.
21. Capella JF. Brachioplasty. Baker, Gordon Symposium. February 1,
2005, Miami, FL.
22. Pascal JP, Le Louarn C. Brachioplasty. Aesthetic Plast Surg.
2005;29:423–429. A technique for brachioplasty is described where the
scar is placed along the posteromedial arm and concomitant liposuction is
used to help preserve both deep and superficial lymphatics, reduce damage
to vessels and nerves, reduce volume, and allow for better tissue
mobilization. The series includes 21 patients. The concepts presented in
this article are similar to the techniques discussed in this chapter and
those I presented in February 2005 in Miami, Florida, at the Baker,
Gordon Conference. Liposuction is a particularly important component of
brachioplasty.
23. Knoetgen J III, Moran SL. Long term outcomes and complications
associated with brachioplasty: a retrospective review and cadaveric
study. Plast Reconstr Surg. 2006;117:2219–2223.
24. Aly A, Cram AE, Pace D. Brachioplasty in the patient with massive
weight loss. Aesthet Surg J. 2006;26:76–84.
25. Hurwitz DJ, Holland SW. The L brachioplasty: an innovative
approach to correct excess tissue of the upper arm, axilla, and
lateral chest. Plast Reconstr Surg. 2006;117:403–411.
26. Cannistra C, Valero R, Benelli C, et al. Brachioplasty after massive
weight loss: a simple algorithm for surgical plane. Aesthetic Plast
Surg. 2007;31:6–9.
27. El Khatib HA. Classification of brachial ptosis: strategy for
treatment. Plast Reconstr Surg. 2007;119:1337–1342.
28. Gusenoff JA, Coon D, Rubin JP. Brachioplasty and concomitant
procedures after massive weight loss: a statistical analysis from a
prospective registry. Plast Reconstr Surg. 2008;122:595–603. The
authors analyze data from a prospective registry of massive weight loss
patients who underwent brachioplasty alone or with concomitant
operations to identify statistically significant complications. Outcome
measures included operative time, time since gastric bypass, need for
revision, arm liposuction, and complications such as seroma, dehiscence,
hematoma, infection, and nerve injury. Patients with a greater change in
body mass index had a higher chance of wound infection. Longer operative
time was associated with increased rates of surgical complications at the
operative site. There was a trend towards increased complications when
arm liposuction was combined with brachioplasty. The series included 101
cases. This article is particularly important in that it reviews a relatively
number of cases and makes conclusions based on data.
29. Bruschi S, Datta G, Bocchiotti MA, et al. Limb contouring after
massive weight loss: functional rather than aesthetic improvement.
Obes Surg. 2009;19:407–411.
30. de Runz A, Colson T, Minetti C. Liposuction-assisted medial
brachioplasty after massive weight loss: an efficient procedure with
high functional benefit. Plast Reconstr Surg. 2015;135:74e–84e.
31. Knotts CD, Kortesis BG, Hunstad JP. Avulsion brachioplasty:
technique overview and 5-year experience. Plast Reconstr Surg.
2014;133:283–288.
32. Nemerofsky RB, Oliak DA, Capella JF. Body lift: an account of 200
consecutive cases in the massive weight loss patient. Plast Reconstr
Surg. 2006;117:414–430.
33. Aly AS, Capella JF. Staging, reoperation and treatment of
complications after body contouring in the massive-weight-loss
patient. In: Grotting J, ed. Reoperative Aesthetic and Reconstructive
Surgery. 2nd ed. St. Louis, MO: Quality Medical Publishing;
2007:1701–1740.
34. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous
thromboembolism. Chest. 2001;119:132S–175S.
35. Buchwald H. Obesity comorbidities. In: Buchwald H, Cowan SM,
Pories WJ, eds. Surgical Management of Obesity. Philadelphia, PA:
Saunders, Elsevier; 2007:37–44.

SECTION II • General Aesthetic Surgery
28 
Post-bariatric reconstruction
Jonathan W. Toy and J. Peter Rubin
SYNOPSIS
■ Obesity is a global epidemic. With the rise in bariatric surgical
procedures, there has been a concomitant increase in the demand for
plastic surgical reconstruction after massive weight loss (MWL).
■ Assessment of the MWL patient begins with a complete history and
physical exam. Weight history, past surgical history, and nutritional
status are key.
■ Preoperative identification of psychiatric comorbidities is imperative in
the MWL population presenting for body contouring.
■ Essential elements of patient management include intraoperative
positioning, maintaining body temperature, venous thromboembolism
prophylaxis, and medical optimization.
■ The abdominal area is the most common area of treatment in MWL
patients. Ventral hernias are common – a high index of suspicion must
be maintained.
■ In the MWL patient, circumferential truncal body contouring
procedures are necessary in many cases to achieve good aesthetic
outcomes.
■ Multiple body contouring procedures may be performed safely in
combination, depending on patient preference, assistants in the
operating room, length of anesthesia time, and the patient’s overall
medical condition.
Obesity
Definition and epidemiology
Overweight and obesity refer to ranges of weight that are
greater than that considered healthy for a given height. The
primary measurement for obesity used to categorize patients
is the body mass index (BMI).1 According to the World Health
Organization, overweight is defined as a BMI between 25
and 29.99 kg/m2. Obesity begins at 30 kg/m2 with obese
class I equivalent to 30–34.99 kg/m2.2 Modifications to the
classification have been added, including the categories of
super obese (50–60 kg/m2), and super, super obese (>60 kg/
m2) (Table 28.1).3
In the United States, obesity is increasing at an alarming
rate.4 In 2012 the prevalence of obesity among American
adults was 34.9%.5 Approximately 5% of the American popu-
lation is considered morbidly obese.6 Worldwide, the over-
weight and obesity population is estimated to be approximately
1.7 billion people.7
Obesity is an independent risk factor not only for all-cause
mortality but also for major diseases including coronary heart
disease, type II diabetes, hypertension, certain malignancies,
and musculoskeletal disorders.8 One cannot ignore the psy-
chosocial ramifications of obesity.9 Disturbingly, obesity is
predicted to overtake smoking as the leading cause of death
in the United States.10 Not only does obesity result in lower
societal productivity and higher healthcare costs, rises in
patient morbidity and mortality have spurred governmental
interventions.11–13
The etiology of obesity is more complex than originally
thought. Although some simplify the problem to “more calo-
ries in than out”, other factors, including genetics, environ-
ment, and psychological factors are influential.9 Notoriously
difficult to treat, obesity is often resistant to many forms of
therapy. Gastric bypass procedures have been shown to
provide cost-effective, durable long-term weight control in
the moderately to morbidly obese.14,15 Improvements in safety
as well as a decrease in morbidity associated with bariatric
surgery have led to a concomitant rise in bariatric surgical
procedures, resulting in growing numbers of patients seeking
removal of the excess skin and fat that remain following
weight loss.16,17
MWL from surgery or diet and exercise alone may be
described as weight loss in excess of 50 lb. Plastic surgeons
have had to modify traditional surgical approaches and
techniques in order to appropriately treat the unique deformi-
ties found in this emerging patient population.
  Access video content for this chapter online at expertconsult.com

710
SECTION II
CHAPTER 28 • Post-bariatric reconstruction
Pories et al. was the first to report significant improvements
in glucose control following bariatric surgery.14 Further studies
have demonstrated 83% and 86% resolution rates of type II
diabetes following bariatric surgery.31,32 Diabetes resolution
was found to occur only days following surgery, well before
weight loss was achieved.14
Bariatric surgery is noted to be the second most common
abdominal procedure performed in the United States.33 Dia-
betes, hyperlipidemia, hypertension, and sleep apnea have
all been noted to improve following bariatric surgery.6,34,35
Increases in life expectancy have been noted in patients fol-
lowing weight loss.34,36,37 Bariatric surgery results in durable
and stable weight loss within 1 year following surgery that is
three to four times superior to that achieved with non-surgical
treatment.6,38
Indications for bariatric surgery as a treatment of obesity
include BMI >40 kg/m2, or BMI between 35 and 40 kg/m2
with a high-risk comorbid condition, failed medical manage-
ment, multidisciplinary evaluation, a motivated and well-
informed patient with realistic expectations, and a commitment
to long-term follow-up.39–41
Multiple surgical techniques have been described to treat
obesity. The plastic surgeon should understand the various
procedures and the effects they may have. Three main catego-
ries exist: restrictive, malabsorptive, and a combination
restrictive–malabsorptive.
Restrictive procedures produce satiety with the surgical
creation of a small gastric pouch with a restricted outlet,
thereby restricting food intake.42 The advantage to restrictive
procedures is the reduction in the malabsorption of nutrients
seen long-term in malabsorptive procedures. Vertical banded
gastroplasty involves the creation of a circular window made
in the stomach a few inches below the esophagus. A small
vertical pouch is made. Complications include esophageal
reflux, stomal narrowing or widening, and less successful
results with stable weight loss compared with gastric bypass,
which has caused this procedure to fall out of favor.43–46
The more popular purely restrictive bariatric surgery is
laparoscopic adjustable gastric banding (LAGB), where a
band is placed around the upper stomach 1–2 cm below the
gastroesophageal junction, creating a 20–30 cc upper gastric
pouch.44 The degree of constriction is adjusted with the altera-
tion in the amount of saline in the band through the subcuta-
neous port. Because the absorptive surface of the gastrointestinal
tract is unaltered, there is a decreased risk of nutritional
deficiencies. Excess weight lost ranges from 52% to 68%.47–50
The disadvantages of LAGB are less weight loss compared
with combination restrictive–malabsorptive procedures and a
permanent intra-abdominal foreign body. One of the most
serious complications of LAGB is erosion of the device
into the stomach, requiring surgical intervention, including
removal of the band.51 As evidence accumulates regarding the
safety and efficacy of LAGB, it is anticipated that the use of
these devices will dramatically increase.45,52
Purely malabsorptive procedures divert nutrients and
interrupt the digestive process. More common techniques
involve both restrictive and malabsorptive mechanisms,
rather than malabsorption alone. Biliopancreatic diversion
(BPD) has evolved to include a limited gastrectomy to reduce
stomach size, as well as the creation of a malabsorptive limb,
with a 50 cm common channel for absorption. Major compli-
cations from BPD include protein-calorie malnutrition,
Methods of weight reduction
Diet and exercise
Diet and exercise play an integral role in any weight loss
regimen. Simplified, in order to lose weight, caloric intake
must be less than total body expenditure of energy in order
to consume endogenous triglycerides.18 Caloric restriction
may take the form of generalized reduction in calories, but
may be aided by adjustments in the types of macronutrients
eaten (e.g., fats, carbohydrates).19,20 A recommended diet of
between 1000 and 1200 kcal/day for women, and 1200–
1600 kcal/day for men is commonly followed for a target
weight loss of 1–2 lb per week. In most cases, an initial weight
loss of 10% of body weight over a 6-month period is sug-
gested.21 Unfortunately, long-term studies have found diet
therapy alone is ineffective in the treatment of obesity.21,22
Often coupled with a reduction in caloric intake is physical
activity or an exercise regimen. Physical activity is valuable,
primarily aiding in long-term weight loss maintenance.23,24
Isolated physical activity with no changes in a high-calorie
diet is insufficient to cause significant amounts of weight
loss.25
Pharmacotherapy
The anorectic agents fenfluramine and phentermine have
both, in the past, been approved by the Food and Drug
Administration (FDA) as individual agents. However, these
drugs are not commonly used to treat obesity due to associa-
tions with the development of primary pulmonary hyperten-
sion and valvular heart disease.26–29
Currently, weight loss drugs are approved by the FDA for
patients who have a BMI ≥30 kg/m2, or a BMI between 27 and
29.9 kg/m2 in conjunction with an obesity-related medical
complication.18 The majority of weight loss medications are
anorexiants. Most are only approved for short-term use, and
patients typically regain weight once discontinued.30
Bariatric surgery
Bariatric surgery in the morbidly obese has been shown to
ameliorate and even cure some chronic diseases that have
long been considered refractory to medical management.
Perhaps the most profound effect of bariatric surgery is the
reduction in type II diabetes. In 1995, a landmark study by
Table 28.1  Body mass index (BMI) and obesity classification2,3
BMI (kg/m2)
Classification
<18.5
Underweight
18.5–24.9
Normal weight
25.0–29.9
Overweight
30.0–34.9
Class I – obesity
35.0–39.9
Class II – obesity
40.0–49.9
Class III – morbid obesity
50.0–59.9
Class III – super obesity
≥60.0
Class III – super, super obesity

