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is also important. A drain tube caught beneath the binder,
blocking important blood flow, may tip the balance toward
ischemia. We suggest the patient have a family member or
friend release and adjust the binder every 2 hours to be sure
there are no folds or kinks. Early postoperative follow-up
also can identify and correct these impending problems.
Additional patient factors such as smoking and diabetes
may also contribute to ischemic complications. Patients should
sion from the overlying binder will contribute to ischemia.
To mitigate these factors, incision closure with all tension
placed on the Scarpa’s fascia will allow for minimal tension
on the skin. Creating essentially bilateral advancement of the
abdominal flaps toward the midline further reduces tension
in this region.12 Maintaining a posture with hip flexion will
relieve tension on the flap as well. Careful attention to the
compression garment, by ensuring that it is not too tight,
Fig. 30.17 Abdominal wall infection. (a) This 42-year-old obese woman underwent extensive liposuction and an abdominoplasty and 3
weeks later developed a fever and worsening abdominal wall erythema extending superiorly from the incision. She was diagnosed with fat
necrosis that became secondarily infected. (b) The incision was opened, revealing an abscess pocket. Cultures were taken and the infection
was determined to be methicillin-resistant Staphylococcus aureus (MRSA). The wound was thoroughly irrigated, wet-to-dry dressing changes
were initiated, and oral antibiotics were prescribed. The wound was successfully closed after several weeks of routine dressing changes.
a
b

467
Chapter 30 Abdominoplasty
a
b
c
d
e
f
Fig. 30.18 Abdominal wall skin necrosis. (a) This 46-year-old woman had abdominal SmartLipo followed by suction-assisted lipectomy at
a different facility (the patient did not have an abdominoplasty). She had a smoking history. Two weeks later she presented to our clinic
with complaints that her “skin was dying.” The wound was very foul smelling. She was febrile and tachycardic. She was taken to surgery
emergently for débridement, with a concern for necrotizing fasciitis. (b) After débridement of the frankly necrotic skin and some of the
necrotic fat. Upon removal of the skin, an infected seroma pocket was encountered. A significant amount of dead fat was attached to the
skin that was noted to be viable, demonstrating that a small amount of skin necrosis may correspond to a much larger area of underlying fat
necrosis. (c) Initiation of wet-to-dry dressing changes. In the early postoperative period, dressing changes with wet-to-moist gauze should
be performed 2 to 3 times a day to clear the infection, maintaining a close watch on the skin viability. The patient should be returned to
the operating room for débridement of frankly necrotic tissue as necessary. (d) Negative pressure therapy. When there is no evidence of
frank infection and the threatened tissue that was initially threatened is deemed viable, switching to negative-pressure wound therapy can
improve healing times by secondary intention. (e) At 5 weeks after débridement. With excellent initial control of the wound, followed by
exceptional wound care, smoking cessation, and emphasis on nutrition, a healthy bed of granulation tissue will form and the wound will
close rapidly. (f) Follow-up 17 months after débridement. The wound is fully epithelialized.
be warned of this possibility during the consultation, and we
often defer this operation in smokers. Operating on a patient
with a significant smoking history or poorly controlled diabe­
tes should be done with caution, if at all (Fig. 30.18).
Early ischemia is typically evidenced by venous conges­
tion, with a dusky or purplish hue to the skin. If pallor is
present, it is typically because of residual epinephrine from
the tumescent fluid and is therefore less worrisome and usu­

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Bleeding and Clotting
Like any surgical procedure, hematoma formation is pos­
sible. Cessation of medications and supplements that in­
hibit clotting should also be emphasized with patients. Oral
supplements including garlic, ginkgo biloba, ginseng, and
others that patients consider harmless can result in greater
bleeding.13 During flap elevation, the “usual suspects” (su­
perficial inferior epigastric, superficial circumflex iliac, and
periumbilical perforators) should be properly identified
and controlled. We routinely perform an intraoperative
hypertensive challenge, having our anesthesiologist chemi­
cally elevate the blood pressure to supernormal levels after
the rectus plication portion of the procedure. This has sig­
nificantly reduced postoperative hematomas.
Hematomas typically occur in the initial 24 hours post­
operatively and are evidenced by abdominal flap fullness that
is spongy, associated with significant skin bruising and in­
creased bloody drainage output (Fig. 30.19). If the hematoma
is small, it may be managed expectantly, with close surveil­
lance to make sure it is not expanding and with subsequent
aspiration once the hematoma has liquefied. An expanding
hematoma is a clear indication for operative exploration.
Even if a hematoma is not expanding, consideration should
be given to operative evacuation. A bleeding vessel may be
identified, and the hematoma contents that would act as a
nidus for persistent inflammation or infection are removed.
If a discreet bleeding vessel is not identified or there is a dif­
fuse oozing of blood, consideration may be given to the use of
topical thrombin spray or other hemostatic agents.
ally resolves within the early postoperative time frame. If
ischemia is noticed, measures should be implemented to im­
prove perfusion to the region. The patient should be flexed
at the waist so no tension exists on the midline skin. Inspec­
tion of the abdomen should be performed to make sure an
underlying hematoma is not developing. The compressive
binder should be removed. Patient warming devices should
be used, treating any hypothermia and reducing peripheral
vasoconstriction. Hydration with warm intravenous fluid
should also be given to ensure adequate intravascular vol­
ume. If these interventions are not successful, application of
topical nitroglycerin paste may be attempted, with reappli­
cation several times a day. If tension on the flap is felt to be
the contributing cause despite appropriate patient flexion,
releasing sutures at the incision should be performed sooner
rather than later to off-load tension at the threatened area.
Dressing changes should be initiated, with possible delayed
primary closure of the wound.
Ischemia may result in epidermolysis. This is usually
localized along the inferior edge of the abdominoplasty
flap. If this occurs, the area should be kept clean, moist, and
protected; antibiotic ointment should be applied and the
wound covered with nonadherent dressings. If the ischemia
appears deeper, we often use povidone iodine ointment to
help create a dry eschar. If one forms, it is best to leave it
alone, because it will act as protection for the underlying
tissues. A wet eschar can be treated with povidone iodine
or silver sulfadiazine cream until the surgeon considers
it appropriate for surgical débridement with subsequent
wet-to-dry dressings. As long as the appearance of the area
continues to evolve, nonoperative treatment should be con­
tinued as the areas fully demarcate. Once the appearance
has stabilized, and the previously ischemic areas have ei­
ther fully recovered or have progressed to frank necrosis,
operative débridement may be performed. All nonviable
tissue should be removed, because it serves as a nidus for
infection and impairs wound healing. Because the blood
supply to the skin is more robust than the underlying fat,
often a smaller area of affected skin corresponds to a larger
subcutaneous area of fat necrosis. Daily dressing changes
should be initiated, with frequent periodic inspection of
the wound to make sure healing is progressing satisfacto­
rily. If the resultant débrided area is large, closure by sec­
ondary intention is usually most prudent. If the wound
allows, retention-type sutures can be placed laterally to
reduce the overall size of the defect and facilitate a more
rapid closure. In certain cases, negative-pressure wound
therapy may be useful and allow for faster healing. For a
small wound, dressing changes should be instituted, lead­
ing to a clean wound that can often be treated with a de­
layed primary closure.
Once the wound is fully closed, appropriate time should
be given to allow for scar maturation. When this has finally
occurred scar revision may be performed as indicated. Re-
elevation of the flap may be necessary to perform proper
scar revision. At this point, the abdominal flap has been “de­
layed” with enhanced vascularity, and revisions are usually
not associated with ischemic sequelae.
Fig. 30.19 Postoperative hematoma. This 66-year-old woman had an
abdominoplasty with progressive tension sutures. She began taking
rivaroxaban as deep vein thrombosis prophylaxis on postoperative
day 1 as is our usual protocol. On postoperative day 3 she presented
to our clinic with increased swelling and bruising. She was taken to
the operating room for hematoma evacuation. A large subcutaneous
vein on the left side was noted to be the culprit, and 400 mL of fresh
clot was evacuated. The patient had multiple prior abdominal scars,
and the midline scar was believed to be tethering her abdominal
skin envelope, creating increased tension on the closure; therefore
multiple z-plasties were performed to lengthen the scar and allow
for appropriate tension on the abdominal closure.

