Reoperative Aesthetic & Reconstructive Plastic Surgery

1676
PART V
R EOPERATIVE SURGERY OF THE TRUNK
This 54-year-old patient had sagging buttocks after excessive liposuction. A deep
gluteal fold combined with skin accidity and lateral femoral fat deposits also con-
tributed to the body contour distortions. A semicircular Pitanguy technique was
performed.
Despite the improvement in contour, the scar is quite evident. The skin does ac-
quire improved turgor with this procedure, making this surgery acceptable for cer-
tain cases.
Surgical augmentation of the buttocks became an acceptable procedure after 1984,
when Robles introduced a technique whereby a silicone implant is placed into a
pocket between the muscular plane of the hip and the gluteus maximus muscle.9

With this procedure access is gained through a 9 cm incision placed vertically along
the intergluteal sulcus 3 cm above the anus. The dissection goes deep to the
aponeurotic plane and then bilaterally above the gluteus maximus fascia.The glu-
teus maximus muscle is opened along its fibers, and the dissection transects the
muscle to the subgluteal space where the pocket for the implant is prepared. No
dissection should be performed below the cutaneous projection of the piriformis
muscle, where the sciatic nerve and the vessels for the lower limbs merge. No mus-
cular opening at the lateral portion of the gluteus maximus muscle should exist.The
prosthesis must be placed completely beneath the gluteus maximus muscle and
above the gluteus medius muscle and all of the other deep muscles.The musculo-
cutaneous tissue above the implant maintains the prosthesis in position with a low
incidence of capsular contracture.
Despite the superior results that can be achieved, occasional problems may occur if
the prosthesis is not inserted exactly into the submuscular pocket. In addition, if a
muscular opening exists in the dissected limits, malpositioning can occur and dis-
tortions and asymmetries can become evident.
1677
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
Midpoint
between
coccyx and
posterior
superior
iliac spine
Coccyx
9 cm incision
3 cm above anus
Piriformis muscle
Sciatic nerve
Vessels to
lower extremities
Pocket below gluteus
maximus muscle
Gluteus maximus
muscle
Prosthetic skin
projection
Posterior
superior
iliac spine
Implant
Trochanteric
projection
Prosthesis
Gluteus maximus
muscle
Sciatic nerve
Gluteus medius
muscle

1678
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Distortion of the buttocks shape is the most common problem observed when the
implant is placed in an abnormally high position. An unnatural curved appearance
becomes evident; the lower portion of the buttocks remains drooped or at, with
some skin excess visible at the gluteal fold. Sagging at the gluteal fold may also oc-
cur. On posterior view an arti cial bulging projection in the upper middle buttock
segment created by the prosthesis is apparent. And if hard spherical contracture of
this implant occurs, an unaesthetic localized bulging results.
Buttocks distortion secondary to implant placement can occur unilaterally or bilat-
erally. The possible reoperative options are (1) skin resection at the gluteal fold
and/or (2) repositioning the implant in a lower position. In the latter situation, the
same sacral access approach is used and the implant is removed. The pocket is re-
constructed as appropriate to correct the problem. Localized sutures in the upper
and lateral aspects to obtain an improved shape or a new dissection in the lower
edge of the pocket to correctly position the implant may be necessary. Special care
must be taken with the vessels and the sciatic nerve.
This 42-year-old patient had at buttocks. Silicone implant placement with the
Roble technique was planned.The prostheses were inserted in submuscular pock-
ets under the gluteus maximus muscle. The circular skin demarcation shows how
the implant bulges bilaterally.This bulge was more evident on the right side. Post-
operatively, the prostheses were too high. During reoperation, the pockets on both
sides were rebuilt.

Despite the new pocket shape created by undermining the lower aspect of the
pocket and closing the capsule in the upper lateral segment, the implant position
was still not completely correct and a bulge projected in the left buttock.The pa-
tient chose not to undergo further revision. No capsular contracture was palpable.
1679
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
Comparison of preoperative and postoperative lateral views shows the improve-
ment of the buttock’s contour. No implant bulge can be detected.

1680
PART V
R EOPERATIVE SURGERY OF THE TRUNK
This 35-year-old patient complained of at buttocks and was a candidate for a sil-
icone implant inserted with the Roble technique.
Nine months postoperatively, improvement in the buttocks volume can be seen, but
the patient still complained about the small size of the prostheses and their high po-
sition, which created a attened appearance in the lower middle portion of the
buttocks.