711
Diagnosis/presentation/evaluation
anemia, and bone demineralization.43,44,46 Although the great-
est degree of malabsorption occurs with this procedure, there
is also a risk of stomal ulcer formation, frequent and foul
smelling stools, and dumping syndrome.51,53
Currently in North America, the most popular bariatric
surgical procedure is the gastric bypass, or Roux-en-Y
gastric bypass (RYGB). Both the size of the stomach and
the gastric outlet are restricted. This is a restrictive and
malabsorptive combination procedure in which the degree
of malabsorption is determined by the length of the jejunum
attached to the gastric outlet.54 Many variations of RYGB are
possible.
Late complications of bariatric surgery are most relevant to
the plastic surgeon.51 These include inadequate weight loss,
psychiatric conditions, dumping syndrome, and most impor-
tantly, nutritional deficiencies.43,53,55 Adequate calorie intake
and nutrition is the cornerstone of postoperative healing.
Folate, calcium, vitamin B12, and iron deficiencies may be seen
following bariatric surgery. Daily supplemental vitamins
reduce the risk of neurological and hematologic complica-
tions.56 The incidence of peripheral neuropathy following
bariatric surgery was 16% in one study.57 A summary of the
advantages and disadvantages of various methods of weight
loss are shown in Table 28.2.
Incidence and decision-making for
body contouring post-bariatric surgery
The burden of obesity is increasingly recognized to continue
after the weight is lost, with redundant skin causing functional
Table 28.2  Advantages and disadvantages of various methods of weight loss
Method of weight loss
Advantages
Disadvantages
Diet and exercise
Non-invasive
Diet modification alone not usually
effective in long term
Pharmacotherapy
Non-invasive
Oily stool
Malabsorption of fat-soluble vitamins
Fecal incontinence
Bariatric surgical procedure
May ameliorate or improve many chronic diseases
Invasive
VBG
Decreased rates of nutrient malabsorption
Esophageal reflux
Stomal narrowing/widening
Less successful stable weight loss vs.
other bariatric surgical procedures
LAGB
Adjustable through port
Lesser degree of weight loss vs. other
bariatric surgical procedures
Decreased rates of nutrient malabsorption
Erosion of device into stomach
Absorptive surface of gastrointestinal tract unaltered
Removal requires surgery
BPD
Both restrictive and malabsorptive mechanisms
Protein-calorie malnutrition
Anemia
Bone demineralization
Stomal ulcer formation
Frequent/foul-smelling stools
Dumping syndrome
RYGB
Both restrictive and malabsorptive mechanisms
Nutritional deficiencies
Many variations possible
Dumping syndrome
VBG, vertical banded gastroplasty; LAGB, laparoscopic adjustable gastric banding; BPD, biliopancreatic diversion; RYGB, Roux-en-Y gastric bypass.
issues. A study by Reiffel et al. found that only 11.6% of
post-bariatric patients chose to undergo body contouring
surgery.58 The most frequent reasons for not opting to have
body contouring was cost and lack of awareness of options.59
Another study by Al-Hadithy et al. demonstrated that
73.4% of patients undergoing bariatric surgery wanted body
contouring procedures post-weight loss,60 while Gusenoff
et al. reported an 11.3% plastic surgical rate.61 It was noted
that those patients with higher socioeconomic status were
more likely to have post-bariatric plastic surgery. In many
instances, plastic surgery in these cases is deemed low priority
and funding is either not available or is subject to specific
criteria.
Diagnosis/presentation/evaluation
History
Patient evaluation includes a complete medical history. A
distinction must be made in the mode of weight loss. Key
information to obtain regarding the patient’s weight includes:
■ Date and nature of bariatric surgical procedure
■ Maximum, lowest, and current weight and BMI
■ Goal weight
■ Recent (past 3 months) changes in weight status.62
Other important history required includes:
■ Past or current tobacco use
■ Prior surgeries
■ Prior pregnancies, plans for future pregnancies

712
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CHAPTER 28 • Post-bariatric reconstruction
which may also help determine the translation of pull (dis-
tance from the pinched area that tissues are affected).70
Scars from prior surgeries are important to document, as a
reduction in blood supply may require technical modifica-
tions during surgery. Commonly, rectus diastasis may be
discovered. Ventral hernias are reducible or non-reducible,
and the edges of the hernia may be palpated. A breast exami-
nation should be performed, noting masses, position of the
nipple areola complex, and skin envelope quality. Asymme-
tries are pointed out to the patient. Lateral thoracic skin rolls
are noted. Standardized photographs are taken.
Investigations
A proper medical work-up is essential. Preoperative clear-
ances from internists, psychiatrists, and other physicians that
care for the patient are the rule. Investigations include a chest
X-ray, electrocardiogram, complete blood count, coagulation
profile, pre-albumin, albumin, pregnancy screen in females of
child-bearing age, and mammogram if breast surgery is con-
sidered.71 Abdominal computed tomography in cases of sus-
pected hernias will aid surgical planning.
Patient preoperative counseling
and education
Preoperative counseling exploring the patient’s goals, expec-
tations, and areas of greatest concern aids in patient selection.
Patients are questioned on areas of the body of greatest prior-
ity requiring correction, especially when multiple procedures
are performed. Education regarding the areas of the body that
may be contoured concurrently and discussion as to the
appropriate staging of procedures are undertaken. Patients
must be made aware of the lengthy scars that occur with large
skin resections and must be willing to trade a better contour
with the resultant scar.
Education must focus on pre- and postoperative expecta-
tions, the length of the surgical procedures, as well as the
nature and length of recovery following multiple procedures.
As the majority of surgeons use drains in the initial postopera-
tive period, information regarding drain care should be given.
Patients must have appropriate social support at home in
order for a smooth recovery to occur. No lifting of items
heavier than 10 lb is a good rule of thumb for patients under-
going abdominal procedures.
Abstinence from medications that predispose to bleeding,
including herbal medications, is important. Tobacco use is a
relative or absolute contraindication for body contouring by
most surgeons. Smoking cessation helps to minimize flap loss
and wound complications such as dehiscence and infection.72,73
Although there is no consensus, a commonly used guideline
is abstinence from tobacco or nicotine replacement therapies
for at least 4 weeks prior to and 4 weeks post-elective cosmetic
or reconstructive procedures.74
Informed consent is a key element of preoperative counsel-
ing. Patients must understand that body contouring after
MWL may require multiple stages and possible revisionary
surgeries. The surgeon’s revision policy must be emphasized
to patients and the difference between secondary procedures
(further skin tightening) and revisions understood. In general,
MWL patients experience mild to moderate amounts of skin
relaxation postoperatively, resulting in the need for further
■ Breast history, including prior surgeries, history of cancer,
family history, mammographic history, breast biopsies
■ Prior deep venous thrombosis/pulmonary embolism, or
coagulopathy
■ Psychiatric history
■ General medical issues.
Many patients will have had numerous medical comorbidities
prior to weight loss that have improved significantly or since
resolved. These benefits commonly occur within 2–5 months
following bariatric surgery.63 Sequelae of gastric bypass must
also be assessed, including history of past or current dumping
syndrome or prolonged emesis.
Screening for nutritional status is important.64 Protein
intake by history is considered adequate if 70–100 g of protein
per day is reported, although serum protein measurement is
indicated before post-bariatric body contouring. Following
bariatric surgery, protein is one of the major nutrients affected
and may be reflected as hypoalbuminemia, anemia, and
edema. Although seen in Roux-en-Y gastric bypass, the most
common procedures associated with protein deficiencies are
malabsorptive in nature, such as the biliopancreatic diver-
sion.40,64 Protein intake is essential for wound healing,
especially if multiple contouring procedures are performed.
Pre-albumin and albumin levels elucidate issues with protein
intake and absorption. Protein supplementation may be
required preoperatively.
Deficiencies in nutrients and vitamins, such as thiamine,
folate, B12, and iron are common.65,66 A history of current or
past supplementation may screen for this. Nutritional defi-
ciencies are most common in malabsorptive procedures,
including Roux-en-Y gastric bypass and biliopancreatic
diversion.64
Anemia is not uncommon in the MWL population and
may be related to generalized or specific nutrient deficiencies.
Although iron deficiency is most common, micronutrients
such as B12, folate, copper, fat-soluble vitamins A and E, or
zinc may be deficient and contribute to anemia.67,68 A complete
hematological work-up, including measurement of iron stores,
should be performed, especially in high-risk patients. In some
cases, iron deficiencies may be refractory to oral therapies and
require more aggressive treatment with parenteral iron, blood
transfusions, or surgical interventions.65 Iron deficiency may
be seen in association with any gastric bypass procedure.
Physical examination
A generalized physical assessment of the degree of skin
excess, distribution of fat, number and location of rolls, and
the quality and elasticity of the remaining skin indicates
which areas of the body would benefit from contouring
surgery. Characteristically, patients will present with predict-
able patterns of tissue descent around the body.
Zones of adherence, which are tight, non-yielding areas of
fascial attachment to the underlying muscular system, act as
tethering points from which skin laxity will hang. These areas
of restriction are located in the midline of the anterior and
posterior trunk and around the pelvic rim. Areas of skin and
soft tissue that are farthest in distance from the zones of
adherence descend the most following MWL, which in most
patients includes the lateral truncal tissues.69 The estimated
skin resections may be simulated by performing “pinch tests”,

