The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

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Part XII  Body Contouring
Combination Technique
In the vast majority of cases we treat our patients using a combination of liposuc-
tion and a lateral thoracic lift (CLTL). With this combination we can reduce the con-
siderable tendency of the tissues to develop a seroma from direct undermining, and
with liposuction we obtain additional movement of the otherwise poorly mobile fas-
cial strands. However, because of the simultaneous liposuction and the greater de-
gree of mobilization of the tissues, the upper incision line should be placed higher
than for a standard body lift incision. The same applies to the mobilization of the
two upper folds toward the axilla. Later shrinking effects appear to have no clinical
relevance to the location or position of the scars.
Upper Folds
If a combination technique is planned, we place the patient prone initially so that
we can treat the entire back first. This yields two benefits: the adipose tissue is re-
duced to an acceptable thickness, and we gain some additional release of the adher-
ent tissue. That leads to more mobility upward and laterally toward the axilla. Then
we turn the patient onto the back for the lifting procedure, as described previously.
Lower Folds
Although hip folds are sufficiently resectable with an LBL, the lower thoracic folds are
more difficult to address. The upper incision line can be raised to catch at least half
of the fold; however, the scar will be visible above the patient’s underwear.

Attempts to address the lower thoracic fold by direct undermining through an LBL
will lead to a massive seroma collection and severe wound-healing problems as a re-
sult of cutting the lower perforator vessels of the latissimus dorsi. We recommend
not undermining the area above the LBL incision.
2871
Chapter 81  Back and Lateral Fold Contouring
To eliminate the lower thoracic fold, we usually place the LBL incision higher than
usual and perform a thorough liposuction above. This deflates the lower thoracic
and hip rolls and enables us to move the tissues downward so that the scar will lie
within the area covered by underwear. During liposuction we address the rolls in a
crisscross manner to disrupt the connective bands and adhesions to the deep fascia.

Upper Lateral Thoracic Lift in Combination
With Upper Arm and Breast Lift
In most of our cases we combine the ULTL with an upper arm lift and a breast lift
to treat the whole unit. We start with the arm, usually with a double ellipse tech-
nique, as described by Aly. At the axillary end of the incision, we open up for the
ULTL as described and close it completely. We then address the breast with the patient
in an upright position, usually with the Rubin technique, to preserve volume and
prevent bottoming out.
This sequence ensures that the areola is not placed too laterally and that we are able
to compensate for the lateral pull being created with the ULTL.
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Part XII  Body Contouring
We usually break the scar with a Z-plasty at the level of the axilla to prevent the scar
from contracting primarily. If necessary, this can be staged to be performed later.
DIRECT EXCISIONAL PROCEDURES
Bra Lift
If the lateral pull test does not correct the entire deformity on the back, a direct ex-
cision with a horizontal or curved elliptical incision should be considered. While the
surgeon is pinching and adjusting the amount to be resected, he or she pays atten-
tion to the thickness of the flap between the fingertips. We recommend proceeding
as described by Aly, employing the double ellipse technique for the arms and thighs
and using liposuction to thin out the flap that will be resected; otherwise, it may not
be possible to close the wound, because the dermis of the back is thick and rigid.

With the patient’s arms elevated, the bra markings are made, and the folds are
marked (note the unequal number of folds bilaterally). The tissue excess is estimated
and pinched.
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Chapter 81  Back and Lateral Fold Contouring
The markings for the upper incision line and lower estimation line are shown. If the
deformity is located more laterally, we extend the lower incision line like a W-curve.
The patient is placed in a prone position with the arms abducted 90 degrees. Infil-
tration and liposuction of the marked areas are performed. Thorough, careful lipo-
suction in all layers preserves the lymphatic vessels in the deep layers. An incision is
made from the top and continued downward, leaving a little fat on top of the deep
fascia. The lateral extent of the Scarpa’s fascia roll usually correlates with a separate
deep fat structure that needs to be resected. It is advisable to reconstruct the fascia
afterward to avoid dimpling.

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Part XII  Body Contouring
We continue with the incision downward to the estimated lower resection line and
do not go below this to prevent any dead space. We then do a final check of the lower
resection line and proceed with careful resection and closure. Usually we insert two
drains and apply compression garments, which the patient wears for 2 to 4 weeks.
The scar may be positioned within the bra line or within the relaxed tension lines of
the back.
Upper Body Lift
To treat the whole upper body circumferentially as one unit, we use the upper body
lift, which includes the following:
1. Breast lift
2. Arm lift
3. Upper lateral thoracic lift
4. Back lift (upper breast and lower scapular folds via bra lift)
The procedure is indicated primarily for massive-weight-loss patients with severe cir-
cumferential deflation. The procedure employs a combination of the four lifting pro-
cedures described previously.
Full Lateral Thoracic Lift
A full lateral thoracic lift (FLTL) with vertical excisions in the midaxillary line may
be indicated in very select cases after a circumferential procedure in which there is
still a skin and soft tissue surplus in the hips and/or upper abdomen as well as up-

per back folds. Careful pinching will demonstrate the potential result on the front
and back with a vertical incision. In some cases it is advisable to break the scar line
with a Z-plasty.
Postoperative Care
As for any other patient after a significant loss of weight, a standard antithrombo-
sis treatment regimen with antithrombotic stockings and chemoprophylaxis is initi-
ated. Prophylactic antibiotic therapy has not been necessary in our experience, and
we avoid it to prevent the development of antibiotic resistance. We initiate patient
ambulation on the day of surgery. We prefer that the patient be placed in a supine
position in bed, even if a direct incision was done on the back; moving the patient
is much easier when the patient is supine.
The patient wears a special compression corset for 4 weeks after liposuction of the
back, with or without any lifting operation. After treatment of the lower folds only
by an LBL, we do not order a special compression corset for the first 1 or 2 weeks,
because we have concluded that compression of this circumferentially resected area
may result in further reduction in perfusion (possibly causing delayed wound healing).
For at least 3 months silicone sheets are applied to the operated areas to improve
maturation of the scars.
Problems and Complications
As in other body-contouring procedures, seromas frequently form in the back and
hips. Even after radical liposuction, sporadic aspiration may be required, since cav-
ities may develop in the septated fatty tissue and will fill with serous fluid.
Because of the risk of seroma, if a direct excision is performed, we suggest leaving
a certain amount of fat beneath the underlying fascia to reduce flap shearing on the
fascia. We further recommend the use of an ultrasonic scalpel to avoid heat while
cutting and to seal the lymph channels. Wound drains are essential, as well as the
compression garment previously mentioned. Wound dehiscence usually occurs in
combination with seroma. Seromas are a minor complication if adequate prepara-
tion and closure have been done and there is no dead space. The axilla has a slightly
higher risk of complications, such as wound-healing problems, because mobility in
that region is high, and hygiene is poorer.
2875
Chapter 81  Back and Lateral Fold Contouring