In a second procedure the prostheses were replaced with larger ones and the im-
plant pockets were rebuilt to place the implants in a lower position. Following this
secondary procedure, the contour was improved and the patient was satis ed with
the volume augmentation.
COMBINED PROCEDURES
The most common combined reoperative procedures in body contouring are
flankplasty and abdominoplasty; flankplasty and upper inner thighplasty; and
ankplasty, thighplasty, and abdominoplasty performed in the same surgical stage.
These combined procedures may be indicated for primary cases and for secondary
situations in which there are localized problems. Patients who have undergone ab-
dominoplasty may also undergo a secondary abdominoplasty combined with pri-
mary ankplasty and/or upper inner thighplasty. Whatever combination of proce-
dures is performed, the nal objective is improvement of body contour and skin
turgor. Liposuction may also be integrated into the surgical program in these areas
or in neighboring regions.
1681
Chapter 42
Reoperation After Liposuction and Body Contour Surgery

After completion of the posterior resection, the patient was repositioned supine
for completion of the anterior portion of the procedure. The old scar was located
10 cm above the anterior vulvar commissure. In this procedure, we attempted to di-
minish this distance to 6 cm.We use a ruler and calipers continuously during pro-
cedures of this type for better symmetry.
1682
PART V
R EOPERATIVE SURGERY OF THE TRUNK
This 34-year-old woman presented 2 years after an abdominoplasty performed
elsewhere. She sought additional improvement. One can see in the preoperative
photographs the high position of the transverse scar along the hypogastrium, with
signi cant skin laxity and fatty excess in the anks.
The ankplasty was performed in surgical steps, beginning with the patient in the
prone position.The amount of skin that could be “pinched” preoperatively was re-
sected in stepwise fashion, undermined, and sequentially closed.

1683
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
The preoperative frontal view is shown, and the result is shown at 4 months post-
operatively and 10 years postoperatively. We used low-dose radiotherapy in the
early postoperative period to prevent hypertrophic scarring. The 10-year result
shows a satisfactory scar.
The preoperative lateral view is shown, with the 4-month result and the 10-year re-
sult showing lasting improvement.

1684
PART V
R EOPERATIVE SURGERY OF THE TRUNK
This 36-year-old patient presented with skin laxity primarily involving the hips
and thighs, with localized fat deposits in the lateral femoral area bilaterally. The
proposed surgery included a circumferential body lift that included resections of the
ank, the upper inner thigh, and liposuction of the lateral femoral area.The mark-
ing pattern shown determines the limits of the excess skin resection, as determined
by the pinch test.

After meticulous measurement, the procedure is initiated with the excision of the
anks with the patient in the prone position.Very often the markings are quite dif-
ferent with the patient standing compared with those in the decubitus position.
The skin is undermined at the level the gluteus maximus fascia, ending in a V-
shape overlying the sacrum. The excess skin is removed in segments, with careful
suturing in three layers from the deep fascia to the intracuticular closure, leaving no
dead space.
1685
Chapter 42
Reoperation After Liposuction and Body Contour Surgery

1686
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The patient is then turned to the supine position and the skin ap is undermined
along the inguinal line of dissection down to the inguinal crease, as shown. The
plane of dissection should be super cial, especially at the anterior superior iliac
spine inferiorly to avoid injury to the lateral femoral cutaneous nerve. Only the
amount of skin to be removed should be undermined in order to avoid dead space.
Separate closure of the super cial fascia is important to reduce tension. One must
avoid distortion of the vulva, which can occur from an overly aggressive skin resec-
tion and failure to properly anchor the closure.

The patient returned for additional scar revisions and improvement in the shape of
the buttocks using a gluteal implant.The preoperative markings, 1 year after the ini-
tial surgery, are shown. Additional liposuction was planned for the lateral thigh with
the amount of additional skin to be resected outlined.
1687
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
The patient is shown preoperatively and at 1 year after the second revision, which
included the gluteal implant and revision ankplasty. Seen 9 years postoperatively,
the result has been stable and the scars are satisfactory.

1688
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The same patient is shown in the anterior view. After 9 years, some recurrence of
inner thigh laxity is apparent.
One year after the revision surgery, well-placed incisions can be hidden by under-
garments.

This 54-year-old patient presented for additional improvements following body
contouring surgery at another center. Preoperative assessment reveals poorly posi-
tioned scars and insuf cient abdominal skin resection.The operative plan included
a secondary abdominoplasty, ankplasty, and placement of buttock implants.
1689
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
The preoperative and 9-month postoperative frontal views show the secondary ab-
dominoplasty procedure performed using the “bicycle handlebar” type of resec-
tion described in this chapter.

1690
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Posterior views preoperatively and 9 months postoperatively show signi cant im-
provements but only partial correction of gluteal shape.The hypertrophic scarring
that was present preoperatively has also recurred following the revision.
The 9-month postoperative lateral view shows improvement from the preoperative
view on the left in the positioning of the ank scars, but with continued hypertro-
phy and spreading.

Intraoperatively, we encountered a huge serous bursa at the lateral aspect of the
trochanteric area. This was completely eliminated using the adhesion sutures de-
scribed earlier without resection of the pseudomembrane.
1691
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
This 54-year-old woman had previously undergone an abdominoplasty and but-
tocks lift at another center. She presented requesting additional improvements.

1692
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The pinch test revealed the amount of excess skin that could be resected in the
abdomen and anks.
The preoperative markings reveal the plan for a secondary abdominoplasty, inner
thighplasty, and ankplasty, with liposuction to be performed in the inner and outer
thighs.