713
Patient selection/timing of surgery
improve, albeit transiently.87 Quality of life, however, has
been found to improve following body contouring surgery,
independent of mood.88
Patient safety and intraoperative
considerations
Any body contouring surgery should be performed in a fully
accredited ambulatory care facility or hospital. An operating
room staff familiar with body contouring is essential for effi-
ciency and timeliness of the surgery. Anesthesiologists should
be familiar with the post-bariatric patient and sensitive to
the physiological and structural changes that are associated
(Box 28.1).89
Prevention of hypothermia is crucial. With lengthy proce-
dures involving the creation of large wounds, exposing the
majority of the patient’s body, all patients must be monitored
carefully. A temperature of at least 35°C should be maintained.
The authors perform pre-warming for all body contouring
patients in the pre-anesthesia holding area with forced-air
warming blankets. Warming continues in the operating room
with elevated basal room temperatures, forced-air blankets,
warmed fluids if needed, and operating table warming pads.
Venous thrombosis prevention is integral. Surgeries are
lengthy, and abdominal wall tightening or reconstruction is
common, elevating intra-abdominal pressures and predispos-
ing to deep vein thrombosis (DVT) and pulmonary embolism.
A preoperative history for risk factors for DVT and careful
prophylaxis reduce these rates. Factors such as increased age,
malignancy, history of spontaneous miscarriages, inherited or
acquired thrombophilia, use of exogenous estrogens, preg-
nancy, and previous venous thromboembolism should alert
the plastic surgeon of increased risk.90–92
Guidelines from the American College of Chest Physicians
in prevention of DVT are available.93,94 Early ambulation,
mechanical lower extremity compression devices (including
intermittent pneumatic compression and elastic stockings),
and chemoprophylaxis with low-molecular-weight heparin or
unfractionated heparin may be used depending on level of
risk.90 Improved efficacy does not occur when chemoprophy-
laxis is given preoperatively compared to within 6–12 h of the
surgery. However, a higher risk of bleeding occurs when
given within 2 h of surgery.95 Guidelines from 2012 in the
prevention of VTE in non-orthopedic surgical patients exist.93,94
Patient positioning may improve the ease of surgery and
prevent untoward complications secondary to pressure. Prone
positioning is often required and pressure must be minimized
to points such as the breasts, genitals, and face. Endotracheal
tube positioning must be maintained. Compression on the eyes
must be avoided, as blindness has been reported following
skin resections. There is also the possibility of contour irregu-
larities and postoperative “dog-ears” at the extents of resec-
tion. A comprehensive guide to informed consent in body
contouring patients following MWL is available from the
American Society of Plastic Surgeons.75
Patient selection/timing of surgery
Patients presenting following MWL should be at or near their
goal weight and be weight-stable for at least 3 months prior
to body contouring surgery. This usually corresponds to a
period of 12–18 months following bariatric surgery. A BMI
<35 kg/m2 is acceptable; a BMI >35 kg/m2 portends increased
risk of surgical complications.76–78 Ideally, patients undergoing
body contouring after MWL should be within 10–15% of their
goal weight and have had no large fluctuations in their weight
(weight-stable) over the past 3–6 months.42 Constantine et al.
demonstrated that wound complications were not increased
in patients having lost 50–100 lb, but were increased when the
patient had lost >100 lb.79
Aesthetic outcomes are improved with a lower BMI. In
general, a BMI of 25–30 kg/m2 is ideal, and patients with a
BMI >32 kg/m2 may have more limited aesthetic outcomes.80,81
Also, a high BMI increases the rate of complications, especially
thrombotic complications such as deep venous thrombosis.82,83
Patients with high BMIs are counseled to further lose weight
and return again at a more ideal BMI. A notable exception to
this guideline is the patient with the disabling giant pannus,
or panniculus morbidus. These patients will generally benefit
from the removal of abdominal excess in order to improve
ambulation, quality of life, hygiene, and further their weight
loss.84
Patients with severe medical comorbidities, psychiatric
comorbidities, unrealistic expectations, or currently using
tobacco are preoperatively optimized. These issues are reas-
sessed at the second preoperative visit and surgical manage-
ment is offered only once improved or resolved.
Systemic medical disease that precludes general anesthesia
an absolute contraindication for body contouring surgery.
Relative contraindications include active smoking, BMI
>35 kg/m2, uncorrected coagulopathies, severe disorders that
affect wound healing, and systemic medical disease that place
the patient at high risk for surgery.
Psychological considerations in post-bariatric
body contouring
MWL is considered by many to be a “life-altering event”. Such
is the same with body contouring procedures. Patients should
be congratulated on their weight loss. Pre- and postoperative
counseling as to the usual postoperative course is essential.
Family and social supports aid in the recovery period.
Prior to bariatric surgery, up to one-third of patients have at
least one psychiatric diagnosis; approximately 40% of patients
undergoing bariatric surgery are undergoing some form of
psychiatric treatment.85,86 Mood disorders, personality disor-
ders, and poor body image are most common. Patients with a
history of bipolar disorder and schizophrenia must be offered
surgery with caution. A high index of suspicion must be
maintained with liberal preoperative psychiatric clearances.
Following MWL, many psychiatric conditions reportedly
BOX 28.1  Safety and intraoperative considerations in body
contouring
• Procedures should be performed in a fully accredited
ambulatory facility or hospital.
• Prevention of hypothermia is crucial.
• Venous thrombosis prevention is essential.
• Be aware of patient positioning.
• Length of surgery is important.

714
SECTION II
CHAPTER 28 • Post-bariatric reconstruction
■ Presence or absence of rectus diastasis
■ Presence or absence of ventral hernias, umbilical hernias
■ Surgical scars
■ Extent of excess tissues laterally and circumferentially
■ Co-existing genital deformities, including mons ptosis.
Operative planning and techniques
A panniculectomy is a functional operation designed to relieve
symptoms related to an overhanging abdominal pannus. It is
performed for patients with higher BMIs or more severe
medical comorbidities. It is considered a functional, recon-
structive procedure removing only skin and fat. Skin flap
undermining is limited, and no plication is performed. The
risks of a traditional abdominoplasty are minimized. In
patients who have lost a considerable amount of weight, the
umbilical stalk may be quite long and preclude its use, result-
ing in excision and possibly the creation of a neo-umbilicus.
Panniculectomy contrasts with abdominoplasty, which is
traditionally performed for aesthetic purposes and includes
not only the removal of skin and fat but also abdominal wall
tightening and umbilical repositioning. The patient is usually
at or around their goal weight.
The assessment of tissue excesses, not only anteriorly but
also laterally and circumferentially, is important. A pannicu-
lectomy or abdominoplasty will resect skin and fat anteriorly;
however, if excess in skin and fat extends laterally and poste-
riorly, these areas are not addressed. Large dog-ears laterally
may occur in this case. Conversion to alternative procedures
such as a lower bodylift, liposuction, or belt lipectomy will
correct larger lateral deformities. This should be documented
and discussed with the patient preoperatively.
Old surgical scars must be considered. The elevation of
flaps surrounding prior healed incisions is always concerning
in regards to blood supply. Limitation of undermining (up to
the scar) reduces the risk of skin flap necrosis. Risk factors for
skin necrosis should also be sought preoperatively and if
present, dissection should be minimized.
With the introduction of minimally invasive bariatric surgi-
cal procedures, abdominal wall incisional hernias are becom-
ing less common. Care must be taken to ensure that the
abdominal cavity will accommodate the reduction of intra-
abdominal contents without causing excessive tension on
the abdominal wall reconstruction. If not, the patient is first
treated with supportive care with an abdominal binder and
counseled to lose further weight prior to reconstruction.
Abdominal wall reconstruction for ventral or umbilical
hernias may be accessed through the low transverse abdomi-
nal incision. Small to moderate ventral hernia repairs may
easily be combined with other body contouring procedures.
However, more extensive hernias require wider dissection
and lysis of adhesions. In these cases, the amount of concomi-
tant procedures is decreased for safety reasons.71 It is the
author’s preference to avoid using prosthetic materials for
abdominal wall reconstruction if avoidable due to the higher
risk in this population of wound dehiscence and infection.
Components separation of the abdominal wall is an excellent
technique for repair of ventral hernias and may avoid the use
of mesh prosthetics.101
Final scar placement must be taken into consideration. The
inferior margin for the transverse resection is planned 6 cm
prone positioning.96 When prone, patients should be placed in
15° of Trendelenburg to prevent excessive pressures on the
globes.97,98 Neural and vascular compression may occur.99
Length of surgery is an important consideration. Combin-
ing multiple body contouring procedures is frequent and can
significantly increase operative time. Time is increased when
turning the patient is required. There is no consensus on the
time limits for body contouring surgery. Surgeons should
consider length of surgery in the context of the operative
setting, medical risk, and technical proficiency of the team.
Surgical techniques by
anatomic region
Abdominal contouring
Abdominoplasty procedures are detailed in Chapter 23.
Abdominoplasty is reviewed here with specific reference to
the MWL patient (Box 28.2).
Deformity/patient evaluation
The abdominal area is the most common reason patients seek
plastic surgical consultation after MWL. Along with aesthetic
concerns, a hanging abdominal pannus may be symptomatic,
causing recurrent intertrigo and infections in skin folds, hin-
dering ambulation, and making intimacy difficult. Following
abdominoplasty or panniculectomy after MWL, patients
indicate a consistent improvement in body image and subjec-
tive quality of life.100
Evaluation of the patient presenting for abdominal con-
touring, in addition to a complete history, includes:
■ Quality, elasticity of abdominal skin
■ Presence of multiple skin rolls
■ Degree of adiposity, deflation of skin rolls
■ Evaluation of intra-abdominal versus extra-abdominal
adiposity
BOX 28.2  Abdominal contouring in the MWL patient
• A panniculectomy is primarily a reconstructive procedure aiming
to remove skin and fat from the anterior abdominal area in
patients who are not at their optimal weight. The term
abdominoplasty is primarily an aesthetic procedure involving the
removal of abdominal skin and fat, along with tightening of the
abdominal wall musculature and repositioning of the umbilicus.
• Ventral and umbilical hernias are common in the MWL
population. A high index of suspicion must be maintained and
structural anomalies sought preoperatively.
• Vertical resection of trunk skin and fat (fleur-de-lis
abdominoplasty) may be required to tighten the abdomen
transversely. Care must be taken to minimize flap undermining.
• In patients with skin and soft-tissue excess circumferentially, a
procedure such as a lower bodylift or belt lipectomy may result
in a more aesthetic result than a panniculectomy or
abdominoplasty alone.
• The genital area or mons may require thinning and
resuspension.
• In the patient with the giant pannus (panniculus morbidus),
special equipment including supportive lifts aid in resection.

715
Surgical techniques by anatomic region
have been shown to have comparable complications rates to
traditional abdominoplasty techniques.105
Ptosis of the pubic/mons area is frequently encountered in
the MWL patient. Resuspension with non-absorbable sutures
from the anterior abdominal fascia to the superficial fascial
system of the pubic area at three to five points helps reposition
this area (Figs. 28.3 & 28.4). Sub-Scarpa defatting of the pubic
area may be required to match abdominal flap thickness. If
mons resuspension is performed, the patient is advised pre-
operatively that there may be a temporary change in the angle
of urine stream.
Extreme cases of pubic ptosis accompanied by excess pubic
fat in males results in a buried penis, in which the shaft and
glans of the penis are concealed from view (Fig. 28.5).106
Increases in abdominal fat may contribute to this condition,
as the penis is tethered by the suspensory ligament, while the
abdominal fat is not.107 With recurrent episodes of infection,
persistent moisture, and superficial skin breakdown, cicatri-
cial changes occur, trapping the penis. Buried penis is a
debilitating condition, interfering with normal urinary func-
tion, proper hygiene, and making sexual intercourse diffi-
cult.108 Correction of such deformities is complex, and multiple
techniques have been developed including suprapubic
superior to the vulvar commissure in females and from the
base of the penis in males. This position allows the final scar
to be hidden in the patient’s underwear.
Variations in abdominal contouring
and reconstruction
In patients with significant epigastric laxity, a vertical trunk
excision may be combined with the low transverse excision,
creating a fleur-de-lis type abdominoplasty (Fig. 28.1).102,103 It
is wise to limit undermining at the edges of the vertical exci-
sion, to preserve as many local perforators as possible, and to
avoid excessive triple-point tension to preserve flap viability.104
Umbilical inset is made within the vertical incision and lateral
vectors will adjust the shape during healing; creating a cut-out
for the inset will result in an unaesthetic widened umbilicus
over time. Defatting superior to the cephalad limit of the verti-
cal excision will reduce the resultant dog-ear. Advantages to
the fleur-de-lis abdominoplasty include the ability to contour
the epigastrium and enhance waist definition (Fig. 28.2).
Disadvantages include the additional vertical abdominal scar
and potential for overtightening at the waist in males, creat-
ing a feminine-appearing torso. Fleur-de-lis abdominoplasties
Fig. 28.1  Surgical technique for fleur-de-lis abdominoplasty. (A) Estimated
resection marked. Undermining of skin flaps is minimized. (B) Transverse resection
of tissues performed first, followed by resection in the vertical axis. (C) Preservation
of abdominal wall perforating vessels minimizes risk of flap necrosis and wound
healing complications. Minimal undermining is key.
A
B
C

716
SECTION II
CHAPTER 28 • Post-bariatric reconstruction
Fig. 28.2  Fleur-de-lis abdominoplasty.
This 38-year-old woman lost 50 kg of
weight. Pre- (A) and postoperative
(B) views 12 months following fleur-de-lis
abdominoplasty including plication. Note
improved waist definition.
A
B
A
B
C
D
Fig. 28.3  Mons correction and resuspension. The patient is marked for abdominoplasty with caudal resection line shown, 6 cm superior to the anterior vulvar commissure
(A). Following abdominal wall plication, resection of deep adipose tissue beneath the mons is performed. The thickness of the mons should match that of the abdominal
flap. The wedge-shaped resection extends to the symphysis pubis, while avoiding the vaginal vault (B–D).