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Chapter 30 Abdominoplasty
Patient Satisfaction
Even if a patient has an excellent aesthetic surgical result,
the overall result will be unfavorable if the patient has an
unpleasant experience. Every effort should be made to en­
sure that the patient (and family members) are attended to
and discomfort is minimized.
Abdominoplasty, especially when a tight rectus plica­
tion and aggressive liposuction is performed, can be very
uncomfortable for patients. Close attention to pain control
is paramount. We routinely use Exparel (a bupivacaine li­
posome injectable suspension that lasts for up to 3 days)
intraoperatively using blunt needle infiltration into the rec­
tus sheath, the entire area of undermining, and the incision
line with great patient benefit.16 Narcotic medications and
muscle relaxers are given liberally.
Although many abdominoplasty procedures are suc­
cessfully performed on an outpatient basis, we routinely
keep our patients overnight. Our nursing staff ambulates
the patients twice the first evening, and fluid balance is
carefully controlled to maintain proper hydration. Main­
tenance of patient comfort and temperature and close sur­
veillance by the nursing staff helps identify any problem
early. Patients are evaluated by the doctors the following
morning before going home and before beginning antico­
agulation. The patient’s caregivers, knowing that the pa­
tient is being well cared for at our facility, are free to relax
at home without the burden of having to provide care that
first most difficult night.
Conclusion
With careful and thoughtful surgical planning and tech­
nique, and careful and thorough postoperative care and
management, unfavorable results after abdominoplasty
can be minimized. If complications do arise, if they are
caught early they commonly can be managed, avoiding an
unfavorable result.
On the opposite side of the hematologic spectrum is ex­
cessive clotting. A deep vein thrombosis (DVT) that propa­
gates, dislodges, and becomes a pulmonary embolus (PE)
may be a fatal event. Abdominoplasty, with its associated
tight muscle plication, abdominal binder placement, and
prolonged postoperative hip-flexed posture, is considered
a procedure with elevated risk for venous thromboembo­
lism (VTE) events.
Preoperatively, the surgeon may use a variety of instru­
ments to assess VTE risk and guide prophylaxis. There are
myriad VTE risk-assessment scales, task force recommenda­
tions, and institutional and organizational guidelines from
which to choose.14 We routinely check for common throm­
bophilic conditions (e.g., factor V Leiden thrombophilia).
Any patient with a clotting disorder or a strong family his­
tory is referred to a hematologist to guide perioperative DVT
prophylactic management. Patients who take oral contra­
ceptives or hormone replacement are asked to discontinue
these medications for 2 weeks preoperatively to allow their
VTE risk to return to baseline.
On the day of the operation, the patient ambulates to
the operating room, is positioned with legs slightly flexed
at the knee, has sequential compression devices on at all
times intraoperatively and in the recovery area, is properly
hydrated, and ambulates early and often postoperatively. We
are also cognizant of efficient use of time while the patient
is under general anesthesia and maintenance of core body
temperature.
Routine postoperative VTE chemoprophylaxis is contro­
versial. Although injectable chemoprophylactic agents (e.g.,
enoxaparin) may be used, newer generation oral anticoagu­
lants are now available. We routinely begin rivaroxaban, 10
mg orally (an off-label use), starting 12 hours postopera­
tively if no hematoma is evident, and continue treatment for
7 days. In our center, the safety profile with this medication’s
use has been excellent.15
Patients are instructed to go immediately to the emer­
gency department for workup for possible VTE if they ex­
perience shortness of breath, dizziness, chest, pain, tachy­
cardia, or lower leg swelling or pain; treatment is initiated
promptly if a blood clot is found.
References
1. Stewart KJ, Stewart DA, Coghlan B, Harrison DH, Jones
BM, Waterhouse N. Complications of 278 consecu­
tive abdominoplasties. J Plast Reconstr Aesthet Surg
2006;59(11):1152–1155
2. Hunstad JP, Remus R. Atlas of Abdominoplasty. Philadel­
phia, PA: Elsevier; 2008
3. Hunstad JP, Jones SR. Abdominoplasty with thorough
concurrent circumferential abdominal tumescent lipo­
suction. Aesthet Surg J 2011;31(5):572–590
4. Gusenoff JA, Rubin JP. Plastic surgery after weight loss:
current concepts in massive weight loss surgery. Aesthet
Surg J 2008;28(4):452–455
5. Matarasso A, Schneider LF, Barr J. The incidence and
management of secondary abdominoplasty and sec­
ondary abdominal contour surgery. Plast Reconstr Surg
2014;133(1):40–50
6. Andrades P, Prado A, Danilla S, et al. Progressive tension
sutures in the prevention of postabdominoplasty seroma:
a prospective, randomized, double-blind clinical trial.
Plast Reconstr Surg 2007;120(4):935–946, discussion
947–951
7. Khan S, Teotia SS, Mullis WF, et al. Do progressive tension
sutures really decrease complications in abdominoplas­
ty? Ann Plast Surg 2006;56(1):14–20, discussion 20–21

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13. Wong WW, Gabriel A, Maxwell GP, Gupta SC. Bleeding
risks of herbal, homeopathic, and dietary supplements:
a hidden nightmare for plastic surgeons? Aesthet Surg J
2012;32(3):332–346
14. Pannucci CJ, Barta RJ, Portschy PR, et al. Assessment of
postoperative venous thromboembolism risk in plastic
surgery patients using the 2005 and 2010 Caprini Risk
score. Plast Reconstr Surg 2012;130(2):343–353
15. Hunstad JP, Krochmal DJ, Flugstad NA, Kortesis BG, Au­
genstein AC, Culbertson GR. Rivaroxaban for venous
thromboembolism prophylaxis in abdominoplasty: a
multicenter experience. Aesthet Surg J 2016;36(1):60–66
16. Morales R Jr, Mentz H III, Newall G, Patronella C, Masters
O III. Use of abdominal field block injections with liposo­
mal bupivicaine to control postoperative pain after ab­
dominoplasty. Aesthet Surg J 2013;33(8):1148–1153
8. Hunstad JP, Michaels J, Burns AJ, et al. A prospective, ran­
domized, multicenter trial assessing a novel lysine-de­
rived urethane adhesive in a large flap surgical procedure
without drains. Aesthetic Plast Surg 2015;39(4):616–624
9. Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma de­
velopment following body contouring surgery for massive
weight loss: patient risk factors and treatment strategies.
Plast Reconstr Surg 2008;122(1):280–288
10. Roje Z, Roje Z, Karanović N, Utrobicić I. Abdominoplasty
complications: a comprehensive approach for the treat­
ment of chronic seroma with pseudobursa. Aesthetic
Plast Surg 2006;30(5):611–615
11. Zakine G, Baruch J, Dardour JC, Flageul G. Perforation of
viscera, a dramatic complication of liposuction: a review
of 19 cases evaluated by experts in France between 2000
and 2012. Plast Reconstr Surg 2015;135(3):743–750
12. Lockwood TE. Maximizing aesthetics in lateral-ten­
sion abdominoplasty and body lifts. Clin Plast Surg
2004;31(4):523–537, v
Discussion by Alan Matarasso and Darren M. Smith
The appearance of the abdomen is often perceived as a
surrogate for health, and maintaining its youthful ap­
pearance plays a powerful role in projecting a young,
vital presence. The desire for abdominal enhancement
is only growing stronger with the aging of a postpar­
tum population that is increasingly concerned with
fitness and appearance. A growing number of massive-
weight-loss patients with a focus on maximizing the
aesthetic results of their life-changing efforts further
contributes to intense demand for the procedure. To
achieve excellent outcomes in abdominoplasty, one
must thoroughly understand the goals of the opera­
tion and have an intimate knowledge of the most fre­
quent modes of failure. This discussion examines pa­
tient goals in abdominoplasty, moves into a survey of
untoward outcomes, and finally presents strategies to
avoid these misadventures.
Goals in Abdominoplasty
The trifecta of abdominoplasty is a firmer, flatter abdo­
men and a natural, aesthetically appealing umbilicus
via an operation that accomplishes the following1:
1. Results in the least conspicuous scar possible
2. Minimizes the duration of drain placement or
avoids their use altogether
3. Causes minimal pain
We have identified our “typical” abdominoplasty patient
as a multiparous woman between 35 and 44 years of
age at the conclusion of her childbearing years.1 These
patients are likely to be distressed by skin changes in
quantity (e.g., increased laxity) as well as in quality (e.g.,
striae) that occur with aging and are accelerated and
magnified by pregnancy. Contour irregularities or even
frank “ledges” of loose excess skin can develop at the
waist, paraumbilically, or overhanging a cesarean section
scar or the hips. Abdominal diameter may also enlarge
as a function of changes in subcutaneous fat content and
muscle relaxation and separation, as well as increases in
pelvic bony girth. After pregnancy and with advancing
age, the amount of intra-abdominal fat tends to increase.
Abdominoplasty patients also commonly present
with a desire to address their “lost waistline.” The ra­
tio of abdominal circumference to hip circumference
strongly influences the perception of waistline1 (Fig.
30D.1). Consistent with the “golden” ratio in visual har­
mony and beauty, the ideal ratio describing this relation­
ship has been widely cited as approximately 1:1.5.2 For
abdominoplasty patients, the circumference of the ab­
domen (the numerator) has typically increased relative
to that of the hips (the denominator). The denominator
is generally not the focus of our surgical interventions
(although fat injections to the hips or buttocks can be
helpful). Instead, plastic surgeons usually approach this
dilemma with maneuvers to decrease the numerator.