The surgery is started with the patient in the prone position. The lines of demar-
cation indicate the areas to be deepithelialized and fashioned into an autogenous
“implant” to improve the buttocks projection.The gluteal skin ap is undermined
at the level of the muscle fascia to the gluteal fold, then advanced superiorly to
cover the deepithelialized fat pads and sutured at 3 levels.The posterior segment of
the upper inner thighplasty was also performed in the supine position.
1693
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
The patient is then turned to the supine position, where the inner thighplasty is
completed from the anterior, extending this resection across the inguinal areas.The
pubis is maintained as a triangular region left intact.

1694
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The secondary abdominoplasty is then performed so that the excess skin can be re-
sected in tension-free fashion with the undermined skin of the anterior thigh.
The completed closure is shown. Drains are no longer used since the use of adhe-
sion sutures has become commonplace.The original abdominoplasty scar was 9 cm
above the anterior vulvar commissure, with the nal scar at 5 cm.
The procedure was complicated by skin necrosis at the junction between the old
gluteal scar and the ankplasty incision. This was treated with reexcision and ad-
vancement of the aps.
9 cm
5 cm

The postoperative result is shown at 6 months and at 11 years postoperatively. Af-
ter 11 years the scars are well positioned and much less noticeable.
1695
Chapter 42
Reoperation After Liposuction and Body Contour Surgery

1696
PART V
R EOPERATIVE SURGERY OF THE TRUNK
INTRAOPERATIVE AND POSTOPERATIVE CARE
Surgery is performed with the patient under epidural or general anesthesia and
with endotracheal intubation. Intravenous antibiotics (cephalosporin 2 g) are ad-
ministered intraoperatively.The bladder is catheterized at the end of the surgery. No
permanent catheter is used. Routine monitoring is performed.
The suture line is covered with sterile Micropore tape and ABD pads, and compres-
sion garments are worn for the next 4 weeks. Patients remain hospitalized for a
minimum of 24 hours and a maximum of 2 days.
Ambulation is encouraged 12 to 24 hours after the surgery. To avoid thrombosis,
early ambulation, massage, and leg movements are encouraged. Bandages on the
legs are indicated during the intraoperative period only in patients with known
circulatory problems. Medications are administered to treat symptoms as appropri-
ate, and antibiotic therapy is continued for 3 to 7 days postoperatively.
Sutures are removed from the abdominal incision between the sixth and tenth post-
operative days and from the umbilicus on the fourteenth postoperative day. Patients
who were operated on in the upper thigh region are told to wash the pudendal area
two times a day and after personal hygiene. No bandages are used in these regions.
Postoperatively, the patient may rest in the supine position or even in the free de-
cubitus position, depending on the type of surgery; the patient will nd the ideal
position. The prone position is not recommended after abdominoplasty. Anti-
in ammatory, hypnotic, and anxiolytic medications are prescribed routinely for the
2-week postoperative period, according to patient requirements.The patient wears
an elastic girdle continuously during the rst 10 to 30 postoperative days, depend-
ing on the surgical program: simple reoperative liposuction requires the use of a
girdle for no more than 1 week, whereas complete body contouring or abdomino-
plasty necessitates use of a girdle for 1 month.
Based on the extent of the surgery, patient age, and physical condition, the patient
is permitted only a moderate degree of activity at home during the rst postoper-
ative week. Ambulation beyond the home and visits to the surgeon’s of ce may be
restricted during this rst week. During the second postoperative week, based on
the extent of the surgery, the patient is freer to participate in activities.
Extensive combined surgeries require a minimum of 2 to 3 weeks before driving
and return to work are permitted. Limited domestic activities are allowed. Sun-
bathing is allowed only after the bruises have disappeared (usually after 2 to 3
weeks). Patients should wear bathing suits that cover the operated areas. Participa-
tion in sports activities is permitted after 6 weeks. Pain, swelling, and fatigue are the
main signs that the patient is engaging in overly strenuous activities too early.The
surgeon should evaluate and monitor the patient in this regard.