717
Surgical techniques by anatomic region
E
F
G
H
The deep surface of the mons is suspended to the abdominal wall with 3–5 braided sutures (E,F). A reduction of the fullness and ptosis of the mons is
seen (G,H).
Fig. 28.3, cont’d
A
B
Fig. 28.4  Mons ptosis correction. A
49-year-old woman with significant mons
ptosis. Pre- (A) and postoperative
(B) views following correction and
suspension with abdominoplasty. Note
improved genital contour with reduction in
mons volume and improvement in position.

718
SECTION II
CHAPTER 28 • Post-bariatric reconstruction
blood vessels. Hemostasis with surgical clips or ties is essen-
tial. In most cases, umbilical excision is necessary (Fig. 28.6).
Complications
Local complications including hematoma, seroma, wound
infection, and wound dehiscence may be seen in the early
postoperative period. Asymmetries involving scar position
and contour are possible. Lateral dog-ears are common, but
avoidable if care is taken in surgical planning or choice of
procedure (e.g., conversion to circumferential truncal surgery).
Resuspension of the genital area may cause a temporary
alteration in the stream of urine.
dermatolipectomy and pubic and penoscrotal tacking with
possible liposuction.109–112
Special consideration is made for the giant pannus. Associ-
ated with a high BMI, a giant pannus causes significant
morbidity. Interference with ambulation, hygiene issues
including recurrent intertrigo and rashes, and chronic pannus
lymphedema may be alleviated with resection.113,114 Since a
large mass of tissue may be present, special lifts provide
access to incision sites.76,115 Steinman pins may be placed
superficially into the edge of the pannus, bearing in mind that
an incisional or umbilical hernia may be present. These pins
may be connected to a Hoyer hydrolic lift. Elevation allows
venous drainage from the pannus and better control of large
Fig. 28.5  Buried penis. A 53-year-old
male with large pannus and buried penis.
The penis has retracted within the pannus
(A,B). Manual extraction is possible in
this case (C). Improved appearance and
exposure of the genitals are seen following
panniculectomy (D).
A
B
C
D

719
Surgical techniques by anatomic region
Fig. 28.6  Giant pannus. A 42-year-old male following gastric banding (352–236 kg change in weight) with
functionally disabling giant pannus preoperatively (A,B). Orthopedic pins are inserted through the edge of the
pannus, held with traction bows and used to suspend the pannus above the patient (C,D). Commonly, large
blood vessels are encountered and ligated (E). Total resected pannus weight was 61 kg.
A
B
C
D
E

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SECTION II
CHAPTER 28 • Post-bariatric reconstruction
authors to perform the lower bodylifting procedure in a first
stage, followed by the medial thigh-lifting procedure in a
second stage. Further details are discussed below.
Markings
Markings for circumferential lower body procedures vary
depending on individual morphology. Placing the resection
more superiorly allows more control over the excision of flank
rolls, provides moderate elevation force on the lateral thighs,
and accentuates the waist. This may be ideal in the female
patient wishing further waist definition, but may be less than
ideal for the male patient who does not wish for a feminized
silhouette.69 Buttock reshaping with autologous gluteal flaps
is more difficult with this higher positioning. Resections
placed more inferiorly allow greater elevation on the lateral
thigh tissues as compared with higher resections. Buttocks
reshaping is also easier. Waist definition may be enhanced in
this case by rectus plication and the addition of a vertical
abdominal skin resection. Choice of resection depends on
individual body type and surgical goals. The authors prefer
to keep the resection low (inferior) to prevent gluteal flatten-
ing, to add control to lateral thigh contour, and to keep the
final scar position reliably covered by most undergarments.
In the supine position, with the abdominal skin on stretch,
a distance of 6 cm is marked from the superior aspect of the
vulvar commissure in females or the base of the penis in
males. Posterior markings are made with the patient facing
away from the surgeon. The superior anchor line posteriorly
is determined in the midline and extended bilaterally to the
mid-axillary line. Vertical reference marks are spaced 6 cm
apart. Laterally, the amount of tissues to be resected is esti-
mated with a pinch test with the legs slightly abducted, and
marked accordingly. This creates the lateral margins of the
inferior resection line. The inferior resection line is then
drawn. A transition zone between the posterior and anterior
resections is marked, usually in the mid-axillary line. The
areas within the resection lines that are to be preserved for
autologous buttocks augmentation are marked.
With the patient facing the surgeon, and the patient holding
the abdominal skin on vertical stretch, the points marking the
lower lateral margin of resection bilaterally are gently con-
nected to the point 6 cm superior to the vulvar commissure
in the midline. This is the inferior margin of resection of the
abdominal contouring portion of the procedure. Areas of
adjunct liposuction are marked (Fig. 28.7).
Operative technique (Video 28.1 )
Although initially described as a three-position procedure by
Lockwood, the authors believe a two-position procedure
(prone, then supine) to be adequate.121–123 Routine Foley cath-
eter, warming blankets, and sequential compression devices
are used. Circumferential sterile prepping of the lower body
is performed. Beginning in the prone position, the gluteal
flaps to be preserved for buttock augmentation are de-
epithelialized. Next, the superior anchor line is incised and an
inferiorly based flap is created, avoiding the de-epithelialized
gluteal flaps. The inferior line is checked during the procedure
and adjusted to ensure reasonable closure, and the resection
is completed.
Laterally, the buttock flaps are undermined, and absorbable
sutures are used to shape the flaps for increased projection
Other complications include deep vein thrombosis, pulmo-
nary embolism, over- or under-resection. Relapse, with recur-
rence of tissue laxity is common and may require further skin
tightening procedures.
Lower bodylift/buttock contouring
Lower bodylift (belt lipectomy) is covered in Chapter 25.2 and
25.3. It is reviewed here with specific reference to the MWL
patient (Box 28.3).
Deformity/patient evaluation
In many MWL patients, abdominal contouring alone is
insufficient. Deflation of soft tissues in the lateral thighs
and buttocks may need surgical correction. Often deflated,
ptotic buttocks with loose skin and adiposity in the lateral
thigh accompany a hanging pannus. A number of procedures
address these deformities, including the belt lipectomy, lower
bodylift, and circumferential torsoplasty, which all achieve cir-
cumferential trunk contouring.80,116–118 The buttocks, abdomen,
and thighs must be treated as a single unit. Advancements
using the superficial fascial system (SFS) by Lockwood, as
well as autologous buttocks auto-augmentation with local
de-epithelialized gluteal flaps to restore buttock projection
and shape, have improved results.119–121
In addition to the patient evaluation described in the
abdominal section, assessment of the lateral thigh and but-
tocks region is essential. The quality, elasticity, and quantity
of skin in these areas are assessed, and the translation of pull
determined with a pinch test. The volume and location of fat
deposits is documented. Buttocks projection and volume in
the buttocks area is determined to aid in operative planning
and the need for auto-augmentation of the buttocks with local
flaps.
Patient selection
The ideal patient for a circumferential lower body contouring
procedure is a patient with an optimal BMI, a deflated skin–fat
envelope with descent of the buttocks and lateral thigh tissues,
who is in good health and has realistic expectations. The
patient must be counseled on the extent of scarring and
postoperative expectations.
Staging of procedures in the MWL patient is important. In
patients undergoing both lower body circumferential con-
touring procedures and medial thigh-lifting procedures, it is
advisable to stage the procedures. It is the preference of the
BOX 28.3  Lower bodylift
• In patients with excess skin and fat circumferentially, an isolated
abdominal procedure is not the ideal choice. A lower bodylift or
belt lipectomy will provide a more aesthetic result.
• Discontinuous undermining of the soft tissues of the lateral thigh
will aid in optimal tissue resection and tension.
• Meticulous repair of the superficial fascial system will support
the tension across the wound in a lower bodylift and help
prevent poor scarring.
• In many cases, flattening of the buttocks may occur without the
preservation of autologous fat.

721
Surgical techniques by anatomic region
A
B
C
D
Fig. 28.7  Lower bodylift markings.
Examples of two patients marked for
circumferential lower bodylift. On the
posterior views (A,D), the red hashed areas
indicate gluteal fat tissue that will be
preserved for buttock reshaping. Note the
difference in body types of these patients,
but both will benefit from preserving gluteal
fat. On lateral views (B,E), the extent of
lateral skin resection is noted. Anterior
views (C,F) demonstrate the low position of
the transverse scar. With the abdominal
tissues on upward stretch, the final
transverse scar position is demonstrated
(F). The second patient (D–F) is marked
for additional extensive debulking
liposuction, thus facilitating improved
results for the second-stage vertical medial
thigh-lift.
Continued
and gluteal augmentation. Inferior to the flaps, moderate
undermining is performed in order to accommodate the but-
tocks flap volume (Fig. 28.8). The lateral thigh region is mobi-
lized with the Lockwood discontinuous undermining device
(Byron Medical, Tucson, AZ) passed into the subcutaneous
tissue (Fig. 28.9). The legs are abducted to decrease lateral
tension, and towel clips are used to hold the wound together.
Closure is performed over drains. The lateral dog-ears are
temporarily stapled closed.
In the supine position, the procedure continues as a tradi-
tional abdominoplasty. Attention must be paid to flexion at
the waist as a high resection in the posterior body will lead to
greater tension on the back wound, allowing a less aggressive
anterior resection. Absorbable sutures placed in the lateral
aspect of the wound to coapt the SFS is essential. Drains are
placed in the abdominal wound, and closure in the usual
fashion is performed. Representative cases are shown in Figs.
28.10 and 28.11.

722
SECTION II
CHAPTER 28 • Post-bariatric reconstruction
Fig. 28.8  Lower bodylift gluteal reshaping technique. Preoperative markings for lower bodylift are shown. Hashed marks demonstrate areas for gluteal fat pad preservation
(A). De-epithelialization of the area of gluteal fat preservation is performed, preserving full-thickness flaps, while laterally excision is deeper. The fat pad is undermined
laterally for rotation. Inferiorly, subcutaneous pocket is created to accommodate volume (B,C). Rotation of the lateral portion of the flap inferiorly into the subcutaneous
pocket with suture to the deep fascia is shown (D). Enhanced buttock projection is achieved with dermal surface plication. Final operative result is shown (E).
A
B
C
D
E
E
F
Fig. 28.7, cont’d

723
Surgical techniques by anatomic region
Fig. 28.9  Lower bodylift. Intraoperative use of Lockwood undermining device of the
lateral thighs (A). Leg abduction over a sterile side table or additional arm boards
decreases tension off of lateral closure (B).
A
B
Fig. 28.10  Lower bodylift with debulking
liposuction. A 39-year-old woman after
45 kg weight loss (A). A first-stage lower
bodylift with 9 L debulking liposuction of
the thighs was followed by a second-stage
vertical medial thigh-lift 6 months following
initial procedure (B). Mid-back rolls were
corrected with a lateral chest excision
concurrent with a mastopexy at the second
stage.
A
B
Postoperative care
The patient is kept in the beach-chair position, with the waist
flexed. Perioperative antibiotics are administered. Mobiliza-
tion with assistance is encouraged on postoperative day 1,
and the Foley catheter is removed at this time. Chemopro-
phylaxis for venous thromboembolism and maintenance of
pneumatic compression devices continue. Hospitalization for
the immediate postoperative course is common and dura-
tion varies depending on the patient’s condition and the
number of concomitant procedures performed. In appropri-
ate candidates bodylifts may be performed on an outpatient
basis.124 Drains are removed when output is <30 cc in a 24-h
period.
Vertical thigh-lift
Deformity/patient evaluation
The thighs are a difficult area to treat in the MWL patient. No
single procedure can address changes in both the medial and
lateral thighs (Box 28.4). A lower bodylift (LBL) may contour
the lateral thighs, but leave the medial thighs minimally
affected, while a vertical medial thigh-lift may tighten the
inner thigh, leaving the lateral thigh untouched.
MWL produces characteristic changes in the medial thighs.
Inferior descent of the soft tissues, as well as significant defla-
tion, may occur. The skin–fat envelope of the thigh is less
tightly adherent medially than laterally, resulting in signifi-
cant soft-tissue descent in this area with MWL.125 Although
this gives the impression of vertical excess, it in fact is primar-
ily horizontal excess that needs to be addressed.