471
Chapter 30 Abdominoplasty
To reduce the circumference of the abdomen, the
surgeon must address the treatable layers of excess skin,
rectus diastasis, and lipodystrophy. He or she must also
recognize (and demonstrate to the patient) conditions
that are not treatable and may therefore negatively in­
fluence postoperative appearance (e.g., intra-abdominal
fat, spine, hip, or uterine position).
A meticulously planned and executed abdomino­
plasty decreases the numerator by achieving optimized
skin and fat resection with simultaneous enhance­
ment of the rectus corset. Although efforts to narrow
the waistline can be unpredictable, in general abdomi­
noplasty will narrow the waistline and shorten all di­
mensions of the abdomen. Circumferential liposuction
around the waist can further enhance the result. For thin
patients, horizontal waistline sutures at the level of the
umbilicus (Fig. 30D.2) can also be helpful.1
Avoiding Unfavorable Results and
Complications in Abdominoplasty
With this understanding of the goals of abdomino­
plasty in mind, we can formulate approaches to avoid
failure to meet those goals. Such failures can take two
forms: (1) unfavorable results (which we consider as
suboptimal aesthetic outcomes) or (2) complications
(which we loosely define as a deleterious local or sys­
temic process secondary to surgery) (Box 30D.1).
a
b
c
Fig. 30D.1 (a) This 36-year-old woman who had one previous pregnancy presented for abdominoplasty. (b) Results 1 year after
abdominoplasty. (c) Preoperative and postoperative images superimposed to demonstrate the change in the waist achieved with
abdominoplasty (highlighted by blue arrows). The red lines indicate the preoperative outline. The yellow lines indicate the post­
operative outline. The green line indicates the circumference of the abdomen. The blue line indicates the circumference of the
hips. The “waist” is perceived as the ratio between these circumferences. (Reproduced from Matarasso A, Smith DM. Strategies
for aesthetic reshaping of the postpartum patient. Plast Reconstr Surg 2015;136[2]:245–257.)
1
2
5
3
4
Fig. 30D.2 Anatomy of plication. An eye shield is sutured to the
umbilicus to ease in identification for inset. The following suture
pattern is used: 1. Toward the xiphoid; undermining proceeds to
this level, where rectus plication begins. 2. Site of supraumbili­
cal plication relaxation. 3. Arcuate line of Douglas: no posterior
rectus fascia is included inferiorly. 4. Pubic bulge. 5. Waistline
suture (when indicated). (Reproduced from Matarasso A, Smith
DM. Strategies for aesthetic reshaping of the postpartum pa­
tient. Plast Reconstr Surg 2015;136[2]:245–257.)

SECTION IV AESTHETIC SURGERY
472
Box 30D.1
•• Unreasonable preoperative expectations and
understanding of outcome
•• Scarring
•• Contour deformities
•• Unattractive or unnatural umbilicus
Potential Unfavorable
Results after
Abdominoplasty
Avoiding Unfavorable Results
Failure to achieve the first component of the abdomino­
plasty trifecta (a scar that is acceptable to the patient)
represents an unfavorable result. The better a patient’s
understanding of the reasoning behind (and necessity
of) a given incision pattern, the more likely he or she will
be to accept the resulting scar. Moreover, the postpartum
abdominoplasty patient may be struggling to accept that
her young woman’s physique is aging into that of a ma­
ture woman whose body has undergone the stresses of
pregnancy. The thought of adding scars to this already
distressing metamorphosis can be extremely unsettling.
Although the most dramatic improvements in contour
come with the trade-off of an umbilical scar and lower
abdominal scar, M. Spira (personal communication,
2014) has stated, “patients will accept a scar if they get
the contour they desire.” The corollary is that a patient’s
acceptance of a scar is proportional to his or her under­
standing of the necessity of that scar.
Another unfavorable result, dissatisfaction caused
by miscommunication about the anatomic areas to be
addressed, is similarly related to preoperative expecta­
tions and understanding. The abdominoplasty patient
is frequently distressed by changes in contour outside
the abdomen proper, including an enlarged or ptotic
mons pubis and adjacent areas of lipodystrophy (e.g.,
back rolls, hips, flanks, or legs). Frank soft tissue laxity
in the flanks (as opposed to lipodystrophy alone) may
also occur, and treatment requires lengthening of the
abdominoplasty incision to include a flankplasty. When
these problems and plans to address (or to defer) their
treatment are not discussed, postoperative dissatisfac­
tion is likely.
Contour deformities of the abdomen itself after ab­
dominoplasty constitute another unfavorable result.
These have several causes:
•• Uneven dissection or excision
•• Incomplete undermining (resulting in lateral
bunching)
•• Failure of complete plication (with resulting bulges
in unplicated regions)
•• Lack of indicated flap suction
•• Pseudobursa formation
•• Other causes
Contour deformities are an especially unfortunate out­
come because they represent a direct failure to meet
the primary goal of the procedure: an improved ab­
dominal contour.
Even the most perfect abdominal contour can be
marred by an unattractive or unnatural umbilicus af­
ter abdominoplasty. The postoperative umbilicus may
assume the unsightly appearance of a “postage stamp”
because of stretching, changes in pigmentation, lack of
surrounding subcutaneous fat, or a short stalk. With­
out meticulous attention to detail, the umbilical circum­
scription necessary in full abdominoplasty can “frame”
these deformities with a surgical scar. Moreover, atten­
tion must be paid to ensuring that the umbilicus is the
correct diameter and situated in the midline at the cor­
rect height.
Avoiding Complications
An important facet of discussing the complications of
any procedure is that data are compiled from numerous
sources, each with inherent biases.3 The CosmetAssure
database captures complications in insured patients oc­
curring within 30 days of surgery and requiring return
to the operating room. The most recent CosmetAssure
data on abdominoplasty revealed that the following
were patient risk factors for complications (Box 30D.2):
•• Older than 40 years
•• Female
•• Body mass index more than 25 kg/m2
Box 30D.2
•• Infection
•• Seroma
•• Deep vein thrombosis and pulmonary
edema
Common Complications
in Abdominoplasty
They also showed that men have a statistically sig­
nificantly greater rate of hematoma formation. Inter­
estingly, although seromas are generally considered
the most common complication of abdominoplasty,
the CosmetAssure database does not include them as
complications. Also, smoking was not identified as a risk
factor for complications in this cohort. These findings
can likely be explained by the fact that ischemia, lim­