FINAL COMMENTS
Body contouring surgery can be performed as separate elements or with combined
procedures where different regions of the body are involved. After many years of
experience with body contouring surgery, we have made the following observa-
tions:
Even the most simple of body contouring procedures involves significant
surgical risk.Therefore we feel that it is important not to increase the risks by
poor patient selection. We operate only on healthy patients and do not
overextend multiple procedures if we think the risk will be increased. Use
good common sense.
The surgical time is important! Although we never hurry the procedure
along to the detriment of the result, we always try to reduce the time as much
as possible. After prolonged use of inhaled anesthetic gas, the risks go up.We
look at anesthetic time like stoplights. Up to 5 hours the light is green; at 6
hours it becomes yellow;greater than 6 hours, the light is red.Therefore the
surgical team must always pay close attention to time so as not to increase
risks.
We must always strive for improvement of the patient’s situation and never
accept a result that is the same or worse than the patient started with. If this
does occur, try to improve the result within the limits of what you can do in
your of ce. Patients look to us for our expertise in improving their appear-
ance. If we create a certain level of expectation and exceed it, we are viewed
as “gods.” Unfortunately, when we deliver less, we are viewed as “devils.”
Results from body contouring surgery are transient, but the extensive scars are
permanent. It is imperative to make certain that scar position can be covered
as much as possible by underwear and swimsuits.When a patient has a beau-
tiful result, she wants to expose it. However, scars are never exposed with
complete patient satisfaction. If the shape and contour are excellent, even pa-
tients with lengthy scars will not complain, especially if the quality of the scar
is good.
The result must be symmetrical.We continuously use calipers and rulers dur-
ing the operation to ensure that the symmetry is as good as we can obtain.
This greatly aids in the positioning of scars at the end of the procedure.The
best time to reposition a scar is at the time of the initial procedure. Scar re-
visions are a fact of life, and the patient must be informed of this preopera-
tively.
Body contouring surgery requires years to achieve expertise. New surgeons
should start with less complex procedures and only advance to more sophis-
ticated combinations as experience is gained.
The surgical team is like an orchestra:every member must know what to do
under the guidance of the conductor—the primary surgeon. Since 1975 we
have been performing combined procedures following these criteria. The
team comprises a chief surgeon, an anesthesiologist and assistant, two surgi-
1697
Chapter 42
Reoperation After Liposuction and Body Contour Surgery

1698
PART V
R EOPERATIVE SURGERY OF THE TRUNK
cal assistants, two scrub nurses, and a circulating nurse.The circulating nurse
must be trained to serve the surgical team and all their requirements, know-
ing what supplies will be required. Time spent during surgery to hunt for
supplies must be scrupulously avoided. It is only by all the members of the
surgical team working in concert that time will be minimized and results
optimized.
References—With Key Annotated References
1. Avelar JM. Abdominoplasty without panniculus undermining and resection. In Avelar JM, ed.
São Paulo, Brazil: Hypocrates, 2002.
2. Saldanha OR, ed. Lipoabdominoplasty. Rio de Janeiro, Brazil: DiLivro, 2004.
3. Saldanha OR. Personal communication, 2003.
4. Baroudi R, Feirreira CAA. Seroma:How to avoid and how to solve it. Aesthetic Surg J 18:439,
1998.
5. Johnson L, Cusick TE, Holmer SD, et al. In uence of brin glue on seroma formation. Am J
Surg 189:319, 2005.
A prospective, randomized, controlled study was conducted of 82 subjects randomized into control
(drain) and experimental (fibrin) groups to determine the effectiveness of Hemaseel APR fibrin
sealant versus conventional drain placement in the prevention of seromas after breast procedures. The
use of brin sealant resulted in a nonsigni cant decrease in seroma formation rate compared with
that of drain placement. The higher cost involved, cumbersome technique, and higher aspirate vol-
umes tend to indicate that there is no advantage to using brin glue over drain placement with the
technique described.
6. Baroudi R, Carvalho C. Neoumbilicoplastias:Un procedimiento eléctico en el transcurso de las
abdominoplastias. Cir Plast Iberolat 7:391, 1981.
7. Baroudi R. Flankplasty: A specific treatment to improve body contouring. Ann Plast Surg
27:404, 1991.
A complete study of the ank region’s unaesthetic distortions, with comments regarding and illustra-
tions of the different clinical appearances of local skin turgor and fat deposits. A classi cation of the
different types of ank distortions, whether or not combined with similar problems of the surround-
ing regions, completed the study for the indications of correct treatment. Liposuction, surgery, or both,
combined in the same or different stages, completes the main steps of the procedure.
8. Baroudi R, Feirreira CAA. Contouring the hip and the abdomen. Clin Plast Surg 23:551, 1996.
This article described the surgical procedures used for the aesthetic improvements of the anks and ab-
domen. A clinical classi cation for patient selection regarding when to use liposuction, surgery, or
both, was included. Isolated flankplasty, isolated abdominoplasty, and combined flanks with abdomino-
plasty performed in the same stage were reviewed. Finally, secondary problems after traditional ab-
dominoplasty are evaluated. Solutions were described and illustrated.
9. Robles JM, Tagliapietra JC, Grandi MA. Gluteoplastia de aumento: Implante submuscular. Cir
Plast Iberolat 4:365, 1984.