724
SECTION II
CHAPTER 28 • Post-bariatric reconstruction
Earlier methods of correcting the medial thigh region were
crescentic and aimed at placing the scar in the groin and peri-
neal crease. A vertical vector of pull towards the groin is
achieved and can treat minor medial thigh laxity, only treating
the upper third of the thigh.126,127 Due to frequent complica-
tions including scar widening, vulvar deformity, and recur-
rence of ptosis, a modification of the upper medial thigh-lift
involved anchoring the inner thigh to Colles’ fascia.128 Advan-
tages to this procedure include avoiding a medial longitudinal
scar, the ability to perform this in conjunction with a lower
bodylift, and decreased recovery and operative time as com-
pared with a vertical thigh-lift. However, laxity of the distal
third of the medial thigh is minimally improved with this
procedure. Many MWL patients with severe skin envelope
deflation require more powerful procedures.
Fig. 28.11  Lower bodylift without abdominoplasty. A 49-year-old woman after 36 kg weight loss. Patient had good skin tone and minimal skin excess of the abdomen and
the patient was marked for a lower bodylift without abdominoplasty. The red line is the proposed scar position, based on the distance the superior incision will move on
stretch. Anteriorly, the scars extend parallel to the groin crease (A–C). Postoperative views at 8 months show scar position well hidden in undergarment (D–F). Note the
anterior scars come very close to the mons to prevent them from descending onto the anterior thigh (G–I).
A
B
C
D
E
F
G
H
I
The aim of a vertical medial thigh-lift is to primarily correct
horizontal laxity with the resection of a vertical component,
focusing tension on the medial thigh as a cylinder. The thigh
may be thought of as two components, the firm and unyield-
ing inner core composed of bone and muscle and the outer
skin and soft-tissue envelope.125 The widest aspect of the thigh
is located 2–3 cm below the perineal crease. The only trans-
verse component of excision in a vertical thigh-lift is at the
superior aspect of the incision, used to remove the resultant
dog-ear in the proximal thigh. Depending on the distal extent
of skin laxity, the scar may be shortened or lengthened towards
the medial knee.
A history of lymphedema or significant varicosities is
important to document. Physical examination should include
the degree and distal extent of skin laxity and quality. A pinch

725
Surgical techniques by anatomic region
BOX 28.4  Thigh-lift
• The thigh must be conceptually divided into lateral and medial
areas. Procedures such as the lower bodylift and lateral thigh-lift
may affect the lateral thigh, but minimally tighten the medial
thigh tissues. Conversely, a medial thigh-lift will only affect
medial tissues, leaving the lateral tissues primarily unaffected.
• In a vertical thigh-lift procedure, the extent of resection distally
may be altered depending on the skin redundancy at the knee
as well as patient preference and acceptance of the length of
scar.
• In patients with minimally deflated thighs requesting thigh-lift,
further weight reduction may be necessary. Alternatively, staged
debulking procedures are required prior to excisional
procedures.
• The lymphatic structures of the leg are primarily concentrated
medially and deep to the plane of the saphenous vein until the
vessels begin to converge in the femoral triangle. Inadvertent
injury to the lymphatics during thigh-lift procedures may result in
lymphedema of the lower extremity.
test of the medial and lateral thighs will demonstrate the
amount of possible skin resection and translation of pull. The
amount of lipodystrophy and whether or not the thighs are
deflated should be documented. Any signs of lymphedema
should raise concern.
Discussion with the patient regarding his or her prefer-
ences in the areas to be contoured is imperative. This will
impact the order and staging of procedures. For example, if a
patient is to undergo a lower bodylift (to correct outer thighs)
and medial thigh-lift (to correct medial thighs), the lower
bodylift procedure is generally performed in the first stage,
followed by a second-stage medial thigh-lift.
Patient selection
Selection of surgical procedure is based on quality, quantity,
and extent of skin excess, the amount and position of adipos-
ity, surgeon and patient preference, and patient willingness to
accept scar in exchange for improved contour.
In patients with mild to moderate skin laxity localized to
the upper thigh with minimal adiposity, a crescentic trans-
versely based excision in the groin and perineal creases with
suspension to Colles’ fascia may provide vertical pull, while
keeping the scar hidden.
In patients with greater degrees of skin laxity in the
medial thigh and mild to moderate adiposity, a vertically
based excision of the medial thigh (vertical medial thigh-
lift) with a transverse component in the groin and perineal
creases may suffice. Adjunct liposuction may be used. The
distal extent of vertical resection may be altered and length-
ened to the level of the knee in more extreme cases of skin
excess.
In the MWL patient with residual thigh adiposity (non-
deflated) and skin excess, either further weight reduction is
recommended or an initial debulking liposuction procedure
of the medial thigh area is performed, followed by a second-
stage vertical medial thigh-lift.
Skin excess and adiposity in the lateral thighs does not
respond well to medial thigh-lifting alone. Procedures such as
a lower bodylift or lateral thigh-lift are required to address
these deformities, usually in a separate stage to the medial
thigh procedure.
Markings
With the patient in the supine position with legs abducted,
the line of incision in the groin crease is made beginning 4 cm
lateral to the midline of the mons. A pinch test estimates the
crescentic resection in the groin crease. Next, the vertical
resection marks are made. The proposed scar position is
marked. The thigh tissues are pulled posteriorly to simulate
the result of the thigh-lift of the anterior tissues. The anterior
anchor line is marked with this maneuver. The posterior mark
is made with a similar traction anteriorly. Reference lines are
placed every 6 cm perpendicular to the resection. Bilateral
thigh markings are compared for symmetry (Fig. 28.12).
If including any degree of horizontal skin resection adjacent
to the groin area, the degree to which any downward traction
is transmitted to the genital area in females is assessed. Labial
spreading with exposure of the labia minora postoperatively
may occur and care must be taken to minimize this risk.
Operative technique (Fig. 28.13)
The legs are prepped and draped circumferentially. Additional
arm boards are placed laterally to support the legs in abduc-
tion. Incision of the anterior line, followed by flap elevation
towards the posterior line, is performed. The saphenous vein
is identified and preserved. The posterior incision line is
checked for the ability to close, and dissection is carried out.
Resection of the horizontal component occurs in a superficial
plane to preserve lymphatics. The lymphatic drainage of the
leg is concentrated medially. Multi-layered closure over drains
followed by circumferential compressive wraps is performed.
A representative case is shown in Fig. 28.14.
An alternative approach to correcting the medial thigh area
has been described by Cram and Aly.125 Vertical resection is
also used in this technique, with the option of a transverse
perineal resection if necessary to correct the resultant dog-ear.
A similar resection is marked; however, the “double ellipse”
technique is used to avoid over-resection. The procedure
begins with aggressive suction lipectomy in the proposed area
of excision in order to completely defat the area. The ellipse
is tailor-tacked to simulate closure. Adjustments are made.
The resection is performed segmentally from distal to proxi-
mal and each section closed with staples temporarily prior to
advancing. This prevents excessive intraoperative edema
from forming and helps avoid the inability to close. Dog-ears
at the superior aspect of resection may be corrected with a
transverse excision in the perineal crease. Small to moderate
amounts of residual fullness distally may be ameliorated with
localized liposuction.
Postoperative care
Ambulation is encouraged the evening of surgery; the legs
remain elevated; 4 weeks in compressive stockings, including
the feet, aids in edema prevention. Drains are removed when
the output is <30 cc in a 24-h period.
Complications
Virtually all patients undergoing medial thigh-lifting proce-
dures develop varying degrees of temporary lower extremity

726
SECTION II
CHAPTER 28 • Post-bariatric reconstruction
Fig. 28.12  Vertical thigh-lift markings. Line of incision drawn in groin crease beginning 4 cm lateral to midline of mons (A). Pinch test estimates vertical component of
skin resection (B). Anterior line of resection drawn by placing posterior traction with left hand and marking along mid-thigh, demonstrating estimated scar position
(C). Posterior line of resection drawn by applying anterior traction with non-dominant hand and marking along mid-thigh (D). Transverse reference lines drawn for tissue
alignment during closure (E). Estimated margins of resection are checked (F).
A
B
C
D
E
F
edema. Compression garments and leg elevation may aid in
minimizing edema in the early period. In the majority of
cases, edema resolves within months. Disabling lymphedema
of the lower extremity is one of the most feared complications
that may occur following any thigh-lifting procedure. Careful
and superficial dissection in the femoral triangle may help
avoid lymphedema.
If including any horizontal resection of skin adjacent to the
groin, labial spreading is possible and is a leading cause of
medicolegal action in thigh-reduction procedures.125 More
common complications such as hematoma, seroma, poor scar-
ring, and asymmetries are also possible.
Contouring of the arms, breast, upper trunk,
and male chest in the MWL patient
Brachioplasty and axillary contouring; mastopexy and breast
reshaping; upper bodylift after weight loss; and gynecomastia
in the massive weight loss patient are covered in Chapter 27.
Staging and combination procedures
Unlike many patients presenting for correction of specific
areas, the post-bariatric patient often presents requesting a

727
Staging and combination procedures
G
H
A
B
C
D
Fig. 28.13  Vertical thigh-lift – surgical technique. The anterior lie of resection is incised and the flap undermined to the posterior estimated line of resection (A).
Identification and preservation of the saphenous vein (marked with vessel loops). The pane of dissection is superficial to the vein (B). Towel clips hold the flap while an
everted towel clip placed at the edge of the anterior incision line is used as a flap marker (C,D).
Distally, the resection crosses the knee in the midaxial position and curves under the patella (G). Symmetry is checked (H).
Fig. 28.12, cont’d
number of areas be treated. Careful preoperative consider-
ations need to be evaluated. Factors including medical status,
length of procedure, vectors of tension, surgeon experience,
operative assistance, and cost to the patient play a role.
There is a paucity of information regarding the safety and
complication rates in patients undergoing multiple concomi-
tant procedures. The MWL population differs significantly
from the non-weight loss population. A study by Coon et al.,
demonstrated that multiple procedures may be combined
safely in the body contouring patient.129 Aggregate minor
complication rates were higher than with single procedures,
and there was no significant increase on a per-procedure basis.
Although no consensus exists, many surgeons believe that
stages should be separated by a minimum of 3 months. A