Subcutaneous depressions may result from liposuction that is overaggressive and too
superficial. These are very hard to correct. They may be avoided by using a correct
liposuction technique with a fine cannula and limited suction pressure.
Minor wound dehiscences and wound-healing problems are not uncommon after
LBL procedures. Shearing forces especially put tension on the scars and should be
avoided. The key to good scar formation is a well-defined preparation and suturing
technique, careful tissue handling, and suture material that is patient compatible.
Outcomes
Upper body–contouring procedures have gained wide popularity among massive-
weight-loss patients and are today performed as part of multistage body recon-
struction after weight loss, whether the reduction has been from a nutritional regimen
or a bariatric procedure. Technical improvements enable plastic surgeons to suffi-
ciently treat the upper truncal contour to achieve patients’ goals and expectations.
Depending on the patient’s preoperative BMI, indications for direct excisional pro-
cedures of the dorsal thoracic region are rarely seen in patients with mild to moder-
ate weight loss, and occasionally are appropriate in patients after massive weight
loss. Although satisfactory results can be achieved with this approach, unfavorable
scar placement and scar quality restrict the implementation of this procedure.
A more common and favorable procedure for improving the contour of the dorsal
thoracic region is the ULTL. With this procedure the surgeon can eliminate appro-
priate amounts of tissue in various anatomic units. Optimal scar placement is pos-
sible, and the procedure can be performed alone or as an integral part of a combined
contouring procedure of the upper arm, the lateral and dorsal thoracic wall, and the
female or male breast. In women it is usually combined with an inverted-T pattern
breast reshaping, elongating the submammary incision to the axillary crease. In men
after massive weight loss we perform the direct excisional procedure for breast re-
shaping, optionally with a free nipple graft, as popularized by Aly, or as a pedicle
transfer, as described by Rubin and colleagues. The submammary scar is ideally
placed at the inferior boundary of the pectoralis major muscle and is well hidden at
the lateral thoracic wall to the axillary crease.
Scar formation in upper body contouring is well accepted by patients, although re-
sults differ widely in quality and appearance as a result of the atonic skin quality
with poor elasticity after significant damage to extracellular matrix components that
can occur from bariatric surgery. In this regard, patients should be told that revi-
sional surgery might be necessary, because the rate for secondary corrections in this
patient group is relatively high as a result of skin and tissue relaxation.
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Part XII  Body Contouring

2877
Chapter 81  Back and Lateral Fold Contouring
Results
This 24-year-old man had reached a BMI of 62 at a weight of 210 kg (462 pounds).
He then lost 130 kg (286 pounds) through diet and vigorous sports activities. He
maintained a stable weight for 2 years and presented with a preoperative circumfer-
ential vertical excess of skin and soft tissue at the lower and upper truncal regions.
His main complaint was the local fat depots in the hip region, which were extremely
resistant to reduction despite his weight-loss efforts. In addition to excision of the
gluteal skin excess, he asked that the lower scapular folds be eliminated bilaterally
and requested breast and arm lifts. The patient is shown 3 months after a circum-
ferential lower truncal dermatolipectomy, followed by an FLTL combined with breast
reconstruction using a free nipple-areolar graft, and arm lifts. His vertical tissue ex-
cess and lower scapular folds were reduced sufficiently.

This 39-year-old woman had her greatest BMI of 64 at a weight of 176 kg (388
pounds); she lost 91 kg (200 pounds) after a gastric bypass procedure, and her weight
stabilized at 86 kg (190 pounds). When initially seen, she had a circumferential ver-
tical and horizontal excess of skin and soft tissue at the lower and upper truncal re-
gions. Although a preoperative BMI of 31 and the documentary appearance might
seem to indicate the need for further weight reduction, the patient felt absolutely
comfortable with her weight, which she considered to be her ideal body weight.
The patient is shown 9 months after a circumferential lower truncal dermatolipec-
tomy, 6 months after breast reconstruction in the technique described by Rubin, and
3 months after a direct horizontal excision in the dorsal thoracic region. The hori-
zontal excision eliminated the preexisting lower scapular folds, including an incom-
plete upper breast fold on the right thoracic wall. Postoperative scar formation was
impaired by scar dehiscence on the left dorsal thorax. Fortunately, the scar line was
well hidden in the bra line.
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Part XII  Body Contouring

This 43-year-old woman had lost 45 kg (100 pounds) 19 years earlier and had un-
dergone breast reshaping and an abdominoplasty 17 years earlier. She had her great-
est BMI at a weight of 183 kg (404 pounds), lost 113 kg (250 pounds) following a
gastric bypass procedure; her weight stabilized at 68 kg (150 pounds). She presented
with an extraordinary circumferential vertical and horizontal excess of skin and soft
tissue at the lower and upper truncal regions, with multiple skin folds in the ab-
dominal regions as well as dominant lower scapular folds, and less defined upper
breast and hip folds. After reconstruction of the lower trunk by circumferential lower
truncal dermatolipectomy and an inner thighplasty, the upper trunk was recon-
structed initially with an upper arm lift and in the final step with a ULTL, in com-
bination with breast reshaping with round silicone implants placed subpectorally.
She is shown 3 months after the final stage demonstrating an outstanding overall
contour; she was very pleased with the results. The less than optimal scar quality in
the axilla may require minor scar revision, which would be scheduled at the earliest
12 months postoperatively.
2879
Chapter 81  Back and Lateral Fold Contouring

This 24-year-old man lost 82 kg (180 pounds) through diet and exercise. His BMI
was 31 before a first-stage circumferential lower truncal dermatolipectomy; further
weight loss was resistant to any soft tissue reduction in the area of the lower trunk.
He was able to stabilize his weight at 78 kg (172 pounds). The first-stage procedure
produced remarkable improvement of the lower trunk; significant recontouring in
the gluteal region resulted in high patient satisfaction. The entire upper trunk was
improved through a total upper body lift, including contouring procedures in the
upper arm, lateral thoracic wall, and breast. The breast was reconstructed with a
free nipple graft, setting the scar into the inframammary fold to emphasize the male
breast shape, as described by Aly; the scar continues into the axillary region.
The patient is shown 6 months after the circumferential lower truncal derma-
tolipectomy and 3 months after the upper body lift. The upper trunk is greatly im-
proved, as are the breasts, arms, and lateral and dorsal thoracic wall. The upper
breast and lower scapular folds were eliminated by means of an indirect excisional
combined lateral thoracic lift. Reconstruction of the inner thigh region is planned as
a final step.
2880
Part XII  Body Contouring

Continued
2881
Chapter 81  Back and Lateral Fold Contouring
Clinical Caveats
 The entire posterior, lateral, and anterior trunk should be considered as inde-
pendent aesthetic units. Recognizing this, planning for treatment of the upper trunk
should include an analysis of every single unit to achieve optimal results in a min-
imum of stages.
 Lower body-contouring procedures such as circumferential lower truncal derma-
tolipectomies should be performed initially, followed by upper body procedures.
 Upper body procedures can be performed in single steps or as combined techniques
to reduce operative and recovery time and produce superior results.
 The correct choice of technique is the key to producing patient satisfaction. Gen-
erally speaking, massive-weight-loss patients are much more tolerant of longer
scars than they are of a procedure that results in insufficient skin and soft tissue
reduction.
 Liposuction in massive-weight-loss surgery is commonly performed as an adjunct
technique for contour refinements or may be performed preceding various exci-
sional procedures.
 Upper lateral thoracic lifts enable elimination of redundant skin and soft tissue in
the lateral and dorsal thoracic regions by placing a well-hidden scar in the lateral
thoracic region. This procedure can be performed alone or as an integral part of
an upper body lift.
 To prevent scar contractions in combined techniques, a Z-plasty can be included
at the axillary crease level.
 Horizontal back excisions that cross the relaxed tension lines usually result in un-
favorable scars, although hiding horizontal scars under the bra straps is easier than
with vertical incisions.
 The postoperative recovery after upper body–contouring procedures can be com-
pared with that for lower body–contouring procedures, although initially after up-
per trunk procedures, a patient’s mobility in activities of daily living is impaired
to a greater degree.
 Key elements in optimizing the outcome of surgery is careful patient selection, op-
timal choice of procedure, careful preparation and dissection, gentle tissue han-
dling, awareness of physiological changes, and the optimal choice of closure tech-
nique.