1699
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
1. Which of the following patient characteristics are least desirable for a patient in-
terested in liposuction?
a. Moderate skin turgor
b. Voluminous fatty deposits
c. Struggling with weight uctuation problems
d. Skin accidity
e. Age over 35 years
2. In a patient undergoing abdominoplasty, the ideal length from the anterior vulvar
commissure to the suture line is:
a. 5 cm
b. 7 cm
c. 10 cm
d. 15 cm
e. One fourth the length of the incision
3. Following abdominoplasty,the distance between the umbilicus and the suture line
should be at least:
a. 5 cm
b. 7 cm
c. 10 cm
d. 15 cm
e. One fourth the length of the incision
4. When using adhesion sutures as a means to prevent seroma/ hematoma, it is im-
portant to place neighboring sutures no more than __ cm apart, so as to fully
eliminate all dead space.
a. 1
b. 2
c. 3
d. 4
e. 0.5
5. According to the Robles technique, which of the following steps is not involved
in the placement of a silicone gluteal implant?
a. Use of a midline incision for placement of bilateral implants
b. Placement of the implant completely over the gluteus maximus muscle
c. Placement of the implant completely over the gluteus medius muscle
d. Lack of dissection performed below the cutaneous projection of the piri-
formis muscle
e. Placement of the implant cephalad to lower extremity neurovascular pedicle
R EVIEW QUESTIONS

(Trang không có chữ)

1701
Staging, Reoperation, and Treatment
of Complications After Body Contouring
in the Massive-Weight-Loss Patient
Al S. Aly and Joseph F. Capella
C ha pter 4 3
Reoperative Problems
Proper sequencing of procedures
Intraabdominal excess
De ated, ptotic breasts
Excess medial thigh skin
Inframammary crease laxity
Inability to close wound
Lateral trunk excess
Dehiscence
Inadequate anterior trunk excision
Laxity of the mons pubis
Abdominal ap thickness disparity
Any transition serious enough to
alter your de nition of self will require not just
small adjustments in your way of living and thinking,
but a full-on metamorphosis.
Martha Beck

1702
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Body contouring after massive weight loss is a relatively new plastic surgery sub-
specialty. On the surface it may seem to be a simple extension of traditional body-
contouring techniques. This perception, however, could not be further from the
truth. Although there are many similarities between the procedures used on the
massive-weight-loss population and those used on the normal-weight-loss popula-
tion, there are signi cant differences.
Massive-weight-loss patients present with deformities that are more numerous and
more severe than those seen in ordinary patients presenting for body contouring.
Because of the quality of the skin-fat envelope after massive weight loss, treatment
of one area of the body often will more dramatically affect the remaining regions
of the body than in non-massive-weight-loss patients. Thus massive-weight-loss
patients have fairly complex presentations that require careful planning and staging
of the multiple procedures that are often needed to rehabilitate the entire body.
Massive weight loss leads to a wide variety of patient presentations (see opposite
page) that can be daunting to evaluate and treat.1 Many factors contribute to this
variability; rst is the body mass index (BMI), calculated as follows:
BMI
Weight in kilograms
(Height in meters)2
or
BMI
Weight in pounds
703
(Height in inches)2
Other factors include the fat deposition pattern and the quality of the skin-fat en-
velope. Some patients stabilize their weight loss at relatively low or normal BMIs
(27 and below); others stabilize in either the obese (30 to 35) or superobese range
(36 and above). The method of weight loss, patient motivation, and the patient’s
support system all in uence and contribute to the level of stabilization. Humans de-
posit fat differentially in various areas of the body while gaining weight, and they
also lose weight in different areas in a particular pattern that is genetically controlled.

1703
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient

1704
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The nal appearance of any particular individual will depend on the pattern of fat
deposition and subsequent pattern of fat loss. Finally, the thickness of the subcuta-
neous fat, the laxity of skin, and how well the skin translates tissue traction (“trans-
lation of pull”) all contribute to the quality of the skin-fat envelope that a plastic
surgeon will have to deal with during the body-contouring process.
In this patient the preoperative pull simulates the proposed effect of a belt lipectomy
on the distal thighs. On the right the result after surgery is shown; it closely mim-
ics the appearance achieved with preoperative manipulation. Thus estimating the
translation of pull can be helpful in predicting results.

1705
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient
Massive-weight-loss patients exhibit permanently altered skin elasticity related to
overstretching of their skin. Open excisional procedures used to improve overall
appearance will alter their body contour but do little to change the intrinsic nature
of their skin laxity.This is an important fact that both the patient and the surgeon
need to understand to prevent disappointment when skin laxity returns 6 to 12
months after surgery.
STAGING OF PROCEDURES
FOR THE MASSIVE-WEIGHT-LOSS PATIENT
Some massive-weight-loss patients choose to undergo solitary body-contouring
procedures, either because of the extent of their presenting deformity or because of
nancial constraints. However, most individuals will opt to undergo multiple pro-
cedures involving various body regions in an attempt to achieve more normal body
contours. Because of the complexity and variability in presentation of massive-
weight-loss patients, it is important to adhere to certain principles when staging
these procedures.The plastic surgeon and the patient should outline a plan to deal
with all areas that will require treatment;this will allow the patient to prepare for the
future in terms of time and nancial needs.
When detailing a plan for a particular patient, a number of issues are considered.
Patient safety should be the highest priority. Many of the surgical pro-
cedures used for body contouring of the massive-weight-loss patient
are lengthy, with the potential for signi cant blood loss.
Although there are no commonly accepted recommendations de ning the duration
of surgical procedures, it is generally agreed that very long operating times should
be avoided, especially for these elective procedures.2 Surgeon fatigue is another
safety issue to consider. It is the unusual surgeon who is as fresh and clear-thinking
after 10 to 12 hours of operating.Thus it is important to nd a happy medium be-
tween treating as many deformities as possible in any single procedure and ensur-
ing patient safety.
When determining what procedures to perform, and in what sequence, some tech-
nical issues warrant consideration.
Caution is in order when performing concomitant procedures that in-
herently lead to opposing vector forces. Ideally, these should not be
performed in a single stage.