728
SECTION II
CHAPTER 28 • Post-bariatric reconstruction
E
F
G
H
The flap is incised at intervals and secured with towel clips (E,F). The posterior line of resection is remarked between the towel clips and incised (G).
Braided nylon sutures approximate the superficial fascial system of the thigh to Colles’ fascia (H).
Fig. 28.13, cont’d
patient should be back to their preoperative health status
prior to a second stage. There is no strong data to suggest a
defined limit for operative time during each stage.130,131
When faced with a patient requesting multiple procedures,
the order in which they are carried out may vary from patient
to patient. Assessing an individual’s desires regarding the
areas of the body of priority is a must. Patient desires com-
bined with surgeon preference and the patient’s overall
medical condition will help decide the order of procedures.131
In general, if a lower bodylift and medial thigh-lift are con-
sidered, the circumferential truncal procedure should be done
in a first stage. This will set the foundation for following
procedures and may safely be combined with upper body
procedures such as breast surgery or brachioplasty. This is our
preference for the following reasons:
1. The LBL will have a more immediate impact on the
patient’s overall body shape and, therefore, body
image.
2. The LBL will relax over time allowing medial and
inferior rotation of the medial thigh tissues.
3. If LBL and medial thigh-lift procedures were performed
at the same time, patient recovery would be more
difficult, and may also be taxing on the surgical team.
If an upper bodylift procedure to treat back rolls and a
circumferential lower body procedure are to be undertaken,
the upper bodylift should be performed in a second stage
following the truncal procedure. If upper body and lower
body posterior contouring procedures are performed con-
comitantly, competing, opposing tensions may lead to banding
with less aesthetic contouring compared with when the pro-
cedures were staged. There is a description of a single-staged
total bodylift for complete torso correction. A combination of
lower bodylifts, upper bodylifts, and circumferential abdomi-
noplasty are performed concomitantly. Brachioplasty, breast
surgery, and liposuction are commonly done at this single
stage. While a complication rate of 76% was noted and mostly
related to wound healing issues,132 the authors considered
single-stage total bodylift to be a safe and effective technique
in selected patients if performed by a plastic surgeon and
team experienced in body contouring surgery.132,133
Complications/secondary procedures
The majority of complications from post-bariatric body con-
touring are wound related. Small areas of wound breakdown
or dehiscence, along with suture extrusion, are common
occurrences.
Seromas occur not infrequently.134 Serial aspiration is per-
formed with a large-gauge needle, usually on a weekly basis
until resolution occurs. In some instances, ultrasound-guided
drainage may be required. Techniques to avoid seromas in
the body contouring patient include sutures to secure the

729
Body contouring centers of excellence
Fig. 28.14  Vertical thigh-lift. A 52-year-old woman after 60 kg weight loss and prior abdominoplasty. (A) Preoperatively.
Postoperative views 1 year after revision abdominoplasty and vertical medial thigh-lift without having had a lower bodylift
(B–D).
A
B
C
D
undersurface of the flap to the deep tissues, the use of tissue
sealants (off-label use), and the use of multiple drains.135,136
Although variable between surgeons, removal of drains
generally occurs when drainage is <30 cc over a 24-h period.
However, some routinely remove drains at 2 weeks and rely
less on the amount of drainage. If the amount of drainage
continues to be substantial at 2–3 weeks postoperatively, the
injection of dilute doxycycline (100 mg in 5 cc of saline) into
the drain tubing may be used. Following injection, the drain
is left off-suction for 4 h. Suction is reapplied. Although
anecdotal, some report improvement in seroma formation
following this technique.137
BMI at the time of surgery may impact complication rates.78
Three or more procedures in a single stage may increase the
risk of blood transfusion and increase the length of postopera-
tive hospital stay.138 The risk of complications is not signifi-
cantly different following bariatric surgery as compared with
massive dietetic weight reduction.139 Recurrence of varying
amounts of skin laxity may also occur, sometimes requiring
secondary procedures (mostly involving further skin tighten-
ing). In many cases, relapse or skin loosening is expected,75
and patients are advised of the possible need for secondary
procedures to address this finding.
Body contouring centers of excellence
Like their bariatric surgery counterparts, plastic surgeons are
realizing that an organized center of excellence that is dedi-
cated to body contouring can have multiple benefits.140 Fol-
lowing MWL, specialized resources are necessary for some in
order to further or maintain their goals. Dedicated, multidis-
ciplinary centers may improve the safety and efficacy of
weight loss surgery and post-bariatric reconstruction.55,141
Patients benefit from on-site nutritional assessments at the
initial consultation. Standardized screening is facile, and
evaluation by all team members occurs. The idea of a team
approach allows the plastic surgeon to perform more proce-
dures in a single stage, as operative time is significantly
decreased. Research and innovation may flourish associated
with a center of excellence, as databases and quality assurance
measures can be used.62

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14. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have
thought it? An operation proves to be the most effective therapy
for adult-onset diabetes mellitus. Ann Surg. 1995;222:339–352.
45. Anon. A review of bariatric surgery procedures. Plast Reconstr
Surg. 2006;117(1 suppl):8S–13S.
70. Aly AS. Belt lipectomy. In: Aly AS, ed. Body Contouring After
Massive Weight Loss. St. Louis, MO: Quality Medical Publishing;
2006:71–145. The authors describe their experience with circumferential
belt lipectomy. Technical aspects and review of results is discussed. This
procedure should be considered for any patients with circumferential
truncal excess who are well informed about the possible risks of the
procedure.
71. Bossert RP, Rubin JP. Evaluation of the weight loss patient
presenting for plastic surgery consultation. Plast Reconstr Surg.
2012;130:1361–1369.
74. Krueger JK, Rohrich RJ. Clearing the smoke: the scientific rationale
for tobacco abstention with plastic surgery. Plast Reconstr Surg.
2001;108:1063–1077.
78. Coon D, Gusenoff JA, Kannan N, et al. Body mass and surgical
complications in the postbariatric reconstructive patient: analysis
of 511 cases. Ann Surg. 2009;249:397–401.
91. Davison SP, Venturi ML, Attinger CE, et al. Prevention of venous
thromboembolism in the plastic surgery patient. Plast Reconstr
Surg. 2004;114:43E–51E. Review of current guidelines and procedures
used to decrease the risk of venous thromboembolism specifically
regarding the plastic surgery patient.
116. Lockwood T. Lower bodylift with superficial fascial system
suspension. Plast Reconstr Surg. 1993;92:1112–1125. The author
presents his experience with patients undergoing lower bodylift alone or
in conjunction with other body contouring procedures. Key technical
elements regarding lower bodylift are highlighted and results are
reviewed.
125. Cram A, Aly A. Thigh reduction in the massive weight loss
patient. Clin Plast Surg. 2008;35:165–172. A review of the authors’
technique and experience with vertical medial thigh-lifts in the massive
weight loss patient.
129. Coon D, Michaels J 5th, Gusenoff JA, et al. Multiple procedures
and staging in the massive weight loss population. Plast Reconstr
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730.e1
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730.e2
SECTION II
CHAPTER 28 • Post-bariatric reconstruction
48. Dargent J. Laparoscopic adjustable gastric banding: lessons from
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64. Bloomberg RD, Fleishman A, Nalle JE, et al. Nutritional
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68. Parkes E. Nutritional management of patients after bariatric
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69. Aly AS. Options in lower truncal surgery. In: Aly AS, ed. Body
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70. Aly AS. Belt lipectomy. In: Aly AS, ed. Body Contouring After
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belt lipectomy. Technical aspects and review of results is discussed. This
procedure should be considered for any patients with circumferential
truncal excess who are well informed about the possible risks of the
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71. Bossert RP, Rubin JP. Evaluation of the weight loss patient
presenting for plastic surgery consultation. Plast Reconstr Surg.
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72. Manassa EH, Hertl CH, Olbrisch RR. Wound healing problems in
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73. Gravante G, Araco A, Sorge R, et al. Wound infections in post-
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75. Anon. Informed consent for body contouring procedures in the
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76. Matory WE Jr, O’Sullivan J, Fudem G, et al. Abdominal surgery in
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78. Coon D, Gusenoff JA, Kannan N, et al. Body mass and surgical
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79. Constantine RS, Davis KE, Kenkel JM. The effect of massive
weight loss status, amount of weight loss, and method of
weight loss on body contouring outcomes. Aesthet Surg J. 2014;34:
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80. Aly AS, Cram AE, Chao M, et al. Belt lipectomy for circumferential
truncal excess: the University of Iowa experience. Plast Reconstr
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81. Nemerofsky RB, Oliak DA, Capella JF. Bodylift: an account of 200
consecutive cases in the massive weight loss patient. Plast Reconstr
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82. Shermak MA, Chang DC, Heller J. Factors impacting
thromboembolism after bariatric body contouring surgery. Plast
Reconstr Surg. 2007;119:1590–1598.
83. Arthurs ZM, Cuadrado D, Sohn V, et al. Post-bariatric
panniculectomy: pre-panniculectomy body mass index impacts the
complication profile. Am J Surg. 2007;193:567–570.
84. Friedrich JB, Petrov RV, Askay SA, et al. Resection of panniculus
morbidus: a salvage procedure with a steep learning curve. Plast
Reconstr Surg. 2008;121:108–114.
85. Kalarchian MA, Marcus MD, Levine MD, et al. Psychiatric
disorders among bariatric surgery candidates: relationship to
obesity and functional health status. Am J Psychiatry. 2007;164:328–
334, 374.
86. Rosenberger PH, Henderson KE, Grilo CM. Psychiatric disorder
comorbidity and association with eating disorders in bariatric
surgery patients: A cross-sectional study using structured
interview-based diagnosis. J Clin Psychiatry. 2006;67:
1080–1085.
87. Song A, Fernstrom MH. Nutritional and psychological
considerations after bariatric surgery. Aesthet Surg J. 2008;28:
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88. Song AY, Rubin JP, Thomas V, et al. Body image and quality of life
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89. Colwell AS, Borud LJ. Optimization of patient safety in
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90. Venturi ML, Davison SP, Caprini JA. Prevention of venous
thromboembolism in the plastic surgery patient: current guidelines
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91. Pannucci CJ, MacDonald JK, Ariyan S, et al. Benefits and risks of
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92. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous
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SECTION II • General Aesthetic Surgery
29 
Energy-based devices in body contouring
Paul N. Afrooz, Jason Posner, and Barry DiBernardo
SYNOPSIS
■ Modern patients demand reduced downtime and better results from
elective surgical interventions. This has led to technological
improvements and developments that allow us to do safer, less
invasive procedures.
■ In the future we will need to better stratify body contouring patients
into those requiring major invasive procedures, those requiring
minimally invasive liposuction techniques with adjunctive energy-
delivering modalities or mesotherapy, and those seeking non-invasive
techniques for volume reduction and skin tightening through additional
energy-delivering modalities.
■ Currently, patients considered the best candidates for these latter
approaches are those who are willing to accept a mild to moderate
result.
Access the Historical Perspective section online at

Introduction
There are several inherent drawbacks to surgical body con-
touring procedures. Hospitalization, anesthetic use, pain,
swelling, and a prolonged recovery are a few of the reasons
that body contouring through non-invasive means has become
so popular and attractive. Patient expectations as well as
technological advances have led to safer, less invasive proce-
dures with less discomfort, fewer side effects, and minimal
downtime.
Energy modalities in liposuction
The tumescent technique in liposuction has optimized the
outcomes and safety profile of liposuction procedures and is
considered the gold standard in body contouring procedures.7–12
Additional refinement such as the development of cannulas
specific to body sites and the use of manual syringe suction
for fat grafting and fine contouring have led to further
improvement of liposuction techniques. Furthermore, out-
comes have been optimized.9 The introduction of energy-
based modalities such as laser-assisted liposuction (LAL) and
ultrasound-assisted liposuction (UAL) are useful adjuncts,
reducing surgery time, operator fatigue, patient recovery
time, and postoperative pain.7–9,12
Laser-assisted liposuction
Laser-assisted liposuction delivers energy to tissues by way
of a small fiber (300–1000 µm) delivered through a narrow
cannula that has a diameter of approximately 1 mm. Laser
energy is delivered subcutaneously rather than transcutane-
ously. Simultaneous cooling mechanisms protect the surface
from intense heat. This causes skin tightening, which is safe
and which is the primary benefit of LAL. LAL has also been
used and found to be effective in treating scaring, dimpling,
and cellulite in the superficial layers. The small cannula used
reduces the potential risk of contour irregularities with larger
cannulas. This equipment, however, is expensive. Further-
more, temperature monitoring is vital, as without it the
potential for burns or blisters is significant. With advances in
LAL technology, additional wavelengths have been proven to
be 40 times more efficient in fat disruption while maintaining
a similar cannula size.
Preoperative preparation
The ideal patient for LAL is one in which fat reduction as well
as correction of skin laxity are needed. Standard markings are
used, but in addition, 5 × 5 cm squares are marked represent-
ing the targets for energy application for the treatment of skin
laxity. Approximately 50–100 ml of tumescent fluid is infil-
trated per 5 × 5 cm2 section (Fig. 29.1). Anesthesia is the choice
of the individual practitioner; however, this can be done with
any or a combination of local anesthesia, sedation, or general
anesthesia.7,13