Clinical Caveats—cont’d
 The closure technique, especially the choice of suture material, can greatly affect
scar outcome. Any patient incompatibility to suture material should be determined
beforehand, since it can result in delayed wound healing and impaired scar qual-
ity and appearance. Nevertheless, secondary scar or wound revisions should be
undertaken as appropriate.
 Complications can be reduced by cautious procedure planning and precise mark-
ings, which will reduce operative time and lead to minimal tissue handling and
damage.
 Complications that occur frequently in lower body–contouring procedures, such as
seromas and minor wound separations, are less often associated with upper body-
contouring procedures.
 In general, patients with a lower BMI before surgery have fewer complications
and a superior result.
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Part XII  Body Contouring
Annotated Bibliography
Coon D, Michaels JV, Gusenoff JA, Purnell C, Friedman T, Rubin JP. Multiple procedures
and staging in the massive weight loss population. Plast Reconstr Surg 125:691-698,
2010.
The authors describe staging multiple reconstructive operations in patients after mas-
sive weight loss.
Strauch B, Herman C, Rohde C, et al. Mid-body contouring in the post-bariatric surgery
patient. Plast Reconstr Surg 117:2200-2211, 2006.
Dr. Strauch and colleagues have developed unique variations of the circumferential and
near-circumferential abdominoplasty operations at the height of the junction of lower
and upper trunk. A cohesive operative sequence that includes optimized patient prepa-
ration and positioning, tailoring of flaps for improved contour with avoidance of un-
necessary midline scars, a strong superficial fascial system closure, and coordination
with the entire operating room team has been developed and is presented. Sufficient
elimination of mild to moderate lower lateral and back folds is presented.
Strauch B, Rohde C, Patel MK, et al. Back contouring in weight loss patients. Plast Recon-
str Surg 120:1692-1696, 2007.
The authors have developed a classification system and surgical treatment for excess
back tissue that eliminates the local folds.

Suggested Readings
Aly AS. Body Contouring After Massive Weight Loss. St Louis: Quality Medical Publishing,
2006.
Aly AS, Cram AE, Chao M, et al. Belt lipectomy for circumferential truncal excess: the Uni-
versity of Iowa experience. Plast Reconstr Surg 111:398-413, 2003.
Gusenoff JA, Coon D, Rubin JP. Pseudogynecomastia after massive weight loss: detectabil-
ity of technique, patient satisfaction, and classification. Plast Reconstr Surg 122:1301-
1311, 2008.
Hunstad J, Repta R, eds. Atlas of Abdominoplasty. Philadelphia: Elsevier/Saunders, 2008.
Hurwitz DJ. Single-staged total body lift after massive weight loss. Ann Plast Surg 52:435-
441; discussion 441, 2004.
Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap. Ann
Plast Surg 56:481-486; discussion 486, 2006.
Jewell ML, Fodor PB, de Souza Pinto EB, et al. Clinical application of VASER-assisted
lipoplasty: a pilot clinical study. Aesthet Surg J 22:131-146, 2002.
Kenkel JM. Body contouring surgery after massive weight loss. Plast Reconstr Surg
117(Suppl):S1-S86, 2006.
Lockwood TE. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg
92:1112-1122, 1993.
Lockwood TE. The role of excisional lifting in body contour surgery. Clin Plast Surg 23:695-
712, 1996.
Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept.
Plast Reconstr Surg 87:1009-1018, 1991.
Richter DF, Stoff A, Velasco-Laguardia FJ, Reichenberger MA. Circumferential lower trun-
cal dermatolipectomy. Clin Plast Surg 35:53-71; discussion 93, 2008.
Rohrich RJ, Gosman AA, Conrad MH, et al. Simplifying circumferential body contouring:
the central body lift evolution. Plast Reconstr Surg 118:525-535; discussion 536-538,
2006.
Song AY, Jean RD, Hurwitz DJ, Fernstrom MH, Scott JA, Rubin JP. A classification of con-
tour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast Reconstr
Surg 116:1535-1544, 2006.
Song AY, Rubin JP, Thomas V, et al. Body image and quality of life in post massive weight
loss body contouring patients. Obesity (Silver Spring) 14:1626-1636, 2006.
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CHAPTER 82
Body Lift:
Belt Lipectomy

AL S. ALY, ALBERT E. CRAM

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Part XII  Body Contouring
T
echniques for altering body contour have evolved significantly over the past cen-
tury. Initially only dermatolipectomy techniques were used, but in the 1980s,
when liposuction was introduced, it facilitated the ability of plastic surgeons to
refine body contour with minimal scarring. Early on there was enthusiasm that li-
posuction might replace dermatolipectomy procedures completely. Although lipo-
suction is still, and probably will always be, the most commonly performed body-
contouring technique, it has limitations, especially in the area of skin retraction. In
patients who have skin that will not conform to underlying structures after liposuc-
tion, dermatolipectomy is still required to effect the desired body contour.
Early in the twentieth century, truncal contouring was limited to excision of the pen-
dulous pannus. Subsequently, abdominoplasty, in its various forms, was introduced
for the treatment of abdominal wall laxity and skin excess. Currently, abdomino-
plasty is best used in patients with truncal deformity limited to the anterior abdomen.
For patients who have a more generalized deformity of the trunk, abdominoplasty
is inadequate. In fact, incomplete or partial treatment of patients with circumferen-
tial excess may lead to worsening of lateral and posterior contours. Thus, to treat the
trunk as a unit, circumferential management is required. If the circumferential ex-
cess is mild to moderate, combining abdominoplasty with liposuction may achieve
the desired contour. However, as the lateral and posterior excesses increase, there is
a greater and greater need to extend the excisional component of the procedure
around the trunk, eventually leading to the need for circumferential resection.
There are many names in the literature for circumferential dermatolipectomy/torso-
plasty: circumferential or extended panniculectomy, central body lift, and lower
body lift. We prefer the term belt lipectomy, because conceptually all of these pro-
cedures involve a combination of “lifting up” and “pulling down” of different as-
pects of the truncal anatomy. The word lift is somewhat inaccurate in this context.
In this chapter, body lifting will be discussed in a wide variety of patient populations
and will be referred to as belt lipectomy.
Evolution of Technique
The first surgeon to coin the term belt lipectomy was González-Ulloa in 1961. He
used the technique on massive-weight-loss patients and described multiple turns in
the operating room. Baroudi subsequently described many body-contouring exci-
sional procedures, including circumferential truncal resections. Dardour and Vilain
briefly described their belt lipectomy technique on patients with massive weight
losses; it placed the final scar at midabdomen and may have added rectus fascia pli-
cation. Hunstad treated his obese patients by circumferential dermatolipectomy, ex-
tensive truncal liposuction, and subscarpal direct fat excision of the abdominal flap.

A number of other investigators subsequently contributed to our understanding of
circumferential truncal contouring. Perhaps the most significant contribution to mod-
ern body contouring was made by Lockwood when he introduced the use of the su-
perficial fascial system as an anchoring layer during closure of massive excisional
procedures. This type of closure has led to better scars and a greater ability to excise
more abnormal tissues during dermatolipectomy without the fear of dehiscence. He
introduced a number of lower body-lift procedures that have paved the way for oth-
ers in the pursuit of excellence in body-lifting surgery. Most recently, we critically
evaluated a large series of belt lipectomy patients in a review article in which we de-
lineated guidelines for patient selection, introduced a classification scheme for pa-
tients undergoing belt lipectomy, defined the truncal deformities encountered in our
patient population, evaluated the effects of surgery on different groups of patients,
and quantitatively reported on our complications.
Principles of Belt Lipectomy
Belt lipectomy is a combination of the following components:
 Abdominoplasty
 Lateral thigh lift
 Buttocks lift
 Liposuction of various areas
However, a belt lipectomy is not simply combining these procedures. The complex-
ity of combining these procedures, and the wide variety of body types that can ben-
efit from body lifting, make belt lipectomy a difficult procedure to master, with a sig-
nificant learning curve. Although the procedure has some basic features that are
common to most patients, the details of the technique are adjusted to each patient’s
present needs. For example, the technique used in a massive-weight-loss patient who
is still obese is different in detail from the technique used on a patient in the normal
weight range.
Belt lipectomy is an extensive procedure. It requires multiple turns of the patient in
the operating room, results in a very large area of surgical injury, and leaves a long
circumferential scar. Although it is possible for a single experienced surgeon to per-
form a belt lipectomy alone, it is often necessary to use an experienced assistant to
reduce potentially long operative times.
Complications are not uncommon with this type of surgery, and both the surgeon
and the patient must be willing and able to deal with setbacks. The postoperative re-
covery can be long, in some cases up to 6 weeks, which can cause strain for the pa-
tient and surgeon alike. Patients require both physical and psychological support for
a relatively long recovery period.
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Chapter 82  Body Lift: Belt Lipectomy