473
Chapter 30 Abdominoplasty
ited wound-healing problems, and seromas can often
be managed in an office and thereby are not captured
by CosmetAssure. CosmetAssure reports an overall com­
plication rate of 4.7% for abdominoplasty, which is more
than double (1.57%) the rate from other cosmetic proce­
dures. Maintenance of Certification (MOC) data reports
the most common complications of abdominoplasty to
be infection, seroma, and deep vein thrombosis (DVT)
and pulmonary embolism (PE). Tracking Operations and
Outcomes for Plastic Surgery (TOPS) data indicates that
the most common abdominoplasty complication is in­
fection (3.5%).
Although failure to achieve the first component of
the abdominoplasty trifecta, an unfavorable scar, is best
classified as an unfavorable result and was discussed
previously, the remaining two factors, minimized drain
use and effective pain management, pertain to compli­
cation avoidance. Drains (or an alternative method such
as quilting sutures) are imperative to prevent seromas.
Seromas may range in severity from a mere nuisance
to pseudobursa formation with secondary contour de­
formity or infection. Recent ultrasound-based evidence
has demonstrated that seromas are quite common (with
their peak incidence of 38.1% on day 11 after abdomi­
noplasty), but they are not clinically relevant nearly this
frequently.4
The third component of the abdominoplasty tri­
fecta, minimized pain, is critical in avoiding severe prob­
lems after abdominoplasty. Although some degree of
pain or soreness is expected after abdominoplasty and
is certainly not to be considered a complication, proper
pain management is paramount, because poorly man­
aged pain can indeed lead to complications. Specifically,
overtreatment can mask the protective effect of some
baseline discomfort (i.e., deterrence of overexertion that
may lead to hematoma formation or disruption of the
plication). Overuse of narcotics can lead to somnolence
or lethargy, putting the patient at increased risk for de­
veloping a venous thromboembolism (VTE). High nar­
cotic doses can also cause a paralytic ileus. Undertreat­
ment of pain (in addition to causing severe discomfort)
can, like overtreatment, lead to immobilization, because
movement is uncomfortable, again increasing the risk of
VTE. Severe abdominal pain can also impede deep res­
piration. Decreased deep respiration can lead to atelec­
tasis, pleural effusion, and even pneumonia.
VTE, the “elephant in the room” during any conver­
sation of abdominoplasty complications, can be devas­
tating, life-threatening events and occur in as many as
1.1% of abdominoplasties.5–8 The American Society of
Plastic Surgeons (ASPS) VTE Task Force9 considers VTE
risk in abdominoplasty high enough to warrant specific
consideration. A survey of more than 1,100 plastic sur­
geons regarding VTE occurrence in their practices dem­
onstrated VTE was found to occur most frequently with
abdominoplasty and abdominoplasty combined with
another procedure.10 The American Association for Ac­
creditation of Ambulatory Surgery Facilities (AAAASF)
data11 on 411,670 cases revealed abdominoplasty to be
the procedure most frequently associated with death
and with death secondary to PE.
Abdominoplasty patients are particularly prone to
VTE for several reasons. Third spacing, increased intra-
abdominal pressure, tight external compression gar­
ments, and flexed positioning that decreases venous
return from the lower extremities may all contribute
to exacerbated venous stasis. Other predisposing risk
factors for VTE in abdominoplasty may include vessel
injury incurred secondary to intense dissection of su­
perficial veins, decreased peripheral vascular resistance
associated with general anesthesia, and decreased post­
operative mobility.
There are three remaining complications in abdomi­
noplasty that are not unique to this operation but are
related to one another and do warrant mention: flap
ischemia, wound-healing problems, and infection. Ab­
dominoplasty flap ischemia can be induced by exces­
sive undermining, poorly planned liposuction, excessive
tension, or a combination of these. An ischemic flap or a
wound closed under tension will predispose to healing
difficulties and breakdown. The risk of wound infection
is increased in the setting of flap ischemia. Infection may
also pose an independent risk for difficulties in wound
healing.
Strategies to Avoid Unfavorable Results
and Complications in Abdominoplasty
The previous sections discussed patients’ goals in
abdominoplasty and the ways in which surgeons’ at­
tempts to meet these goals may fall short. This section
focuses on our approach to obtaining the highest de­
gree of patient satisfaction in abdominoplasty, orga­
nized by strategies for the preoperative, intraoperative,
and postoperative periods.
Preoperative
Any successful operation begins with careful patient
selection.12 In the case of abdominoplasty, this means
a patient who is healthy at baseline and poses a low
surgical risk (ideally American Society of Anesthesiolo­
gists [ASA] physical status category 1 [ASA 1]). There
are several “red flag” patient characteristics that war­
rant pause in this context: pulmonary conditions, his­
tory of or propensity for VTE, cardiac insufficiency,
peripheral vascular disease, hypertension, obesity,
bleeding diathesis, smoking, exposure to secondhand
smoke, and diseases affecting microcirculation. Screen­
ing should be performed for hereditary thrombophilias
if suspicion is aroused by a history of miscarriages or
other factors. History of previous surgical infection is

SECTION IV AESTHETIC SURGERY
474
also a potential warning sign for adverse outcomes. Re­
gardless of history, our patients use nostril mupirocin
ointment and antimicrobial body scrubs in the peri­
operative period. At the time of surgery, we prep with
alcohol-based solutions (paying special attention to the
umbilicus) and adhere to MOC data advising a single
dose of antibiotics.
Once a patient has been deemed a good candidate
for an abdominal contouring procedure, open commu­
nication is essential to select the proper operation based
on that patient’s anatomic requirements and personal
goals. We have detailed the abdominolipoplasty system
of classification and treatment to guide this process else­
where.13 Ultimately, patients opposed to having a peri­
umbilical scar or desiring shorter lower abdominal scars
should recognize that adequate skin excision and rectus
plication may not be possible with limited approaches3
(Fig. 30D.3). It is also important to note that numer­
ous aesthetic units of the trunk and surrounding regions
can be of concern to patients seeking abdominoplasty.
Whereas surgeons recognize the anatomic boundaries of
the abdomen, patients may perceive these boundaries to
extend to include adjacent regions, again underscoring
the importance of clear communication in the preopera­
Type I
Type II
Type III
Type IV
Fig. 30D.3 The four common abdominal procedures: Type I, liposuction; type II, mini abdominoplasty; type III, modified abdomi­
noplasty; type IV, full abdominoplasty with liposuction (lipoabdominoplasty) or without liposuction.