1706
PART V
R EOPERATIVE SURGERY OF THE TRUNK
For example, a lower truncal circumferential lipectomy potentially elevates the lat-
eral, anterior, and even the medial thighs, especially in patients who have large
translations of pull.The pull of a vertically oriented medial thigh excision is in the
opposite direction.The opposing vectors of both procedures can cause a lack of scar
position control and possibly lead to unwarranted surgery. In patients who have
a signi cant translation of pull, the medial thighs can be affected enough to either
reduce the extent of, or eliminate the need for, an open thigh reduction.Thus it is
best to perform the lower truncal procedure rst and delay the thigh reduction to
a subsequent stage.
Directly opposing vectors are also exempli ed by an upper body lift and a lower
truncal circumferential lipectomy.The lower truncal procedure exerts a large down-
ward force on the thoracic tissues, especially anteriorly and laterally along the in-
framammary crease. In an upper body lift the vector of pull is directly opposite that
of the lower truncal procedure. This may potentially lead to an incorrectly posi-
tioned inframammary crease, which is an important landmark and transition point
between the lower and upper trunk.
Although combining too many procedures can be problematic, in some situations
it is helpful to use procedures such as liposuction to set up subsequent procedures.
For example, it is reasonable to liposuction large thighs in a preliminary lower trun-
cal circumferential procedure so that the thighs can be de ated for a subsequent ex-
cisional thigh reduction.The same can be said of the arms if they are very large at
presentation.
In staging massive-weight-loss body-contouring procedures, it is imperative to be
aware of the vascular supply of all tissues manipulated. Some of the tissues can be
vascularly compromised as a result of the original procedure performed on them.
For example, if abdominal ap elevation during abdominoplasty or a circumferen-
tial lower truncal procedure is combined with other more extensive procedures
such as vertical lateral upper truncal excisions, the potential for more extensive vas-
cular compromise exists.
SEQUENCING AND COMBINING PROCEDURES
In this section we present staging scenarios for two typical massive-weight-loss pa-
tients. Clearly, there are numerous approaches to sequencing these operations;
however, these examples are provided to demonstrate the principles involved when
determining the appropriate staging plan.

1707
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient
This 30-year-old woman lost 130 pounds (59 kg) after open gastric bypass surgery.
Her highest weight and BMI before gastric bypass were 280 pounds (127 kg) and
43, respectively. Her weight stabilized at 140 pounds (63 kg), with a BMI of 25, 12
months after surgery. She presented with the typical concerns of most women af-
ter massive weight loss: excess skin at the arms, axilla, and ank areas; breast ptosis
and hypomastia; and excess skin along the abdomen and thighs (both medial and
lateral).
Initially a body lift, or simultaneous abdominoplasty and thigh-buttock lift, was
performed. Six months later, the patient underwent bilateral breast augmentation
and brachioplasty.Three months after that combination, she underwent a bilateral
medial thigh lift.

1708
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The patient is shown 10 months after the body lift and 4 months after the medial
thighplasty.

1709
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient
Her improved breast and arm contours are shown 10 months after bilateral brachio-
plasty and augmentation mammaplasty.

1710
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Sequencing Rationale
The sequence and combination of procedures per-
formed on a weight-loss patient are important both for safety and aesthetic consid-
erations. Our preference is to perform a body lift as an initial procedure on appro-
priate candidates.This single operation addresses the abdomen, thighs, and buttocks,
and to some degree the back and ank areas as a single aesthetic unit.There are sev-
eral reasons for this approach. First, an attempt to only treat one or two components
of this aesthetic unit will probably result in a suboptimal outcome in the post-
bariatric population. Second, because a body lift is a circumferential procedure,
standing cones or dog-ears are not a concern. Consequently, an appropriate and
optimal amount of tension can be applied at the closure line. Third, because the
body lift has a signi cant effect on the ank, back, and medial thighs, it may obvi-
ate the need for procedures speci c to these areas that are often associated with
much more perceptible scars.The body lift scar along the waistline is well-concealed
by most undergarments. After a body lift, many patients have had enough improve-
ment of their medial thighs to not need a medial thigh lift. Similarly, the improve-
ment to the anks and back resulting from a body lift may make a transverse scar
across the upper back unnecessary for individuals with signi cant deformities in this
area. Furthermore, a prior body lift will often make the outcome from these upper
or lower body procedures more effective.
We do not perform a medial thigh lift at the same time as a body lift
for a number of reasons, including the fact that the forces of traction
can be in opposite directions. This is particularly relevant if a medial
thigh lift with a vertical component is necessary.
For patients who require a medial thigh lift, our preference is to have them wait at
least 3 months after a body lift. After the body lift, patients may then be candidates
for a combination mammaplasty and brachioplasty, which usually includes the ax-
illa and may include the anks and back or a medial thigh lift as mentioned previ-
ously. Just as there are bene ts to addressing the abdomen, thighs, and buttocks as
an aesthetic unit, similar bene ts exist for addressing the arms, anks, axilla, and
breasts as an aesthetic unit. Most postbariatric women with concerns about breast
ptosis and/or involution have tissue excess along the anks and axilla. Combining
brachioplasty with mammaplasty affords the opportunity to combine the scars of
these two procedures, addressing excess in all of these areas.