2888
Part XII  Body Contouring
The trunk is a body unit, with the thorax constituting the superior subunit, and tis-
sues from the lower aspect of the thorax to the pelvic rim constituting the inferior
subunit. The unit principle described by Millard dictates that when one is recon-
structing defects, it is best to reconstruct the whole unit and place the final scars
along natural junctions or between anatomic units. Burget and Menick, in discussing
reconstruction of the nose, emphasized the importance of creating proper contour
matching of the natural topographic nasal anatomy within each reconstructed sub-
unit. Belt lipectomy surgery is an extrapolation of these important principles, ap-
plied to the trunk. The surgeon’s goal is to create proper contour of the inferior sub-
unit of the trunk and to place the resultant scar in natural junctions.
Another major advantage of circumferential dermatolipectomy procedures, despite
their being extensive and associated with significant morbidity, is the high patient
satisfaction rate. Studies conducted on patients who have undergone belt lipectomy
demonstrate an improvement in the overall truncal contour in a wide variety of pa-
tients, as rated by both the surgeon and the patient.
Indications and Contraindications
Indications
There are many patients who can benefit from a belt lipectomy. Their presentations,
goals, and outcomes vary considerably. They are grouped here into clinically rele-
vant categories.
Massive-Weight-Loss Patients
Advances in bariatric surgery and the recognition of obesity as a leading health risk
factor in the United States, have led to an increase in the number of patients re-
questing body contouring after massive weight loss. Although the medical benefits
of weight loss, such as reduction or elimination of diabetes and high blood pressure,
are by themselves worth the time and effort, the resultant body contour in most pa-
tients is less than ideal. Often these patients are surprised and dismayed by their ap-
pearance. If they are able to undergo body-contouring surgery, it can be the final step
in their life transformation. Post–massive-weight-loss body contouring is the new
frontier in plastic surgery, and it will become one of its major subspecialties in the
near future.

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Chapter 82  Body Lift: Belt Lipectomy
The plastic surgeon will see a wide range of body contours and sizes in massive-
weight-loss patients. These individuals also have differences in the thickness of sub-
cutaneous fat, skin-fat envelope redundancy, and in their fat deposition patterns.
Multiple factors have been found to contribute to the diversity encountered with
massive-weight-loss patients. The first and most important is their BMI at presenta-
tion. BMI relates the patient’s weight to their height and is the most commonly used
obesity index. It is calculated as shown in the box on p. 2890.

2890
Part XII  Body Contouring
Calculating Body Mass Index
The upper limit of normal is 25; 26 to 29 is considered overweight; 30 to 35 is considered
obese; and greater than 35 is considered morbidly obese.
or
Weight in kilograms
(Height in meters)2
Weight in pounds  703
(Height in inches)2
The actual weight-loss process, whether from bariatric surgery or changes in lifestyle,
will stabilize or plateau at different levels in different individuals. The level of this
plateau is not easily altered. Thus BMIs at presentation will range on a continuum
from individuals who are still significantly obese to those who are near their ideal
weight. A second factor contributing to the diversity in presentation is the quality of
the skin fat envelope, which includes its thickness, elasticity, and, what is most im-
portant, what we have coined as the translation of pull.
The translation of pull is determined by pinching tissues in the proposed area of re-
section, simulating the effects of the surgical resection on the tissues above and below.
This patient demonstrates a significant translation of pull, which can be seen by the
patient and surgeon before surgery. The third major factor affecting the diversity of
massive-weight-loss patients is their genetically controlled fat deposition pattern,
which dictates the amount and location of fat during weight gain and loss.

Although quite variable in presentation, massive-weight-loss patients share a com-
mon factor: almost all will have an inverted-cone appearance to their inferior trunk—
narrower at the ribcage and wider at the pelvic rim. Anteriorly, they have varying
degrees of pendulous panniculi and may have one, two, or, occasionally, three rolls.
It is not clear why these extra rolls develop, but there are probably fibrous connec-
tions between the skin and underlying muscle fascia that are similar to the infra-
mammary crease anatomically. Almost all massive-weight-loss patients will present
with some degree of abdominal wall laxity. Many also have hernias of varying sizes
and locations, especially patients who have had open bariatric surgery procedures.
The mons pubis frequently has ptosis, lipodystrophy, and varying degrees of verti-
cal and horizontal excess. The opening of the vulva in women and the takeoff of the
penis in men will face downward to varying degrees, rather than the normal ante-
rior vector.
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Chapter 82  Body Lift: Belt Lipectomy
Laterally, massive-weight-loss patients will lack definition of the waist because of
excess tissue hanging from the narrower ribcage to the relatively wider pelvis, which
tends to camouflage the underlying anatomy. Many patients have fairly large and
distinct hip rolls. The lower back is often indistinct from the superior aspect of the
buttocks. Some patients have lower back rolls; others do not. The buttocks in many
patients are overprojected and simply blend superiorly with the hip excess, giving
the buttocks a vertically long appearance. In other patients, the buttocks may have
no excess in posterior projection but often still lack definition. The superior extent
of the central buttocks crease in some is fairly low, and it may be combined with a
loss of soft tissue cover over the coccyx. The infrabuttock crease varies greatly in
presentation, depending on the BMI. When patients are still in the obese range, the
infrabuttocks creases are usually very abnormal in appearance and are horizontal
rather than semicircular. In patients who have reached BMIs near their ideal body
weight, often the infrabuttocks creases will show redundancy.

The goals for an individual patient may vary within the massive-weight-loss group,
but in general, there is a desire to return the patient’s truncal contour to the normal
range for the general population. More specifically, goals in the abdominal area in-
clude elimination of hanging tissue and restoring a flat contour. If the mons pubis is
ptotic, it should be lifted to a more superior position to produce an anterior-facing
vulva in women and an anterior penile takeoff point in men. An hourglass figure,
with narrowing at the waist, should be reconstituted, although to a lesser degree in
a male patient. Posteriorly, lower back rolls should be reduced or eliminated. A clear
delineation between the lower back and buttocks should be created. The desired im-
provement in the buttocks proper is highly dependent on the initial presentation. If the
buttocks are overprojected, they should be reduced. If they are already underpro-
jected, they should be better defined but not reduced in projection. The central but-
tocks crease in some patients requires elevation to a more superior position. If pos-
sible, the infrabuttocks crease should be altered to approximate a normal semicircular
appearance.
A subgroup of massive-weight-loss patients includes individuals who have under-
gone anterior truncal resections but are still unhappy with persistent lateral dog-ears,
a lack of definition in the waist, and lack of improvement in posterior truncal con-
tour. The number of patients presenting in this manner is increasing as massive-
weight-loss patients are either convinced to, or choose to, undergo resections lim-
ited to the anterior trunk. The goals of this subgroup of patients are similar to those
of massive-weight-loss patients who have not undergone these resections. Depend-
ing on the extent of their initial procedure, these patients may need a full belt lipec-
tomy, a modified belt lipectomy, or a partial belt lipectomy limited to the lateral and
posterior resections.
Non–Massive-Weight-Loss Patients
Patients Who Are 20 to 30 Pounds Overweight
Non–massive-weight-loss patients usually request either liposuction or an ab-
dominoplasty but are 9 to 14 kg (20 to 30 pounds) over their ideal body weight.
They have usually tried to lose the weight over many years but have been unable to,
despite genuine attempts. They may be young with good skin elasticity, or older with
significant skin laxity. Typical truncal contour deformities include abdominal wall
laxity, skin and fat excess, and lateral and back excess. Many will have lower back
rolls and buttocks ptosis. They may or may not have lateral and medial thigh lipodys -
trophy. If these patients undergo simple abdominoplasty, significant lateral dog-ears
may be created, and their lateral and posterior contours will not be improved. If lipo -
suction is combined with abdominoplasty, adequate improvement may be achieved.
However, this combination of procedures will not result in lifting of the lateral thighs
2892
Part XII  Body Contouring