475
Chapter 30 Abdominoplasty
tive planning process. This point is of special importance
with regards to the potential need for formal flankplasty
with an extended abdominoplasty incision (see the fol­
lowing intraoperative discussion).
As mentioned earlier, VTE is a potentially devas­
tating complication of abdominoplasty. As evidenced
by the myriad papers and recommendation schemes
that have been and continue to be published on risk
reduction, no consensus exists to date. Although the
evidence in this debate is far from clear, the operating
surgeon should be familiar with all available data to be
well equipped to make patient-specific decisions using
metrics such as the Davison-Caprini model or equiva­
lent systems.13 In the preoperative period, our patients
discontinue the use of all female hormones (including
drug-eluting patches and intrauterine contraceptive de­
vices) and nicotine. They are offered prothrombogenic
blood test screening and postoperative venous Doppler
testing. In the operating room, our patients are liber­
ally hydrated and compressive stockings and sequen­
tial pneumatic compression devices are applied before
the induction of anesthesia. The legs are actively bent at
the hips and knees by the circulating nurse periodically
throughout the procedure.
Efforts to achieve ideal outcomes in abdomino­
plasty begin with meticulous surgical marking. To en­
sure a low, well-concealed incision, marking is initiated
by delineating the upper and lower edges of the patient’s
standard undergarment. The patient is then seated, and
the length of the abdominoplasty incision is indicated
by marking the ends of the pannus’ skin creases. Next
the patient gently elevates his or her pannus while the
surgeon joins these lateral marks, making an effort to in­
corporate the removal of any old scars into the excision.
The upward pull accounts for eventual upward scar con­
traction or migration, thereby helping to prevent a high
scar. The middle of the incision is approximately 6 to 9
cm above the vulva cleft. Further details of the marking
process are detailed in other reports.3
When designing the abdominoplasty excision, it is
useful to bear in mind that the greatest improvements in
abdominal contour are achieved at the points of maxi­
mal skin tension. Tension, in turn, is generated by skin
excision, which is proportional to the length of the inci­
sion. This relationship must be brought to the patient’s
attention when determining how far laterally the der­
matolipectomy (and resulting scar) will be extended. At
the extreme, to address a great deal of excess flank skin,
the abdominal dermatolipectomy can be extended lat­
erally into a flankplasty1 (Fig. 30D.4).
The ideal surgical result after abdominoplasty is not
simply a flat abdomen; indeed this outcome appears op­
erated and boardlike.14 In a full abdominoplasty, rec­
tus fascia plication works in synergy with dermatoli­
pectomy and liposuction to achieve a youthful, natural
contour. Although many acceptable methods of ab­
dominal wall plication have been described, we opt for
a multilayered plication with permanent sutures from
xiphoid to pubis. Further details of the abdominoplasty
technique have been detailed elsewhere.3 As the pan­
nus is preexcised and the upper flap is undermined
in an inverted-V fashion to maintain its blood supply,
“puckering” is bound to develop in the flap where it re­
mains adherent to the underlying muscle after fascial
closure. This is relieved by blunt and selective sharp dis­
section (the zone of discontinuous undermining). Small
amounts of bunching are tolerated, because these irreg­
ularities represent intact blood supply to the skin and
resolve in the early postoperative period.
We perform our abdominoplasty dissection with
electrocautery, although multiple techniques have been
advanced to minimize seroma formation, including ex­
clusive sharp dissection with a scalpel. Others advocate
leaving a loose areola layer over the fascia, or perform­
ing progressive tension sutures. Some surgeons advocate
compressive garments to prevent seromas, but others
caution against their use. A tissue glue was recently ap­
proved by the FDA to eliminate the use of drains and
decrease seroma rates. We use closed-suction drains
that exit through the incision and remove them as early
as permitted by volume and character of drainage. Pa­
tients are inspected frequently for seromas after drains
are removed.
Great care is taken to produce a natural umbili­
cal appearance. A midline position is verified with silk
marking sutures and using the vulva cleft as a reference.
A 2.5-cm inverted-V incision is made at the new umbili­
cal site. The upper and (more so) lower skin edges of the
umbilical opening are defatted. We avoid suturing the
umbilicus to the fascia, because disrupted sutures could
alter the midline position. After deep absorbable sutures
are placed from umbilicus to skin flap, skin closure is
achieved with interrupted 3–0 and 4–0 nylon sutures.
We pack the umbilicus with a strip of xeroform gauze.
In addition to scar placement, which is optimized
during surgical marking, efforts are made to enhance
scar appearance during closure. We perform a layered
closure with barbed suture in the deep dermis to dis­
tribute tension and thus reduce scar prominence. Pri­
neo (Ethicon) is used to further reduce tension on the
skin closure.
The importance of pain control in abdominoplasty
cannot be overstated. Preoperative consultation with the
surgeon and anesthesiologist to decrease expectations
of pain is the first step in effective pain management. All
prescriptions are filled preoperatively; because much

SECTION IV AESTHETIC SURGERY
476
of the reported pain is a consequence of rectus muscle
plication, nonnarcotic analgesics and muscle relaxants
are used preferentially to narcotics. A history of nausea,
vomiting, or seasickness is an indication for a preoper­
ative scopolamine patch. General anesthesia is always
used, and we inject the abdominoplasty operative site
with approximately 1 liter of superwet solution (1 liter
of lactated Ringer’s solution with 20 mL of 1% lidocaine
and 1 mL of 1:1,000 epinephrine). One gram of intra­
venous acetaminophen is administered 1 hour before
the conclusion of the procedure. We inject Exparel (1.3%
bupivacaine liposome suspension) prepared as 20 mL of
Exparel in 80 mL of saline with 30 mL of 0.25% bupiva­
caine hydrochloride with epinephrine at strategic sub­
muscular points and in the wound edges after muscle
plication at least half an hour after lidocaine adminis­
tration and before wound closure. Postoperatively, when
patients attempt to sit up, it is helpful to support their
back and to place a sheet around the footplate of the
bed so they can assist themselves. A pillow pressed to
a
b
c
d
Fig. 30D.4 A 55-year-old before (a,b) and 2 months after (c,d) abdominoplasty with 950 cc liposuction. The area denoted by the
F constitutes a flankplasty—direct excision of excess flank skin and fat resulting in extension of the scar lateral to the standard ab­
dominoplasty scar (denoted by the green lines). (Reproduced from Matarasso A, Smith DM. Strategies for aesthetic reshaping of
the postpartum patient. Plast Reconstr Surg 2015;136[2]:245–257.)

477
Chapter 30 Abdominoplasty
the abdomen when coughing is supportive and reduces
discomfort.
Postoperative
A well-thought-out postoperative care plan can have
a dramatic effect on limiting complications. First, we
advise checking the suprapubic region for ischemia and
the drains for maintenance of suction and quantity and
quality of output before discharge. Patients should be­
gin ambulating on the day of surgery. Liberal fluid in­
take is encouraged if medically appropriate, and we use
a Foley catheter to monitor urine output. We promptly
evaluate any patient with leg pain or swelling for DVT.
Patients are carefully monitored for seroma or pseu­
dobursa formation and overall quality of healing. Al­
though the ultimate responsibility for safety is always
the surgeon’s, the shift toward outpatient abdomino­
plasty requires the patient and caregiver to play an ac­
tive role in detecting postoperative problems; educat­
ing these individuals is key in this regard.
Conclusion
A thorough understanding of patient goals allows for
educated vigilance in avoiding unfavorable results and
complications in abdominoplasty. Efforts to achieve
excellent outcomes begin preoperatively with careful
patient selection. Intraoperatively, the surgeon must
demonstrate efficient technique characterized by me­
ticulous attention to detail. Postoperatively, patient
education and watchfulness on the part of the patient,
caregiver, and surgeon are key. When these techniques
are practiced in the context of a comprehensive un­
derstanding of the literature allowing for informed
patient-specific decision-making, the plastic surgeon
is well positioned to deliver excellent results that meet
the abdominoplasty patient’s exacting standards.
References
1. Matarasso A, Smith DM. Strategies for aesthetic re­
shaping of the postpartum patient. Plast Reconstr
Surg 2015;136(2):245–257
2. Livio M. The Golden Ratio: The Story of Phi, the
World’s Most Astonishing Number. New York, NY:
Broadway Books; 2002
3. Matarasso A, Matarasso DM, Matarasso EJ. Abdomi­
noplasty: classic principles and technique. Clin Plast
Surg 2014;41(4):655–672
4. Di Martino M, Nahas FX, Kimura AK, Sallum N, Fer­
reira LM. Natural evolution of seroma in abdomi­
noplasty. Plast Reconstr Surg 2015;135(4):691e–
698e
5. Grazer FM, Goldwyn RM. Abdominoplasty assessed
by survey, with emphasis on complications. Plast Re­
constr Surg 1977;59(4):513–517
6. Hester TR Jr, Baird W, Bostwick J III, Nahai F, Cukic
J. Abdominoplasty combined with other major sur­
gical procedures: safe or sorry? Plast Reconstr Surg
1989;83(6):997–1004
7. Stevens WG, Cohen R, Vath SD, Stoker DA, Hirsch EM.
Is it safe to combine abdominoplasty with elective
breast surgery? A review of 151 consecutive cases.
Plast Reconstr Surg 2006;118(1):207–212, discussion
213–214
8. Teimourian B, Rogers WB III. A national survey
of complications associated with suction lipec­
tomy: a comparative study. Plast Reconstr Surg
1989;84(4):628–631
9. Murphy RX Jr, Alderman A, Gutowski K, et al. Evi­
dence-based practices for thromboembolism pre­
vention: summary of the ASPS Venous Thrombo­
embolism Task Force Report. Plast Reconstr Surg
2012;130(1):168e–175e
10. Spring MA, Gutowski KA. Venous thromboembolism
in plastic surgery patients: survey results of plastic
surgeons. Aesthet Surg J 2006;26(5):522–529
11. Keyes GR, Singer R, Iverson RE, et al. Mortal­
ity in outpatient surgery. Plast Reconstr Surg
2008;122(1):245–250, discussion 251–253
12. Matarasso A, Smith DM. Combined breast surgery
and abdominoplasty: strategies for success. Plast Re­
constr Surg 2015;135(5):849e–860e
13. Matarasso A. Abdominolipoplasty: a system of classi­
fication and treatment for combined abdominoplasty
and suction-assisted lipectomy. Aesthetic Plast Surg
1991;15(2):111–121
14. Patronella CK. Redefining abdominal anatomy: 10 key
elements for restoring form in abdominoplasty. Aes­
thet Surg J 2015;35(8):972–986