731.e1
Historical perspective
Historical perspective
Two Italian gynecologists, Arpad and Giorgio Fischer, created
a blunt tunneling method for the removal of fat.1 However,
liposuction was popularized by the French surgeon Dr. Yves-
Gerard Illouz in 1982.2
The “Illouz method” featured a technique of suction-
assisted lipolysis after tumesing or infusing fluid into tissues
using blunt cannulas and high-vacuum suction and demon-
strated both reproducible good results and low morbidity.
Pierre Fournier, another French surgeon, used lidocaine as
local anesthetic, modified the incision technique, and began
to use compression after the operation.3 Liposuction began in
the United States in the mid to late 1980s and was frequently
done under sedation rather than general anesthesia. Concerns
over the high volume of fluid and potential toxicity of lido-
caine with tumescent techniques eventually led to the concept
of lower-volume “super wet” tumescence.
The Italians were the first to experiment with using ultra-
sound to emulsify fat.4 Ultrasonic energy was initially applied
to the field of body contouring surgery in the late 1980s by
Scuderi.5 It was later popularized by Zocchi, who introduced
the technique to the United States in 1993.6

732
SECTION II
CHAPTER 29 • Energy-based devices in body contouring
0.2 s. With this safety feature, the excess accumulation of
energy in a given area is prevented.7 The tip of the cannula
contains a thermostore probe. The probe is set for the appro-
priate range according to parameters discussed above. If the
safe range is exceeded, the laser automatically stops firing.13
A two-layer technique is used such that the deep and
superficial layers are treated separately. The deep fat layers
(1–3 cm below the epidermis) within the premarked squares
are treated first (see Fig. 29.2). A No.11 blade is used to make
stab incisions for insertion of the microcannula. In the second
step, the superficial subdermal layer (0.5 cm below the epi-
dermis) is treated (Fig. 29.3). A standard 3-mm suction cannula
Patients must understand that the skin-tightening effect
depends on several factors including age, genetics, and the
underlying skin condition. The confounding effects of envi-
ronmental factors such as smoking and sun exposure must be
factored in and explained, and, above all, patient expectations
must be realistic.
Surgical technique
The laser system (Triplex, Cynosure, Westford, MA) allows
individual as well as sequential emission of energy at 1064 nm,
1320 nm, and 1440 nm wavelengths. As already mentioned
above, energy is delivered through a fine fiber threaded
through a 1-mm cannula. The fiber extends 2–3 mm beyond
the distal end of the microcannula. The laser is activated when
the microcannula is inserted into the tissue. The microcannula
is moved slowly and evenly through the deep fat layer with
a combination of 1064–1440 nm wavelengths or through the
superficial subdermal layer with a 1064–1320 nm combination
(Fig. 29.2). Wavelength combinations are used for ideal
absorption and performance and for the preferential target
affinity of fat and water.
With a biplanar technique, fat is disrupted and emulsified
into a liquefied material that can be removed with a smaller
cannula. The subsequent ease of removal, particularly close
to the surface, reduces the potential contour irregularity that
can be seen with larger instrumentation. Surface temperature
goals of 40–42°C superficially and 45–47°C in the deep plane
(and even less in darker skin colors) are delineated to achieve
increased skin elasticity and tightening, and, as mentioned
already, it is vital to monitor temperature and maintain these
ranges throughout the procedure to avoid damage to the skin.
An accelerometer delivery system (Smart Sense, Cynosure)
is attached to the laser hand piece. This hand piece minimizes
the occurrence of localized thermal damage during treatment.
The hand piece contains a motion-sensing feedback chip that
constantly monitors cannula motion and relays this informa-
tion to the laser device so that laser power waxes and wanes
with the speed of cannula advancement, being reduced on
slow movement and increased during more rapid movement.
Whenever the hand piece stops, energy delivery stops within
Fig. 29.1  Application of tumescent fluid 50–100 mL per sector. (Reproduced from
Afrooz PN, Pozner JN, DiBernardo BE. Clinics in Plastic Surgery, 2014-10-01,
Volume 41, Issue 4, Pages 789–804, Copyright © 2014 Elsevier Inc.)
Fig. 29.2  Diagrammatic representation of placement of deep laser energy for
adipocyte and fibrous disruption. (Reproduced from Afrooz PN, Pozner JN,
DiBernardo BE. Clinics in Plastic Surgery, 2014-10-01, Volume 41, Issue 4, Pages
789–804, Copyright © 2014 Elsevier Inc.)
Epidermis
Dermis
Subcutaneous tissue
Fig. 29.3  Superficial laser application just under the dermis, with visualization of
helium neon guiding beam. (Reproduced from Afrooz PN, Pozner JN, DiBernardo
BE. Clinics in Plastic Surgery, 2014-10-01, Volume 41, Issue 4, Pages 789–804,
Copyright © 2014 Elsevier Inc.)

733
Energy modalities in liposuction
Conclusion
The safety and efficacy of LAL has progressed, thereby
enhancing the cosmetic results. By minimizing blood loss, and
through the skin-tightening effect, LAL has proven to be a safe
and effective body contouring procedure in appropriate
candidates. Further applications of fiber-deliverable energy
modalities will aim to address the superficial contour irregu-
larities of the skin such as dimpling, scars, and cellulite.7,13,15
Ultrasound-assisted liposuction
The introduction of ultrasound to the field of body contouring
surgery occurred in the late 1980s and was introduced to the
is used to aspirate the remaining fat, disrupted cells, and free
fat oils.13 Clinical examples are shown in Figures 29.4–29.6.
Optimal use of LAL depends largely on maintenance of an
adequate safety margin, which is in turn dependent on a
sufficient and controllable delivery of energy. Insufficient
temperature control during the procedure may lead not only
to skin injury or fat necrosis in situations of excess heat but
also to suboptimal skin tightening when there is insufficient
heat. Excessive heat applied superficially may result in skin
blistering, burns, or pigmentation changes. The built-in safety
mechanisms help control temperature and avoid harmful
accumulation of heat.13
Postoperative care
Pressure dressings are applied once aspiration is complete.
Compression garments are worn for 3–4 weeks postopera-
tively. Dependent incisions are left open for drainage, and oral
antibiotics are administered.7,13,14
Patients are examined 1 week postoperatively, and skin
and tissue are assessed for firmness. If excessive swelling or
dense edema is present, the areas are treated with the Triactive
Device (Cynosure Inc., Westford, MA) or an equivalent
massage, edema reduction, and lymphatic drainage enhance-
ment for 3 weeks postoperatively. The time necessary for skin
changes to occur during the dynamic fibroblast-stimulation
period is approximately 90 days, and patients are reminded
of this in the postoperative period. If, after 3 months, further
skin enhancement is desired, external devices can be applied,
and additional treatments in adjacent areas can be performed
after tissue effects have subsided.13
Complications and management
Complications of LAL may include blisters, end hits, burns,
blowholes, prolonged edema, neurapraxia, permanent nerve
damage, contour irregularities, asymmetries, and undercor-
rection.7,14 These complications are minimized with careful
attention to detail and meticulous technique.
Fig. 29.4  Clinical example of back rolls treated with
laser-assisted liposuction. Preoperative (A) and 3
months postoperative (B). (Reproduced from Afrooz
PN, Pozner JN, DiBernardo BE. Clinics in Plastic
Surgery, 2014-10-01, Volume 41, Issue 4, Pages
789–804, Copyright © 2014 Elsevier Inc.)
A
B
Fig. 29.5  Clinical example of brachial fat removal and skin tightening from laser.
Preoperative (A) and 3 months postoperative (B). (Reproduced from Afrooz PN,
Pozner JN, DiBernardo BE. Clinics in Plastic Surgery, 2014-10-01, Volume 41,
Issue 4, Pages 789–804, Copyright © 2014 Elsevier Inc.)
A
B

734
SECTION II
CHAPTER 29 • Energy-based devices in body contouring
respect to collagen structure and septi among the fat cells, as
described by de Souza Pinto.22 In order to achieve the best
outcome, knowledge of these differences is essential.
Tissue penetration is influenced by the diameter of the
probe, as well as the number of grooves at the tip of the probe. A
probe of a given diameter with more grooves will emulsify fat
tissue more efficiently than one with fewer grooves. However,
a probe with more grooves will not penetrate fibrous tissues
as easily due to vibratory energy that is dispersed to the
sides of the probe as opposed to the front surface. In general,
fibrous tissues are better addressed with probes with fewer
grooves as the energy is more concentrated. Furthermore,
when addressing fibrous tissue, smaller-diameter probes pen-
etrate the tissue more easily. The 3.7-mm probes can achieve
efficient debulking and contouring of medium to large
volumes of soft to fibrous tissues. The number of grooves at
the tip of the probe should correspond to the fibrous nature
of the tissue. Fine contouring of smaller, soft to extremely
fibrous localized fat deposits is achieved with 2.9-mm
probes.22
As a general rule, continuous mode is frequently used for
fibrous tissue, faster fragmentation, and, in instances where
tissue emulsification is not readily achieved, in VASER mode.
VASER mode is typically suited for finer, more delicate sculpt-
ing or softer tissues. Smooth movement of the probe through
tissues is ideal, and settings must be adjusted in order to
achieve this end.22
Application times have been delineated through practice
and experience. Generally, 1 min of application time in VASER
or continuous mode can be applied for every 100 mL of
infused wetting solution. The surgical endpoint is loss of
resistance to probe movement in all intended areas. Aspira-
tion can then be performed with suction-assisted or power-
assisted liposuction.22
Surgical technique
General endotracheal anesthesia is preferable, particularly if
prone positioning is required, as well as for large-volume
US in 1993. In 2001, the third-generation VASER system
(Sound Surgical Technologies, Louisville, CO) was introduced,
and it is currently the most commonly used ultrasound-
assisted liposuction (UAL) technology.16–18
There are three basic mechanisms by which ultrasound
interacts with tissue: thermal, mechanical, and cavita-
tion.13,16,19–22 The thermal effect is produced by heat generated
from the rapidly vibrating ultrasonic probe.23 The mechanical
effect is created when the rapidly vibrating tip of the ultra-
sonic probe contacts tissue.24 Cavitation is the tissue interac-
tion largely responsible for the fat emulsification that occurs
with current UAL devices. Following dispersion of the wetting
solution, microbubbles are lodged within the fat tissue matrix.
With the application of ultrasound, these microbubbles
implode and collapse. Fat cells are then separated within the
fat tissue matrix, which then mix vigorously with the tumes-
cent solution by acoustic streaming to create an emulsion.
This emulsion is subsequently aspirated with a suction
cannula.13,16,20–22
Preoperative preparation
Preoperative markings are made with the patient in the stand-
ing position. As in traditional liposuction, there are five distinct
anatomical zones that should be avoided in UAL. These areas
are the “zones of adherence” and include the gluteal crease,
the lower lateral thigh area of the iliotibial tract, the posterior
distal thigh above the popliteal crease, mid-medial thigh area,
and the area of the lateral gluteal depression. Contour defor-
mities frequently result following attempts to treat these
areas. Careful planning of skin incisions is important prior to
the procedure because UAL requires a greater number of
slightly longer access incisions to accommodate the skin
protectors. Furthermore, carefully planned incisions avoid
torque on the ultrasonic probe, particularly over curved
anatomical areas.16
The characteristics of localized fat in the area to be treated
must be considered when selecting the appropriate VASER
probe. Fat cells differ in various regions of the body with
Fig. 29.6  (A,B) Clinical example of neck treatment
with laser-assisted liposuction in a 48-year-old patient,
3 months postoperative. Note slight muscle bands are
evident. (Reproduced from Afrooz PN, Pozner JN,
DiBernardo BE. Clinics in Plastic Surgery, 2014-10-
01, Volume 41, Issue 4, Pages 789–804, Copyright
© 2014 Elsevier Inc.)
A
B