and buttocks or a more defined waist, especially if the typical abdominoplasty inci-
sions are not extended around to the back. The goals for this group of patients in-
clude a flat abdominal contour, waist and hip definition, elimination or reduction
of lower back rolls, raising and definition of the buttocks, and reduction in lateral
thigh excess and ptosis. These patients start out with bodies that are within the norm
for the overall population, and they desire a greater shift toward ideal when com-
pared with many massive-weight-loss patients.
Normal-Body-Weight Patients
Patients of normal body weight present with abdominal wall laxity and/or skin ex-
cess. They also usually have different degrees of isolated fat deposits in the lateral
thighs and hip regions. Most patients who present in this manner can benefit from
abdominoplasty, with liposuction of the areas involved with lipodystrophy. The rea-
sons for considering belt lipectomy in this group include a desire for significant an-
terior and lateral thigh elevation, buttocks elevation, and a remarkable improvement
in lower truncal contour.
Contraindications
As with any elective surgery, belt lipectomy should not be performed in patients with
significant medical or psychiatric problems. The possible fluid shifts and alterations
of intravascular volume during a belt lipectomy can stress a less than optimally func-
tioning heart. Almost all patients who undergo a belt lipectomy will need a significant
amount of abdominal wall tightening by various forms of rectus fascia plication. As
the abdominal wall is tightened, the intraabdominal contents are pushed up onto
the diaphragm and in turn onto the lungs, leading to some restriction of pulmonary
capacity. In patients who have significant lung disease, pulmonary compromise may
occur. Thus patients with significant chronic obstructive pulmonary disease (COPD)
or restrictive lung disease are not good candidates for belt lipectomy. With the in-
herent compromise of blood supply of undermined abdominal tissues during the
procedure, conditions associated with decreased vascularity, such as smoking, are to
be avoided in most instances. We have recently performed belt lipectomy on well-
selected diabetic patients; however, it is not clear at this point whether this will
become routine.
Patients who have lymphedema of their anterior abdominal pannus are not good
candidates for belt lipectomy, since they will almost universally redevelop lymphedema
and a hanging pannus. It is best to avoid such extensive surgery in the face of almost
certain failure, and such patients should be counseled accordingly.
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Chapter 82  Body Lift: Belt Lipectomy

2894
Part XII  Body Contouring
Patients with excessive intraabdominal content are not good candidates for belt lipec-
tomy. The illustrations below demonstrate why this is true.
Conceptually, the inferior trunk can be thought of as two balloons, one inside of the
other. The outer balloon is the skin and the inner balloon is the abdominal wall mus-
culature, within which the intraabdominal contents are contained. Fat is contained be-
tween the two balloons and inside the abdominal cavity.
If both balloons are overinflated by weight gain and subsequently deflated by weight
loss (second from left), then reducing the outer balloon without being able to flat-
ten the inner balloon will lead to a persistently convex contour (third from left). The
appearance of a patient with excessive intraabdominal content after a belt lipectomy
is similar to a patient who undergoes a simple panniculectomy. Since a panniculec-
tomy is a simpler and less risky procedure, obese patients who have excessive intra -
abdominal content are advised to lose weight or undergo a traditional panniculec-
tomy. Thus a basic requirement for patients undergoing belt lipectomy is that their
intraabdominal contents allow abdominal wall flattening by rectus fascia plication.
Hormonal manipulation of body fat content is an emerging field in the medical man-
agement of obesity. In general, growth hormone deficiency is associated with an in-
crease in both subcutaneous and intraabdominal fat, with a preferential increase in
intraabdominal fat. Growth hormone replacement will lead to an overall decrease
in body fat content, with a relatively greater loss of intraabdominal fat. Testosterone
is also known to decrease the overall body fat content, with selective activity at the
intraabdominal level. Thus in the future it may be possible to use these hormones to
decrease intraabdominal fat in patients who tend to retain it after massive weight
loss to allow better abdominal wall tightening during body-contouring procedures.

Pertinent Anatomy
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Chapter 82  Body Lift: Belt Lipectomy
Less adherent
Strong adherence
Variable adherence
The soft tissues over the inguinal region and at the junction between the hip and lat-
eral thigh fat deposits are anchored by zones of adherence consisting of fascial at-
tachments that restrict both elevation and descent of the tissues surrounding this
region. The inguinal region zones of adherence, along with a variable-strength supra-
pubic zone of adherence, create a lower abdominal area of restriction that is re-
sponsible for why a hanging pannus hangs. It is also these horizontal zones of ad-
herence that are essential to understanding how to control scar position in the
marking process. There is a weak midline abdominal zone of adherence that is usu-
ally inconsequential to excisional body-contouring procedures.
The blood supply of the abdominal flap after its elevation off the underlying mus-
cular fascia is reduced to the lateral intercostal, subcostal, and lumbar vessels, as
shown. Although this is similarly encountered in a traditional abdominoplasty, the
blood supply in a belt lipectomy maybe jeopardized to a greater extent when some
techniques are used in particular patients because of the need for more extensive lat-
eral dissection of the abdominal flap.
Superficial
epigastric artery
Deep inferior
epigastric artery
Superior
epigastric artery
Subcostal artery
Ascending branch of
deep circumflex artery
Lumbar branches
Intercostal branches

Massive-weight-loss patients also have various zones of adherence in the superior
truncal subunit of the thorax.
Preoperative Assessment
History and Physical Examination
A complete history is taken and a thorough physical examination is conducted on
all patients being considered for belt lipectomy. The patient’s weight history, exer-
cise routine, and nutritional habits are documented. Patients whose weight is fluc-
tuating when they are initially seen should not be operated on until they reach a sta-
ble weight. Patients who are in the midst of heroic efforts to lose weight, such as
starvation diets or overly taxing exercise regimens, should not be considered candi-
dates, because most patients are not able to sustain such efforts over a lifetime. Pa-
tients with significant medical problems, uncontrolled psychiatric difficulties, and
smokers are not good candidates and should be counseled accordingly.
As stated, postoperative recovery from a belt lipectomy is long, and complications
are not uncommon. Even for patients with adequate psychological reserves to handle
such stress, psychiatric difficulties can arise. Many massive-weight-loss patients pre -
sent with a concurrent psychiatric illness and are at risk for acute flare-ups during
recovery. A preoperative psychiatric clearance should be considered in these patients.
2896
Part XII  Body Contouring

The patient’s BMI should be determined. Although the BMI is not always accurate,
especially in an athletic male with a relatively large muscle mass, it is helpful for pre-
dicting results and potential complications. The patient’s overall body contour is ex-
amined circumferentially, with close attention to the inferior truncal subunit, thighs,
thorax (superior truncal subunit) and upper arms.
The surgeon must determine the extent of abdominal wall laxity and whether the
amount of intraabdominal content is excessive. In patients within the normal weight
range, this is determined by abdominal wall palpation and the classic “diver’s test,”
in which the patient bends forward from the waist, revealing any abdominal wall
laxity. This is more difficult to determine in patients with higher BMIs but can be es-
tablished by placing the patient in the supine position and observing the abdominal
wall contour. If the abdomen is scaphoid, it is likely that the intraabdominal con-
tents are not excessive, which should allow rectus fascia plication to tighten and flat-
ten the abdominal wall. Conversely, if the abdomen in the supine position is convex
and protrudes above the ribcage, intraabdominal content is excessive and belt lipec-
tomy should not be considered as an option. The surgeon should search thoroughly
for hernias, because it is not unusual for patients to have incisional, ventral, or peri-
umbilical hernias. The patient’s fat distribution pattern and skin quality should be
examined. Subcutaneous fat thickness and skin mobility over the underlying mus-
cular anatomy are noted. Generally, thinner subcutaneous fat layers increase the like-
lihood that the skin will be fairly mobile when resection is attempted. For patients
who have had bariatric surgery, the following laboratory tests should be obtained:
complete blood cell count, blood urea nitrogen, creatinine, electrolytes, glucose, uri-
nalysis, liver function, iron, calcium, albumin, prealbumin, total protein, and thia -
mine. Chest radiographs and electrocardiograms are obtained if indicated.
Patient Education
Because of the magnitude of belt lipectomy surgery, patients should be counseled
extensively in the preoperative period. This will help the patient and the surgical team
develop rapport, which is invaluable in the relatively long postoperative recovery pe-
riod. Both the patient and plastic surgeon should clearly understand the presenting
deformities and the patient’s realistic goals. An overview of the surgery, the typical
postoperative course, and the possible risks and complications should be thoroughly
discussed. This is especially important because patient cooperation is essential in
preventing complications in the early postoperative period. For many patients, es-
pecially massive-weight-loss patients, body-contouring surgery is the culmination of
a life transformation, and it may be the toughest hurdle from a physical, psycholog-
ical, and financial standpoint for them. Thus it should be presented to them as a “ma-
jor life event.”
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Chapter 82  Body Lift: Belt Lipectomy