478
CHAPTER
31
Body and Extremity Contouring after
Massive Weight Loss
Joseph F. Capella
Body contouring after massive weight loss (MWL) is inher­
ently challenging. The challenges relate to the severity of
the deformities, the relatively poor quality of the tissues,
and the comorbidities that are often present in patients
who have had bariatric surgery. Unfavorable results are
commonly the result of these inherent challenges but may
also be secondary to choices made by the surgeon in for­
mulating an approach to address patient concerns. Subop­
timal choices may be influenced by many variables, includ­
ing the following:
•• Application of routine body contouring procedures to a
patient who has had bariatric surgery
•• Patient or surgeon desire to minimize scars
•• Simultaneous performance of procedures with opposite
vectors of tension
Post–bariatric-surgery deformities derive from individuals
being in an obese state for variable periods of time. Pock­
ets of excess fat produce increased tension on skin and the
underlying connective tissues. Greater time in an obese
state and a higher weight produce greater tissue damage.
Through weight loss and the metabolism of fat and poten­
tially protein (muscle wasting), the tension on the soft tis­
sue envelope diminishes, and the failure of the damaged
soft tissue envelope to retract completely leads to the char­
acteristic appearance of an individual who has had bariatric
surgery (Fig. 31.1). Aside from the patient’s length of time
in the obese state, the deformity is influenced by factors
such as genetics, exposure to environmental agents such as
ultraviolet light, tobacco consumption, and the age of onset
of obesity. Individuals who gain and lose weight as teenag­
ers will usually have less sequelae than older individuals.
In addition, gender greatly affects the characteristics of the
weight loss deformity: The deformity in men is quite con­
sistent, whereas that of women varies from a gynoid body
type to a more android body habitus (Fig. 31.2).
Obese individuals often suffer multiple comorbidities,
including heart disease, hypertension, diabetes mellitus, os­
teoarthritis, and breathing problems such as sleep apnea and
asthma.1 After weight loss many of these conditions may be
improved but not be entirely resolved. The residual effects
of these illnesses may affect wound healing and early am­
bulation, complicating the recovery of potentially extensive
surgical procedures. Furthermore, the average MWL patient
is overweight at the time of body contouring, representing a
risk factor in and of itself.2
Body contouring after weight loss is a relatively new
specialty within plastic surgery. Before 2000 very few of
these procedures were being performed, and even today
many practicing plastic surgeons did not receive formal
instruction in this discipline as part of their training.3 Lim­
ited exposure to this patient population may lead to an
incomplete understanding of these deformities and of the
application of traditional body contouring procedures to
the MWL patient, resulting in less than optimal outcomes.
The magnitude and extent of the MWL deformity is usually
far greater than in the traditional body contouring patient.
Therefore many regions of the body often need to be ad­
dressed to satisfy patient concerns. The typical MWL pa­
tient is in the third or fourth decade of life, is very active,
and usually wants the fewest scars and the quickest pos­
sible recovery in achieving their goals.2 The plastic surgeon,
in an effort to accommodate patient requests, may perform
short-scar versions of procedures and multiple operations
simultaneously with opposite vectors of tension with un­
favorable results.
The severity of the MWL deformity and the emotional
and functional toll it presents for many individuals provides
the plastic surgeon with an opportunity to provide a high
level of satisfaction. The focus of this chapter is on mini­
mizing complications and unfavorable results after brachio­
plasty, vertical medial thigh lifts, and circumferential lower
body lifts.

479
Chapter 31 Body and Extremity Contouring after Massive Weight Loss
bariatric surgery safely and effectively, every effort should
be made to screen patients appropriately, minimize and
manage complications effectively, and make the best surgi­
cal choices in addressing their contour deformities. Com­
plications after different body contouring procedures for
patients who have had bariatric surgery are similar, but
the rates vary between extremity and truncal contouring
procedures, with truncal procedures having a higher rate of
more serious complications.4–6 Unfavorable results may be
the result of complications but more often are the conse­
Avoiding Unfavorable Results
and Complications in Body
Contouring After Massive
Weight Loss
Complication rates and the potential for unfavorable out­
comes are greater in MWL contouring than traditional
body contouring.4–6 To manage patients who have had
a
b
c
d
e
f
Fig. 31.1 (a–c) A 27-year-old man 12 months after weight loss of 225 lbs. through lifestyle changes. His weight here was 175 lbs., and
his body mass index (BMI) was 27. His peak weight and BMI were 400 lbs. and 61, respectively. (d–f) A 55-year-old woman 13 months
after gastric bypass surgery and weight loss of 115 lbs. Her weight here was 156 lbs., and her BMI was 30. Her peak weight and BMI were
271 lbs. and 53, respectively. The patient has a gynoid body type.

SECTION IV AESTHETIC SURGERY
480
nents of weight history to obtain are the patient’s highest
weight, length of time at this weight, current weight, and
length of time at this weight. Physical examination should
focus on the region of the body where the patient has ex­
pressed concerns but should also make note of the extent of
the deformity of the adjoining regions. Scars, striae, inter­
trigo, hernias, degree of fascial laxity, edema, skin sequelae
relating to edema, and the extent of soft tissue excess
should be documented. Images should be obtained of the
relevant areas of the body. The initial visit, in addition to
developing rapport, should serve as a critical opportunity
to gain a clear understanding of the patient’s goals, expec­
tations, and tolerance for scars. In addition, existing work,
family, and financial constraints should be explored.
Surgery should be deferred in individuals whose weight
is not stable. Significant, active weight loss can result in met­
abolic imbalances that may result in poor healing and an
quence of deficiencies in preoperative screening and edu­
cation and surgical choices.
Preoperative Planning and Patient
Selection
Avoiding complications and unfavorable outcomes begins
with careful patient selection, education, and planning.
Initial consultation should include a detailed history with
an emphasis on weight, a focused physical examination,
and a thorough discussion of the patient’s goals.7 MWL is
usually a result of bariatric surgery and less often changes
in lifestyle. Bariatric surgical procedures tend to produce
rapid weight loss, with weight stability achieved within 18
months.8 Lifestyle changes usually produce slower weight
loss and have higher rates of recidivism. Important compo­
Summary Box
Patient Outcome Data of Complications

Body Lift (%)
Brachioplasty (%)
Vertical Medial Thigh Lift (%)

(N = 425)
(N = 700)
(N = 335)
Pulmonary embolism
1.18
0.00
0.00
Deep vein thrombosus
2.35
0.3
0.3
Hematoma
2.59
0.6
0.3
Infection
4.94
2.6
1
Skin necrosis
8.47
0.6
0.3
Seroma
20.94
10
19
Dehiscence
27.94
25
28.4
a
b
c
Fig. 31.2 A 50-year-old woman 42 months after gastric bypass surgery and weight loss of 80 lbs. Her weight here was 170 lbs. and her body
mass index (BMI) was 31. Her peak weight and BMI were 250 lbs. and 46, respectively. The patient has an android body type.