735
Energy modalities in liposuction
Gynecomastia
■ 3.7-mm one-ring probe or the gynecomastia arrow probe
are used in this area
■ Energy levels are 80–90% continuous mode for
approximately 3–4 min per breast
■ Aspiration with a small-diameter cannula.
Face and neck
■ Three incisions are recommended: one directly posterior
to each earlobe, and one in the submental crease
■ Small-diameter, highly precise instruments are used for
facial UAL
■ Ultrasound application with a 2.4-mm three-ring
ultrasonic probe at 50–60% energy levels in VASER mode
for 2–3 min
■ Aspiration with a fine cannula.
HIV-associated cervicodorsal lipodystrophy
■ 3.7-mm one- or two-ring probe, depending on the fibrous
nature of the area
■ The energy setting is 80% continuous mode, and time
varies according to the volume of fat being treated
■ Aspiration with a fine cannula.
Optimizing outcomes
■ Apply the smallest amount of ultrasound energy
necessary to achieve fat emulsification.
■ The desired endpoint of ultrasound application is loss of
tissue resistance against the probe.
■ Plan incision placement carefully to facilitate access to the
treatment area while avoiding torque on the ultrasonic
probe.
■ Small-diameter cannulas provide the greatest accuracy,
particularly for superficial fat.
■ Wetting solution should be used liberally and dispersed
evenly through the fat to maximize efficiency of
ultrasonic cavitation, minimize blood loss, and provide
added protection against thermal effects of UAL.
■ Circumferential contouring yields a more uniform result
than local fat extraction.
■ Postoperative foam compression garments, lymphatic
drainage massage, and skin-moisturizing regimens
contribute to optimal UAL outcomes and decrease
recovery times.
Postoperative care
After large-volume UAL procedures, fluid replacement and
monitoring of urine output is essential. Most patients with
large-volume aspirations leak fluid through the incisions for
24–36 h postoperatively. A significant volume of the wetting
solution is absorbed during the first 12 h after major UAL,
and this must be taken into account during fluid replace-
ment. Early ambulation is encouraged, and patients are
routinely discharged on the first postoperative day. Foam
and compression garments are routinely applied to most
UAL patients. Lymphatic drainage and skin-moisturizing
regimens are helpful adjuncts to healing as soon as they are
tolerated.16
aspirations. The back, flanks, lateral thighs, and superior
posterior thighs are easily accessed in the prone position.
Many surgeons also prefer the lateral decubitus position.
Despite the fact that additional repositioning is required,
some surgeons maintain that the lateral decubitus position
offers better access and facilitates large-volume evacuations
from the flanks and back in order to achieve more aesthetic
waistlines. To access the abdomen, anterior and medial thighs,
knees, calves, arms, ankles, breasts, and face, the supine posi-
tion is used.16
Core body temperature maintenance is essential and is
accomplished infusing warmed intravenous (IV) fluids as
well as the use of forced warm air with a Bair Hugger (Arizent
Inc., Eden Prairie, MN). The access incisions are placed using
a No.11 blade and must accommodate the fluid-infiltrating
cannula. In general, the wetting solution is prepared with
1 mL of epinephrine added to a 1 L bag of Ringer’s lactate at
room temperature (1 : 1, 000, 000 dilution).16 Lidocaine may be
added to the wetting solution for an additional local anesthetic
effect. Lidocaine dosing should typically not exceed 35 mg/
kg, although some authors routinely use doses exceeding
50 mg/kg while maintaining a safety margin.25
Recommended treatment protocols16
Abdomen
■ 3.7-mm three-ring ultrasonic probe used at an energy
setting of 80% in VASER mode
■ Continuous mode for the area above the costal margin
■ Average ultrasound time is 8–9 min
■ Aspiration with a small-diameter cannula.
Posterior trunk
■ 3.7-mm two-ring probe at 80% energy level, continuous
mode for the majority of the back
■ 3.7-mm one-ring probe at 80% energy level, continuous
mode for fibrous back rolls
■ Posterior trunk areas require longer ultrasound
application, between 12–14 min on average
■ Aspiration with a small-diameter cannula.
Extremities and buttocks
■ 3.7-mm three-ring ultrasonic probe at 70% VASER mode
for the superior medial thigh
■ Around the knees and superior posterior thigh, a short
3-mm three-ring probe is used in 80% VASER mode
■ The anterior and lateral thigh areas are also performed
with the 3.7-mm three-ring probe in 80% VASER or
continuous mode, depending on how fibrous the
subcutaneous layer is
■ Average ultrasound time: approximately 3 min for both
knees, 5 min for both superior medial thighs, 8 min for
both anterior thighs, 6–7 min for both lateral thighs, and
4 min for both superior posterior thighs
■ For the axillary area: a 3-mm three-ring probe is inserted
into the subcutaneous space through a small access
incision in the axillary fold
■ Energy setting is 70% VASER mode, applied for
approximately 2 min per arm
■ Aspiration with a small-diameter cannula.

736
SECTION II
CHAPTER 29 • Energy-based devices in body contouring
Technique
The treatment regimen is selected from the machine’s console.
Some treatment regimens include a brief massage session,
which enhances the selective injury to adipocytes.
Once the applicator is properly placed and the patient is
positioned, the cooling cycle begins. Vacuum suction is used
to draw the tissue into the applicator for optimal cooling.13
Optimizing outcomes
Proper patient selection for cryolipolysis is essential to achiev-
ing successful outcomes and patient satisfaction. Ideal candi-
dates should be at or near their ideal body weight with good
skin tone, minimal skin laxity, and distinct pockets of fat that
are resistant to diet and exercise.13
With each treatment, a 20% reduction in the thickness of
the fat layer is typically achieved (Figs. 29.9 & 29.10).30 Though
results are typically appreciable with a single procedure,
multiple treatments may be recommended to achieve the
aesthetic goals. Results may be observed as early as 3 weeks
Complications and management
The most common complications of liposuction are under-
extraction, over-extraction, and contour irregularities. These
complications can be mitigated by the use of intraoperative
flow sheets documenting infusion and aspiration volumes for
each anatomical area. Under-extraction is usually corrected by
secondary extraction, while over-extraction may require
autologous fat grafting. Paresthesias, edema, and ecchymosis
are not uncommon and are usually self-limiting. The vibrating
ultrasonic probe generates heat, which may cause a thermal
injury, particularly around the incision site. Therefore, the use
of skin protectors is essential, in addition to a wet towel
adjacent to the incision for added protection. The avoidance
of torque on the probes is the most important factor for avoid-
ing thermal injury at the entry site.16,26
Seromas are usually the result of too much application of
ultrasonic energy, either as a result of increased generator
settings or prolonged application.16,26 It is seldom necessary to
use energy settings above 80% applied for 1–1.5 min for every
100 mL of wetting solution to an area.16
Non-invasive modalities
Cryolipolysis
Cryolipolysis is a non-invasive technology utilizing precisely
controlled cooling to selectively target and eliminate adipo-
cytes without damaging surrounding tissues.13,27 Cryolipolysis
is performed with the Zeltiq Breeze system as part of Cool­
Sculpting (Zeltiq Aesthetics, Pleasanton, CA).
While the mechanism of cryolipolysis is not fully under-
stood, evidence suggests that an inflammatory reaction is
triggered within the adipose tissue in response to cold expo-
sure.28 Adipocytes are unique in their response to cooling in
comparison to other cell types. Precisely controlled cooling
causes lipid crystallization and triggers apoptosis in adipo-
cytes. However, in non-lipid storing cells, lipids are left
undamaged. The lipids released from apoptotic fat cells are
slowly evacuated through the lymphatic system, thereby
reducing tissue volume.27,29
Pre-procedure preparation
Proper evaluation is performed with the patient in the stand-
ing position such that local adiposity is subject to gravity. An
assessment of the amount of fat that will be drawn into the
applicator opening is done by mimicking the applicator
opening using a C-shaped cup technique (Fig. 29.7). For
optimal results, a minimum of 2.5 cm of fat should be drawn
into the cup.13
Before the treatment, the center point of each bulge should
be marked with an “X” using the templates provided by
Zeltiq. If a large section is being treated, multiple marks may
be required. These marks are placed such that there is slight
overlap of the applicator when treating adjacent marked
areas.13
A gel pad provides thermal contact between the patient’s
skin and the applicator and should be centered over the treat-
ment site. The applicator is positioned directly on the gel pad
over the “X”. The gel pad should extend beyond the edges of
the panels in the applicator cup (Fig. 29.8).13
Fig. 29.7  Assessing a patient’s fat using a C-shaped cup technique. (Reproduced
from Afrooz PN, Pozner JN, DiBernardo BE. Clinics in Plastic Surgery, 2014-10-01,
Volume 41, Issue 4, Pages 789–804, Copyright © 2014 Elsevier Inc.)
Fig. 29.8  Proper placement of the gel pad and applicator on a patient.
(Reproduced from Afrooz PN, Pozner JN, DiBernardo BE. Clinics in Plastic Surgery,
2014-10-01, Volume 41, Issue 4, Pages 789–804, Copyright © 2014 Elsevier Inc.)

737
Non-invasive modalities
Conclusion
Cryolipolysis is a safe and effective option for appropriate
candidates desiring a non-invasive procedure. It is ideally
suited for distinct areas of adiposity such as fat in bulges, rolls,
or other small areas that are resistant to diet and exercise.
While local fat deposits can be reduced, cryolipolysis does not
have a tightening effect within the skin or deeper layers.
High-intensity focused ultrasound
High-intensity focused ultrasound (HIFU) devices UltraShape
(Syneron Inc., Irvine, CA) and Liposonix (Solta Medical,
Hayward, CA) are technologies that result in adipocyte death
leading to non-invasive volume reduction and body contour-
ing. These devices differ in the frequency of the ultrasound
waves used to target fat. The UltraShape device operates at
following treatment, but final results are appreciable at 2–4
months post-treatment.13
Post-procedure care
The treatment areas may feel cold and firm with a red and
raised appearance following the procedure. These effects are
temporary and typically resolve within a few minutes to
hours. Other effects include bruising, soreness, tenderness,
cramping, and tingling, but these effects usually resolve
within a few days to weeks.
Complications and management
On rare occasions, some patients may experience significant
pain following treatment. This is usually self-limiting and
often resolves within weeks.
Fig. 29.9  Before (A) and 2 months after
(B) CoolSculpting, front view. (Reproduced from
Afrooz PN, Pozner JN, DiBernardo BE. Clinics in Plastic
Surgery, 2014-10-01, Volume 41, Issue 4, Pages
789–804, Copyright © 2014 Elsevier Inc.)
A
B
Fig. 29.10  Before (A) and 2 months after
(B) CoolSculpting, profile view. (Reproduced from
Afrooz PN, Pozner JN, DiBernardo BE. Clinics in Plastic
Surgery, 2014-10-01, Volume 41, Issue 4, Pages
789–804, Copyright © 2014 Elsevier Inc.)
A
B