Preoperative Planning
Markings
The markings are usually done 1 or 2 days before surgery. These are photographed;
the surgeon evaluates the photos and may make changes based on the findings. As
with the whole field of body lifting, the markings have evolved and will continue to
evolve to produce the best results and to adjust to new and unique problems. The
markings are different for every patient, and the sequence described here is intended
to be a starting point from which to diverge and adjust to attain the best result.
A number of concepts should be stressed in performing the markings:
 The money is in the belly. The abdominal contour attained after surgery should
be as good as possible given a particular patient’s anatomy. It should be of
higher priority than the posterior contour in treating most patients because it
is the area of greatest deformity, especially in the massive-weight-loss patient,
and it is also the most visible area to the patient.
 The lateral resection should be maximized. The patient’s lateral contour is also
very important and should be stressed because it is highly visible and easily
judged by the patient. Although in some patients the waist region does not
need significant improvement, in most patients it is essential that this area be
contoured as aesthetically as possible.
2898
Part XII  Body Contouring
B
A
 The markings delineate the superior and inferior extents of a circular excision
in an inverted-cone shape. If the circumference of the superior proposed line
of excision (A) is compared with the circumference of the inferior proposed
line of excision (B), A is always shorter. Occasionally the distances are equal,

but B is almost never shorter than A. This is important, because it explains the
fact that in almost all patients there is no need to decrease upper truncal hor-
izontal excess, as would be attempted with a fleur-de-lis pattern.
 The markings should be considered as guides to the resection. The actual re-
sections should be adjusted to intraoperative tension.
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Chapter 82  Body Lift: Belt Lipectomy
The patient’s anterior midline is marked. In non–massive-weight-loss patients, the
horizontal mons pubis mark is made similar to the marking for traditional ab-
dominoplasty, usually at the natural suprapubic crease. A massive-weight-loss pa-
tient is placed in the supine position, the mons pubis is pulled up into a pleasing ap-
pearance, and the pubic bone is palpated. At a point 1 to 2 cm above the bone, the
horizontal mark is made from one lateral edge of the mons to the other. In some pa-
tients this may lead to eliminating as much as 15 cm of hair-bearing skin.
With the patient in the supine position and slightly bent at the waist, a line is drawn
from the lateral aspect of the mons pubis and directed toward the anterior superior
iliac spine (ASIS). The mark is made after the abdominal tissues are manually ele-
vated superomedially to estimate the amount that the inguinal tissues will lift. The
zone of adherence in the inguinal region limits the extent of this lift. This maneuver
simulates tissue dynamics at closure and allows the surgeon to predict final scar po-
sition to a great degree. The pull of the manual elevation of the flap simulates the su-
peromedial pull of the resected abdominal flap. The inguinal zone of adherence acts
to limit that elevation. We prefer a “French bikini” angulation of this mark, with the
line drawn aiming slightly above the ASIS. If the surgeon prefers a flatter-angled scar,
the same superomedial elevation of the abdominal tissues is performed, and the scar
is drawn where the surgeon wants it.

The proposed superior extent of the anterior resection is marked. Centrally, the mark
is made similar to that for a traditional abdominoplasty and should not be tempered
by the subsequent back resection, because the anterior resection is stressed over the
back resection. In non–massive-weight-loss patients it is usually just above the um-
bilicus, whereas in massive-weight-loss patients the mark may be considerably higher.
Because of the circumferential nature of belt lipectomy, the lateral abdominal exci-
sions are marked without concern for possible dog-ears, as in the case of ab-
dominoplasty markings. The markings are made with the aid of the pinch technique
and should be as aggressive as they need to be to create a flat lateral contour. Later-
ally, the superior proposed mark should be made fairly flat, because angulating this
aspect of the mark may lead to compromise of some of the remaining abdominal
flap intercostal, subcostal, and lumbar vessels. In turn, this can cause central flap
necrosis.
Anteriorly, the inferior marks control scar position.
2900
Part XII  Body Contouring

With the patient standing, the back midline is marked. A decision has to be made as
to the vertical level of the posterior resection. In many patients this is a fairly easy
decision, because the area of posterior excess is fairly well delineated by the natural
anatomy. In others it is not evident, and the surgeon has to decide on the level based
on the desired goal. Some patients have excessive buttock protrusion, and their re-
section level should include the superior aspect of the buttocks proper to allow for
an appropriate reduction. Other patients have normal or less-than-normal buttock
projection, and the level of resection in these patients should be more superior to
avoid decreasing the projection farther. Part of this decision is also based on the sur-
geon’s aesthetic sense and the patient’s desires. Once the level of resection is decided
on, the inferior midline mark is made.
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Chapter 82  Body Lift: Belt Lipectomy
The superior extent of the midline back excision is marked with the patient flexed
at the waist to approximate the bent position in which the patient will be at the com-
pletion of the anterior resection. This is a very important step in preventing wound
dehiscence.

2902
Part XII  Body Contouring
The inferior aspect of the back excision is then marked from the midline toward the
lateral aspect of the trunk. Centrally, a shallow widow’s peak is created at the mid-
line, and bilateral lazy S’s are drawn. In most patients the areas that need the great-
est elevation posterolaterally are the lateral buttocks and lateral thigh regions. Re-
secting more laterally in these regions will create a better lateral contour and will
improve the shape of the infrabuttocks crease in most patients.
The superior extent of the back excision is marked using the pinch technique. Gen-
erally, this mark is placed fairly close to where the actual final scar will end up, since
back tissues are restricted in their movement because of their stronger zones of ad-
herence, whereas buttocks tissues are quite mobile. Thus tissues from the buttocks
and lateral thighs are lifted to the position of the superior incision in this region
rather than the lower back tissues descending to the inferior tissues.
Posteriorly, the superior marks control final scar position.

At this point in the marking process, both the anterior and the posterior marks are
in place. There may be a transition from the anterior to the posterior marks. Supe-
riorly, connecting the anterior and posterior marks is usually not difficult, because
they typically line up well. Inferiorly, in some patients the anterior mark may be sig-
nificantly higher than the posterior mark. A compromise then needs to be made be-
tween these marks. The anterior marks are lowered and the posterior marks are
raised. Often this transition will fit in the natural creases, especially in massive-weight-
loss patients. The patient is then placed through the operative positions, supine and
both lateral decubitus positions, and the marks are checked for symmetry and
whether they are reasonably placed.
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Chapter 82  Body Lift: Belt Lipectomy
A series of vertical marks is made to facilitate align-
ment at closure, because many patients who undergo
a belt lipectomy have tissues that become signifi-
cantly distorted in the operative positions. In patients
with an extremely ptotic and redundant mons pu-
bis, normal contour should not be expected nor
promised. A compromise should be accepted rather
than risking overresection, which can potentially
lead to permanent lymphedema of the mons pubis.
After complete healing from belt lipectomy, a sepa-
rate mons puboplasty can be considered and dis-
cussed with the patient.