1711
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient
This 33-year-old woman lost 175 pounds (79 g) after undergoing gastric bypass sur-
gery and requested body contouring.
She is shown 18 months after the body lift and 10 months after the combination
brachioplasty, ankplasty, and mastopexy were performed.
We prefer not to perform breast surgery before a body lift because the
abdominoplasty portion of the body lift may shift the breasts caudally
and distort work that has already been performed in this area.This is
particularly relevant to augmentation mastopexy, where the implant is
less likely to shift than the soft tissue of the breast.

1712
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Performing combination procedures simultaneously on both the upper and lower
body of massive-weight-loss patients increases the likelihood that blood transfu-
sions will be required, and may increase the possibility of other serious complica-
tions such as deep vein thrombosis. In addition, because the forces of traction are in
opposite vectors, simultaneous upper and lower body-contouring procedures may
compromise the aesthetic outcome.
This 50-year-old man reached a BMI of 57 at his greatest weight before undergo-
ing a gastric bypass procedure. He subsequently dropped to a BMI of 35 before his
weight stabilized.

1713
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient
His rst procedure was a belt lipectomy combined with liposuction of the thighs.
Thigh liposuction was performed to de ate his thighs in preparation for a subse-
quent open thigh reduction procedure, performed after the belt lipectomy result
had stabilized.

1714
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Two months after the belt lipectomy and thigh liposuction, he underwent an up-
per body lift. The procedure included upper arm reduction, elimination of upper
back excess, and gynecomastia reduction, treating the entire thorax as a unit.

1715
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient

1716
PART V
R EOPERATIVE SURGERY OF THE TRUNK
His last procedure was a thigh reduction, which was performed 1 month after the
upper body lift.

1717
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient

1718
PART V
R EOPERATIVE SURGERY OF THE TRUNK
He is shown here 6 months after his initial operation and after undergoing belt
lipectomy and thigh liposuction, and an upper body lift and thigh reduction.

1719
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient
Sequencing Rationale
The belt lipectomy is performed rst because the lower
truncal region is most often the area of greatest concern for massive-weight-loss pa-
tients; if the patient is unable to afford any further surgery, this is the area that the
patient usually prefers to improve. It is also the area that, as a single procedure, has
the greatest effect on the patient’s overall body contour.The circumferential treat-
ment of the lower trunk can be thought of as foundation on which the remaining
procedures will be built. Once it is performed, it acts as a solid anchor for upper
truncal and thigh procedures.
Occasionally the upper body procedure can be performed before a belt lipectomy.
However, thigh procedures are always performed after a belt lipectomy because the
thighs are essentially anchored anterolaterally by a belt lipectomy, which will help
lift the thighs to a more aesthetic position, thus reducing the amount of medial lift
that may subsequently be needed. In some patients who have excellent translation
of pull, a belt lipectomy alone will affect the medial thighs enough to actually elim-
inate the need for further surgery.
This patient underwent a belt lipectomy primarily and was planning on having a
thigh reduction in a subsequent procedure. However, she decided that the improve-
ment to her thighs achieved from the belt lipectomy alone was enough to avoid
further surgery. Had she undergone a thigh reduction at the time of her belt lipec-
tomy she would have had an operation that could have been avoided.
The results achieved after open thigh reduction of thighs that are still very in ated
on presentation are often disappointing. Preliminary liposuction in these patients is
warranted to de ate the excessive lipodystrophy so that a subsequent open thigh re-
duction can signi cantly improve contour. Some surgeons advocate combining li-
posuction and open excision in a single procedure, which may have some merit.
However, we often nd this route to be disappointing.