481
Chapter 31 Body and Extremity Contouring after Massive Weight Loss
clearly explained to the patients. These values are recorded
in the patient’s chart and their significance reiterated at fol­
low-up visits.
Managing Complications in
Body Contouring After Massive
Weigh Loss
Extremity Contouring
Skin Dehiscence
Complications after extremity contouring and truncal con­
touring are similar but differ in frequency (see Summary
Box). The most common complication after extremity
contouring, brachioplasty, or vertical medial thigh lift, is
skin dehiscence at the junction of the extremity with the
torso. The wounds tend to be small, 2 to 3 cm in length,
and present approximately 10 to 14 days after surgery. The
complication can be attributed to the wide range of motion
at the arm– or thigh–torso interface, the moisture that is
often present in these areas, and relative soft tissue isch­
emia at the confluence of scars at the axilla or groin. Exces­
sive tension at closure may be a contributing factor as well.
Management of this complication is usually limited to dry
dressing changes. In most instances the wounds are closed
by 6 weeks. On occasion, when hypergranulation tissue
forms, the application of silver nitrate may be needed (Fig.
31.3). Efforts to prevent this complication by avoiding scars
at this junction will invariably adversely affect the aesthetic
outcome.
early recurrence of soft tissue excess. Ideally, patients should
be at a stable weight for several months, but more impor­
tantly, they should have a healthy metabolic profile. Surgery
should be discouraged in individuals with unrealistic expec­
tations both regarding the expected outcome and the recov­
ery process. Patients seeking outcomes similar to individuals
with very different profiles, such as lower body mass index
(BMI), smaller BMI change, and younger age, will invariably
be disappointed. Individuals whose finances are limited and
for whom unforeseen expenses could cause disruption in
their lives should be discouraged from having surgery. In
addition, surgery should be avoided in cases where the mo­
tivation for surgery is unclear or when surgery is requested
by someone other than the patient.
The history, physical examination, and discussion of
goals and expectations provide much of the information
needed for the education component of the initial consul­
tation. Patient education should include a discussion about
complications and should be tailored to the information
gathered from the history and physical examination. Al­
though complications are never a pleasant occurrence, they
are much better tolerated and perceived very differently by
patients who are accurately informed of the likelihood of
these adverse events and how they are managed. Every ef­
fort should be made at the first office visit to educate pa­
tients about expected outcomes and to highlight elements
of their history and examination that may lead to an unfa­
vorable outcome. Before and after images of individuals with
similar patient profiles, including age, BMI, BMI change, body
type, and deformity, can be very helpful and provide candi­
dates with an accurate perspective on likely outcomes. Scars
and their management should be reviewed.
At the conclusion of the initial consultation, a plan
can be formulated and discussed with the patient. Safety
should always be the first priority, and in any plan every ef­
fort should be made to account for the generalized soft tis­
sue excess, avoid opposing vectors of tension, and minimize
scar perceptibility.
An office visit before surgery should serve as an oppor­
tunity to answer any remaining patient questions; review
potential complications and their management; and discuss
preoperative and postoperative guidelines, laboratory val­
ues, and consultations. One of the most important compo­
nents of the second office visit is to discuss the images taken
at the first visit. Areas to be addressed by the proposed sur­
gery and the regions not affected by the procedure should
be noted. Features that may lead to an unfavorable outcome
should be highlighted once again. At this visit, we advise pa­
tients that they will be weighed immediately before surgery
and that all tissues removed during surgery will be weighed.
The importance of maintaining the weight from the day of
surgery minus what was removed at the time of surgery is
Fig. 31.3 Hypergranulation tissue at the left axilla of a 46-year-old
woman 6 weeks after bilateral brachioplasty. Silver nitrate has been
applied to area.

SECTION IV AESTHETIC SURGERY
482
Body Lifts
Skin Dehiscence
The more extensive nature of truncal contouring, particu­
larly circumferential lower body lifts, leads to more serious
and higher rates of complications. Most skin dehiscences
are at the buttock cleft (Fig. 31.5). The separation typically
becomes apparent between 10 and 14 days postoperatively
and is mostly the result of tissue ischemia. Diminished tis­
sue perfusion to this region can be attributed to tension in
the area while patients are flexed at the waist, the inelastic
quality of the zone of adherence of the midline back, and
direct pressure over the coccyx bone. Another important
factor is persistent moisture in a deep buttock cleft. Partic­
ularly in women with a more gynoid body habitus, where
the lower body circumference is far greater than the upper
Seromas
Seromas are the second most common complication after
extremity contouring. The fluid collections form immedi­
ately beneath the closure along the distal one third of the
extremity. The cause may be attributable to motion at the
elbow or knee. Needle aspiration is associated with a high
recurrence rate. Marsupialization of the bursa leads to a
prolonged healing process and a potentially unacceptable
scar. Placement of a Penrose drain into the fluid pocket for
a period of 1 week or until drainage is minimal has proven
to be highly effective and well tolerated by patients (Fig.
31.4). Antibiotics are prescribed while the drain is in place.
Other Complications
Complications such as skin necrosis, infection, and throm­
boembolism are rare. Prolonged edema, though often as­
sociated with medial thigh lift procedures, has not been a
concern in our series. A key element to avoiding this com­
plication is maintaining dissection at a superficial level in
the region of the femoral triangle. After MWL patients may
present with chronic stable edema. In those cases, patients
return to their baseline level of edema within 3 months of
surgery. We do not routinely prescribe extremity garments
postoperatively in extremity contouring. Upper extremity
garments produce swelling of the hand and do not appear
to improve outcomes. If patients develop foot and leg swell­
ing after medial thigh lift, lower extremity compression
garments are advised. Patients with a presentation more
suggestive of thromboembolic disease are further evalu­
ated.
Fig. 31.4 Penrose drain placed into seroma cavity along distal medial
arm after brachioplasty.
a
b
Fig. 31.5 (a) Buttock cleft skin dehiscence at approximately 2 weeks
postoperatively. (b) Appearance at approximately 4 weeks postop­
eratively.

483
Chapter 31 Body and Extremity Contouring after Massive Weight Loss
ten be subtle and go undetected by patients. Consequently,
one of the most important reasons for a 6-week follow-up
visit is to assess patients for seromas. In our patient popu­
lation, seromas are typically found in the hip region and
are effectively managed by needle aspiration. To prevent
the formation of a bursa, we advise patients to come every
few days to resolve the seroma as quickly as possible. For
patients who live far from our office or when seromas ap­
pear to be large (larger than 200 mL), we often introduce a
Jackson-Pratt drain into the seroma cavity through the pa­
tient’s existing scar. We have not needed sclerosing agents
or any other modalities to resolve seromas. Efforts to mini­
mize seroma formation by the placement of quilting stiches
has proven unsuccessful.
Skin Necrosis
Skin necrosis is an ongoing concern with lower body
lifts, as it is with any procedure involving a full abdomino­
plasty. Most cases occur along the suprapubic region, and
risk factors include tobacco consumption, abdominal wall
scars, excessive undermining and tension, and liposuction.
Undermining in abdominoplasty should be limited to the
fascia overlying the rectus muscle in the epigastric region.
If an epigastric roll results from this limited dissection, par­
ticularly after fascial plication, additional digital dissection,
scissor spreading, or liposuction can smooth this region. In
an effort to maintain the vascularity of the flap, liposuction
should be limited to the epigastric portion of the abdomen.
Excess fat deep to the superficial fascial system in the hypo­
body, the directly opposing skin surfaces are conducive to
moisture retention and skin breakdown. The problem of
moisture is further exacerbated when leakage of serous
fluid occurs at the cleft. This complication is effectively
managed with dry dressing changes and silver nitrate ap­
plication when needed. Efforts to diminish the frequency
of this complication include minimal tension in the perfor­
mance of the procedure in the region of the cleft and pa­
tient guidelines to avoid excessive flexion at the waist and
prolonged periods in a recumbent position during the first
several weeks postoperatively. More recently, we have ad­
vised our patients to keep a dry dressing in the cleft begin­
ning from the immediate postoperative period to avoid any
moisture in this area.
Seromas
The management of seromas after lower body lifts is chal­
lenging. The frequency of this complication is the result of
the extensive nature of this procedure and shearing of tis­
sue surfaces. Our primary approach to minimizing seroma
formation is with the placement of five drains intraopera­
tively, with one specifically in the epigastric region. Sero­
mas are usually not noted by patients and may be easily
missed by the surgeon. Management begins preoperatively
when patients are educated on seromas. We advise them
that a resulting bursa may adversely affect their aesthetic
outcome by not allowing their skin envelope to adhere to
the deeper structures (Fig. 31.6). We also advise patients
on how to recognize seromas. Regardless, seromas can of­
a
b
Fig. 31.6 (a) This 27-year-old woman was disappointed with an early recurrence of soft tissue excess along the lateral thigh 1 year after a
body lift. (b) A bursa secondary to a seroma was discovered at the time of lateral thigh revision.