2904
Part XII  Body Contouring
With typical markings, the vertical marks are helpful in aligning tissue during clo-
sure. Often two sets of lines are drawn as possible superior extents of resection, and
the appropriate line is used at surgery based on the tension encountered.
Markings continue underneath the hanging pannus.
If the patient needs lateral and anterior thigh liposuc-
tion, those areas are marked.

Operative Technique
Because of the circumferential nature of belt lipectomy, it is not possible to perform
the total resection using a single body position in the operating room. Both the num-
ber of body positions employed and the sequence in which they are used can be var-
ied and will differ from surgeon to surgeon. Based on the need to stress the anterior
resection over the posterior resection and to maximize the lateral resection, the se-
quence of supine-lateral/decubitus-lateral/decubitus has been found to optimize the
results and will be described here.
Preoperatively the patient has an epidural catheter placed for postoperative pain
management. We have found that epidural analgesia considerably reduces the risk
of deep venous thrombosis/pulmonary embolism; thus chemoprophylaxis is not used.
If the surgeon chooses not to use an epidural—which most will not—they should
consider the use of chemoprophylaxis, although it is not easy to determine the best
regimen to use.
Sequential compression stocking are put on the patient in the holding room. The pa-
tient is then taken to the operating room and placed in the supine position on the
operating table with an underlying beanbag. Symmetry is checked before induction
of general anesthesia. Once general anesthesia is induced, the arms are placed at a
90-degree angle and padded, and an indwelling urinary bladder catheter is placed.
An 18-gauge needle dipped in methylene blue is used to tattoo the vertical marks
above and below the extents of possible resection. The methylene blue tattoos will
last for a few weeks and are very helpful for tissue orientation at closure.
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Chapter 82  Body Lift: Belt Lipectomy
Because the anterior resection has to end where the patient’s body makes contact
with the operating table, a temporary dog-ear is marked in the shape of a V. This
area is temporarily closed with staples at the end of the anterior resection. The pa-
tient is then prepared and draped.
6
82-1 Belt lipectomy

Two 2-0 silk sutures are placed through the skin of the superior and inferior um-
bilicus as traction sutures. If the umbilical stalk needs to be shortened, the sutures
can be placed deeper within the umbilicus. A circumbilical incision is then made and
dissected down to the level of the rectus fascia with some fat left on the stalk.
2906
Part XII  Body Contouring
The anterior abdominal inferior mark is then incised and carried down to the level
of the Scarpa’s fascia. The abdominal flap is elevated superiorly, at or just below
Scarpa’s fascia up to the umbilicus. In patients with a thin pannus, the dissection is
carried up to the costal margins and xyphoid, indicated above by the methylene blue
chevron-shaped marks. In patients with a thick pannus, the supraumbilical dissec-
tion is limited to the medial edges of the rectus muscle fascia and the flap is lipo-
suctioned directly to thin it.
Patients with scars from an open cholecystectomy are at risk of tissue necrosis infe-
rior to the scar if that tissue is elevated off the underlying muscle fascia and advanced
as the inferior aspect of the abdominal flap. In these patients, the proposed superior
mark is incised first. A limited central supraumbilical dissection is performed, just

enough to allow advancement of the flap to the proposed inferior marks. The blood
supply of the tissue inferior to the cholecystectomy scar is then examined. If it ap-
pears viable, the inferior flap is elevated down to the level of the inferior marks and
is then tailored to the superior mark. If the tissues appear to be vascularly compro-
mised, all of the tissue below the cholecystectomy scar is resected and the inferior
flap is elevated and tailored to the level of the resection at the cholecystectomy scar.
In this case the final scar is going to be much higher onto the abdomen, and the mons
pubis will most likely not be addressed adequately, requiring a secondary excisional
procedure.
Abdominal wall plication is performed with a nonpermanent, running, long-lasting,
barbed suture. If any hernias are encountered, they are treated before the plication
is done. In a small number of patients the umbilical stalk is part of the hernia sac
and may need to be sacrificed.
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Chapter 82  Body Lift: Belt Lipectomy
The infraumbilical plication is usually performed before the supraumbilical plica-
tion, because this is the area of greatest laxity in most patients, especially women.
During plication, peak respiratory pressures should be checked. Most patients’ respi -
ratory pressures will rise mildly with the plications, but if they are significantly ele-
vated, restriction of pulmonary function could develop. This can be avoided by mak-
ing certain that the patient does not have excessive intraabdominal contents during
the preoperative examination.

Ferguson clamps are used during tailoring of the abdominal flap. Extensive amounts
of anterior abdominal excess will often need to be resected in massive-weight-loss
patients. Laterally, in the area of the previously marked V, the temporary dog-ear is
stapled.
In patients who have midline vertical supraumbilical scars, occasionally the scar is
tethered and may prevent advancement of the inferior flap during the tailoring pro-
cedure. In these patients the surgeon makes a series of horizontal nicks in the verti-
cal scar to release the scar and allow appropriate advancement. We prefer not to re-
sect the scar during a belt lipectomy, because it increases the risk of vascular
compromise of the distal aspect of the abdominal flap at the T intersection.
2908
Part XII  Body Contouring
The patient is then flexed at the waist and the abdominal flap is redraped inferiorly
and tailored to the inferior incision. As the flap is redraped, it is also conveniently
split in the inferior midline. Splitting the flap facilitates the initial flap elevation in a
patient with a large hanging pannus.

The abdominal wound is then closed in multiple layers, the first and most important
layer being the reapproximation of superficial fascia, or Scarpa’s fascia. One of the au-
thors (A.S.A.) prefers to use Quill 1 PDO nonpermanent, long-lasting, running barbed
suture to reapproximate Scarpa’s fascia, whereas the other author (A.E.C.) prefers
0 PDS nonpermanent, long-lasting, interrupted sutures. We have found no difference
in scarring between these different closures. The next layer of closure is accomplished
with nonpermanent subcuticular staples. The final layer is closed with a running sub-
cuticular 2-0 Monocryl temporary suture. Finally, tissue glue is applied to the skin
to complete the closure.
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Chapter 82  Body Lift: Belt Lipectomy
Three nonpermanent sutures (we prefer 3-0 Monocryl) are placed at the 3, 6, and 9
o’clock positions at a subcuticular level on both the abdominal flap and the umbili-
cus, as well as through the surrounding rectus fascia to help invaginate the umbili-
cus when the sutures are tied. The remainder of the umbilicus is sutured to the ab-
dominal flap with simple interrupted, nonpermanent, subcuticular sutures.
Before abdominal closure, a series of interrupted quilting sutures are placed from
the abdominal flap to the rectus fascia, to help close dead space. We think that this re-
duces the risk of seroma formation.
A closed suction drain is placed and brought out through a lateral stab incision. If
the patient requires liposuction of the anterior and medial thighs, this is performed
either through the open abdominal wound or through appropriate stab incisions.
The proper location of the umbilicus is then determined with the abdominal flap
temporarily tacked in place with Ferguson clamps. A vertical 1.5 to 2 cm incision is
made in the midline at the chosen location. The fat deep to the incision is bluntly
dissected apart to allow a path for the umbilicus.