1720
PART V
R EOPERATIVE SURGERY OF THE TRUNK
REOPERATIONS AFTER MASSIVE-WEIGHT-LOSS
PLASTIC SURGERY
As mentioned previously, multiple areas are treated in the massive-weight-loss pa-
tient. In this section we will address the different body regions, problems that may
present after an initial surgical intervention, and how these problems are solved.
What is key here is that the reader understands the principles involved rather than
the actual technique used to ameliorate these problems.
BREASTS
De ated, Ptotic Breasts
This 33-year-old woman lost approximately 150 pounds (68 kg) after undergoing
gastric bypass surgery. She presented with concerns about the sagging and de ated
appearance of her breasts. She wanted her breasts to be lifted and to be larger and
fuller.
She was initially managed with a vertical augmentation mastopexy and placement
of 390 cc submuscular, saline- lled, round smooth implants. After this procedure
the patient lost approximately 20 pounds (9 kg).One year after the initial procedure,
she presented with concerns about the size of her breasts. She underwent an im-
plant exchange to 560 cc smooth, saline- lled, round submuscular implants.

Nine months after this procedure the patient returned with concerns about the
excessive fullness and rippling along the lower pole of her breasts. She underwent
a third procedure with revision of the vertical augmentation to an inverted-T pro-
cedure to address the lower pole, and 600 cc silicone gel implants were placed. She
is shown 10 months after revision of her augmentation mastopexy and implant
exchange.
Similar to what is seen in the postpartum condition, women’s breasts can have a
wide range of presentation after weight loss. Some women, usually those less than
30 years of age, can present with minimal or no ptosis and mild to moderate invo-
lution. Others may present with severe ptosis and involution. Several factors, how-
ever, can make breast contouring in the weight-loss patient more challenging than
in the routine body-contouring candidate. The breasts, particularly the tail of the
breast, anks, and axilla are common areas for fat deposition in the obese individ-
ual. The history of “yo-yo” dieting that often precedes bariatric procedures and a
typical history of obesity since childhood or adolescence predispose postbariatric
patients to particularly poor skin tone. After weight loss and de ation of the breasts,
excess tissue often remains along the axilla and anks.This tissue causes the lateral
extent of the breasts to be poorly de ned because the lateral inframammary crease
“drops out” or descends laterally.The laxity of the soft tissues of the chest wall may
cause the breasts to migrate caudally; this may be further exacerbated by traction
from abdominoplasty.
1721
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient

1722
PART V
R EOPERATIVE SURGERY OF THE TRUNK
When mammaplasty is considered in a weight-loss patient, it is crucially important
to carefully advise the patient of the risks and bene ts of each approach, and specif-
ically which procedures are likely to require a revision or second stage. For patients
who have concerns about ptosis but are satis ed with their breast size, mastopexy
alone requires few revisions and provides fairly good longevity, particularly if a sta-
ble weight is maintained. For patients desiring larger breasts, upper pole fullness, and
correction of breast ptosis, augmentation/mastopexy is recommended. Unlike
mastopexy alone, augmentation/mastopexy has a signi cant revision rate or need
for a second stage.The need for a second operation is directly correlated to the de-
gree of ptosis, the size of a woman’s breasts, and the size of the implant chosen.
Inframammary Crease Laxity
The inframammary crease fascial attachments in many massive-weight-loss patients
is weakened and can easily be altered in position or destroyed by surgical manipu-
lation.
This 32-year-old woman is shown after undergoing a belt lipectomy and losing
150 pounds (68 kg).She requested a breast lift and a signi cant increase in breast size.
Although her inframammary crease did not “drop out” laterally, which often occurs
in many massive-weight-loss patients, it was weakened by virtue of the weight gain
and subsequent weight loss.The extensive dissection from the belt lipectomy may
have further loosened the breasts’fascial attachments.

A large implant was used to augment the patient’s breasts to her desired size; a
“donut mastopexy” was performed to correct ptosis.The inframammary crease did
not hold the implant on the right side and it slipped inferior to the newly posi-
tioned crease. The patient was taken back to the operating room 3 months later
where her inframammary crease was repositioned by excising the inferior compo-
nent of the implant capsule and closing that aspect to match the opposite breast.Per-
manent sutures were used to anchor the crease to the underlying rib perichondrium.
1723
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient
Thus, for massive-weight-loss patients whose inframammary crease is to be oper-
ated on but whose preoperative evaluation reveals a signi cant lack of adherence of
the skin to the underlying natural inframammary crease, we recommend using su-
ture xation to surgically secure the crease in its desired position.This is especially
true if large implants are used.

1724
PART V
R EOPERATIVE SURGERY OF THE TRUNK
LOW ER TRUNK
Lateral Trunk Excess
Inadequate excision of lateral excess of the lower trunk is a problem that can oc-
cur during circumferential procedures.3 This error may result from poor planning
during the marking process or as the result of an inability to remove enough tissue
during the operation.
This patient was positioned supine and then prone for a belt lipectomy. Despite
planning to eliminate an aggressive amount of lateral excess, it became apparent
during the procedure that the amount of lateral tissue to be resected was limited by
the patient’s position during surgery.The legs and hips were not abducted, and this
led to a limited lateral excision.
To eliminate the lateral excess, the patient was subsequently taken back to the op-
erating room 3 months after the initial procedure. She was placed in the lateral de-
cubitus position with pillows between her knees to abduct the hip laterally, and a
more aggressive lateral excision was performed.