Just past the midline of the back, a temporary V-shaped dog-ear is again marked to
allow for the subsequent turn.
The patient is prepared and draped again in this position. The lateral thigh is suc-
tioned if necessary. Unlike the anterior resection, the superior mark is incised first
during the back resection. The reason for this is twofold. First, most patients have
more inferior than superior laxity in the lateral trunk, so it is best to dissect inferi-
orly rather than superiorly to lift the ptotic buttocks and lateral thighs. Second, the
back has tendency to develop seromas, and less dissection in this area is desirable.
The level at which the inferior flap is elevated is based on the patient’s anatomy. If
the patient has overprojected buttocks, as is the case in most high-BMI patients, the
dissection is performed at a level just above the muscle fascia, leaving a small amount
of fat on the fascia.
2910
Part XII  Body Contouring
The patient is then turned over to one of the lateral decubitus positions, which al-
lows maximal resection of the lateral trunk and more direct access to the lateral
thighs for liposuction. To accomplish the turn efficiently and safely, five or six people
should be involved. One person is assigned the responsibility of making certain the
patient is flexed at the waist to prevent dehiscence. Multiple pillows are placed be-
tween the knees to flex the hip as much as possible. All pressure points are padded,
an axillary role is placed, and the beanbag is molded and hardened to hold the pa-
tient in the desired position. In this position, resection from the created lateral dog-
ear to the midline of the back is performed. If lateral thigh liposuction is needed, it
is also performed while the patient is in this position.
The lateral and back marks are reinforced and the vertical marks are tattooed in this
position.

This illustration demonstrates the extent of direct elevation (blue) and possible in-
direct, or discontinuous, lateral thigh elevation (green), usually performed with a
large, unconnected liposuction cannula.
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Chapter 82  Body Lift: Belt Lipectomy
If the patient has underprojected buttocks, the elevation is performed at the level of
the superficial fascia so that as much fat tissue as possible is left behind. In either
case, the flap is elevated at least to the level of the proposed inferior line of excision.
The dissection can be carried down as low as needed to get the desired amount of
tissue resected; not infrequently, this can be down to the level of the midbuttocks.
The inferior flap is then redraped superiorly and, with the aid of Ferguson clamps,
tailored accordingly. The vertical marks, placed every 10 cm or so, are extremely
helpful in aligning tissue at this juncture.

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In patients with excessive buttocks protrusion, there is a discrepancy in thickness be-
tween the lower back and the buttocks. Tailoring of the inferiorly based flap should
be more aggressive in the fat deep to the superficial fascia to equalize the thickness
of the subcutaneous fat of the two edges brought together. This is an important step
in helping create a smooth transition between the buttocks and the back, which many
of these patients lack. If there are still small discrepancies after closure, liposuction
can be performed to create a smooth con tour from the waist through the hip and
down onto the lateral thighs and buttocks.
One closed suction drain is placed in the back through a stab incision made later-
ally. The closure of the back is similar to the anterior closure. Just past the midline,
the temporary dog-ear is closed with staples to allow for the final turn.
The patient is turned to the other lateral decubitus position, and the other side of
the resection is completed in a similar manner. Occasionally, the second side does
not allow for as much resection of tissue as the first side; thus the surgeon should
not assume that the same amount can be removed.
After the second side is completed, the patient is placed in the supine position on the
operating table, with the waist flexed to the appropriate position. This turn, as all
other turns, requires five or six people to accomplish safely, with one person mak-
ing certain that the waist is flexed appropriately. There is the danger of causing ab-
dominal flap necrosis with circumferential compression; thus compression garments
are not routinely used.
After extubation, the patient is placed on a flexed hospital bed under the guidance
of the surgeon to prevent dehiscence.
Back
Buttocks

Adjunctive Procedures and New Concepts
Upper Body Lift
Belt lipectomy addresses problems of the inferior subunit of the trunk, from the
ribcage to the pelvic rim. For non–massive-weight-loss patients, the procedure ad-
dresses their problems well, since their deformities are usually limited to the inferior
subunit. Massive-weight-loss patients, on the other hand, often have problems in-
volving the superior subunit of the trunk, or the thorax.
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Chapter 82  Body Lift: Belt Lipectomy
Midaxillary
line
When thoracic soft tissues are inflated by obesity and then deflated by weight loss,
they will hang lower than their original position, onto the underlying skeleton, with the
exception of the zones of adherence located at the anterior and posterior midlines.
The soft tissues overlying the midlines thus are tethered, while the rest of the thoracic
tissues are free to hang down as a curtain drapes down from two tethering pleats.

The region of greatest descent is located at the midaxillary line, because that is the
greatest distance from the zones of adherence. Anteriorly the breast will demonstrate
varying degrees of ptosis. The nipple-areola complexes will often appear medially
displaced, but this is an optical illusion, because the lateral inframammary crease is
free to descend, while the midline zone of adherence tethers the medial inframam-
mary crease. The transition from the lateral breast onto the lateral chest wall usu-
ally is in the form of a roll that is an extension of the lateral breast and may extend
onto the back as an upper back roll. In some patients a second roll is also present.
The upper back roll occurs in various sizes and will travel in a superior direction to-
ward the midline posterior zone of adherence. Overall, the thorax has both vertical
and horizontal excess as a result of the deflation of weight loss.
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Part XII  Body Contouring

In massive-weight-loss patients, the upper arm excess often spills onto the lateral
chest wall. This is important, because most brachioplasty techniques do not address
the lateral chest wall excess, which is part of the horizontal thoracic excess created by
massive weight loss.
The constellation of upper truncal deformities in massive-weight-loss patients has
not received much attention, because the abdominal pannus tends to be the over-
whelming problem that massive-weight-loss patients complain about—and what in-
surance companies are willing to pay for. However, as these patients become more
familiar to plastic surgery as a whole, there will be greater emphasis on all their ar-
eas of deformity, including the thoracic region.
The individual massive-weight-loss patient may or may not have any or all of the
thoracic deformities described here. The deformities depend on the amount of weight
gained and lost and on the patient’s genetically controlled fat deposition pattern.
Each of these deformities can be treated separately, or together in a single procedure.
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Chapter 82  Body Lift: Belt Lipectomy

Massive-weight-loss patients have upper arm excess that is in con-
tinuity with the thoracic tissue’s horizontal excess is marked preop-
eratively for a brachioplasty technique that crosses the axilla, onto
the lateral thoracic wall. Previously we would perform a Z-plasty in
the axilla to avoid the potential for scar contracture, but we have
abandoned its use as part of the primary procedure, using it only in
a secondary procedure if a contracture occurs.
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Part XII  Body Contouring
An advantage for patients who undergo brachioplasty with this technique is the ex-
cellent contour achieved, as can be seen in these two patients. This level of im-
provement is usually not attainable in massive-weight-loss patients if techniques lim-
ited to the axilla are employed.

The lateral thoracic rolls, or lateral breast rolls, that extend onto the back to differ-
ing degrees as upper back rolls, are usually not eliminated by belt lipectomy. Thus if
the patient desires elimination of these rolls, a direct dermatolipectomy will be re-
quired (see Chapter 83). This resection eliminates the rolls and lifts the lateral tho-
racic tissues into their proper anatomic position, which includes lifting the lateral
inframammary crease to its correct location and creating its normal upward sweep.
It also shortens the vertical excess created by the weight loss. Subsequently, lifting
or reducing breast tissue can be performed based on a correctly positioned infra-
mammary crease.
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Chapter 82  Body Lift: Belt Lipectomy
This massive-weight-loss patient underwent a complete upper body lift that com-
bined brachioplasty, lateral breast/upper back roll excision, and breast surgery. Pre-
operatively the patient had upper arm excess that crossed the axilla and involved the
lateral thoracic wall, prominent lateral breast rolls, and descent of the lateral infra-
mammary crease.

The upper body lift shortened both the horizontal and vertical excess of the thorax
and allowed the augmentation-mastopexy to be performed based on the corrected
position of the lateral inframammary crease.
Another important anatomic area that is especially difficult to treat in massive-weight-
loss patients is the thigh region. The thighs in some patients have minimal or no ab-
normality, even after fairly large amounts of weight gained and lost. These patients
simply never deposit fat in their lower extremity because of their genetically pro-
grammed fat deposition pattern and do not require treatment. In others, large
amounts of fat are deposited in their lower extremities and lost along with the rest
of their body fat as they reduce their weight. Depending on the amount of excess re-
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Part XII  Body Contouring