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isting drains often serve as a nidus of infection and should
be removed.
Thromboembolism
Thromboembolism after lower body lift, although rare,
represents the most serious complication. Risk factors in­
herent to this procedure and population include the ab­
dominoplasty component of the operation, the length of
the procedure, the higher-than-average BMI of these pa­
tients, and the residual comorbidities of patients who have
had bariatric surgery. Our approach to this risk has evolved
over time. Patients on medications that increase coagula­
tion such as birth control or hormonal therapy are advised
to stop for 2 weeks before surgery, and smokers are advised
to stop 6 weeks before and after the procedure. Sterile se­
quential compression devices are activated before anes­
thesia induction and are maintained postoperatively until
patients are ambulatory. On postoperative day 1, a lower
extremity venous Doppler is performed. On postopera­
tive day 3, patients e-mail an image of their drains before
evacuation. If the fluid is serosanguinous and not bloody,
they are advised to start subcutaneous injections of low-
molecular-weight heparin and continue until postopera­
tive day 10 (Fig. 31.7). If the fluid is bloody, images are re­
quested the next day and reevaluated. In the past, we have
attempted to give low-molecular-weight heparin perioper­
gastric portion can be directly excised. Patients with exist­
ing transverse or oblique epigastric scars need to be assessed
on an individual basis. Those with older scars in the epi­
gastric region may still benefit from abdominoplasty; how­
ever, undermining in the epigastric region should be very
limited. Candidates with newer scars in this region should
be avoided altogether. Smokers should be informed of the
risks associated with tobacco consumption during the pre­
operative evaluation and advised to stop for 6 weeks be­
fore and after surgery. Laboratory tests and affirmation from
patients will not guarantee that they are not smoking, so
if surgery is considered in this patient population, limited
undermining and flap tension and careful use of liposuction
are particularly important. To minimize the potential for flap
ischemia, our patients are kept in a beach chair position for
several days postoperatively and binders are placed loosely
with the primary function of holding sterile dressings in
place. Flap ischemia and the potential for necrosis usually
becomes apparent within 24 hours. If an area appears to be
ischemic, nitroglycerin paste can be applied, although we
have not seen significant benefit from this therapy. Any ex­
ternal factor, such as a tight binder of constrictive dressing,
should be eliminated. Silver sulfadiazine cream 1% should
be applied to the area if signs of skin breakdown, such as
blister formation, become apparent. Moist-to-dry dressing
changes become the mainstay of management if tissue ne­
crosis develops. Sharp débridement at the bedside can be
implemented as well with careful attention to not remove
viable tissue. Once granulation tissue has formed and wound
contracture begins, soft tissue defects will become consider­
ably smaller. Our preference is to allow these wounds to heal
by secondary intention and consider scar revision 1 year
postoperatively.
Infections
Infections, particularly those requiring intravenous anti­
biotics, are uncommon after lower body lifts. To reduce
the risk of this complication, patients are advised to bath
with chlorhexidine the day before surgery and are given
intravenous antibiotics before the first surgical incision.
Patients are prepped standing, and sterile technique is
followed throughout the procedure. Intraoperatively, tis­
sue manipulation is minimized and cutting is used over
cautery whenever possible. Antibiotics may be redosed
during surgery, depending on the length of the procedure.
Postoperatively first generation cephalosporins are pre­
scribed while drains are in place, usually for 2 weeks. In­
fections possibly requiring intravenous antibiotics usually
become clinically evident at 7 to 10 days postoperatively
and may be associated with erythema and induration
along the incisions, tenderness, elevated temperatures,
and purulent discharge through the drains or drain inci­
sions. Hospital admission is usually required. Computed
tomography should be performed to evaluate for a pos­
sible collection requiring drainage, and consultation with
an infectious disease specialist should be considered. Ex­
a
b
Fig. 31.7 (a) Drain fluid considered to be too dark to start antico­
agulation therapy. (b) Satisfactory fluid appearance for starting an­
ticoagulation therapy.

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Chapter 31 Body and Extremity Contouring after Massive Weight Loss
Managing Unfavorable
Outcomes in Body Contouring
After Massive Weight Loss
Unfavorable outcomes may be secondary to complications,
but often they are a result of choices made by the surgeon
and from inadequate preoperative screening or education.
MWL patients seeking extremity contouring are eager
to avoid lengthy scars. In an effort to please patients and
perhaps feeling that short-scar versions of procedures are
more satisfying than more invasive operations, surgeons
may offer brachioplasties limited to the axilla and medial
thigh lifts limited to the groin. Upper extremity contour­
ing procedures with an excisional component limited to
the axilla will usually result in some distortion of the axil­
lary dome and a failure to correct the excess soft tissue of
the arm, which is primarily in a vector perpendicular to the
arm (Fig. 31.8). Furthermore, in an effort to avoid a stand­
ing cone, aggressive resection of soft tissue in the axilla may
result in the need for a readily visible scar that extends to
the front and back of the shoulder. Medial thigh techniques
limited to the groin, in addition to failing aesthetically, may
result in some functional issues as well (Fig. 31.9).
Our preference is to perform lower body lifts before con­
sidering medial thigh lift procedures. The medial thigh de­
formity is a consequence of the collapse of the soft tissues
of the mons pubis, lower abdomen, thighs, and buttocks
toward the medial thighs. In addition, there is soft tissue
excess in a horizontal vector at the thigh. Lower body lift
procedures very effectively address the vertical vector com­
ponent of the medial thigh deformity. In many cases, this
atively. Anecdotally, more bleeding was noted in the opera­
tive field and postoperatively the drainage appeared darker.
All patients are assisted with ambulation the morning after
surgery and advised to ambulate frequently. The signs and
symptoms associated with deep vein thrombosis and pul­
monary embolism are reviewed. If a deep system thrombus
is discovered at the screening ultrasound or any time after­
ward, a pulmonary or vascular consultation is requested.
Patients with signs or symptoms suggestive of pulmonary
embolism are referred immediately to the hospital. Can­
didates for surgery with specific risk factors, particularly
those with hypercoagulable conditions, are managed on a
case-by-case basis, typically with consultation from a he­
matologist.
Hematomas
Few hematomas require surgical evacuation. The robust
blood supply of a large pannus and the magnitude of
post–bariatric-surgery circumferential lower body lift pro­
cedures predisposes to bleeding and the potential for he­
matomas. Careful hemostasis is critical in minimizing this
complication. Our preference is to use cautery set to a high
level to achieve this goal. Despite meticulous hemostasis,
more bloody than expected output may come through the
drains, usually within hours of the surgery, particularly
among men. Aggressive drain stripping may mitigate the
need for surgical evacuation. Once drains have become
clogged and blood is accumulating in a distinct region, sur­
gical evacuation at the bedside or in the operating room
should be considered. The need to replace clogged drains
often makes the operating room a more attractive option.
a
b
c
Fig. 31.8 A 38-year-old woman before (a) and 3 months after (b,c) brachioplasty limited to the axilla. The patient was disappointed with
results, which included distortion of axillary dome. She reports no significant correction of her initial concern, particularly with her arm at
her side.

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486
Fig. 31.9 (a) This 33-year-old woman with a presenting weight of 179 lbs. (with a body mass index of 31) lost 172 lbs. after gastric bypass
performed 11 years previously. (b) Three months after a body lift. She had concerns about remaining excess skin along her medial thighs.
(c) Three months after a bilateral type 1 medial thigh lift with the approach limited to the thigh perineal and gluteal creases. The patient
was now primarily concerned about the lack of improvement of her medial thighs and was somewhat concerned about the distortion of
her labia and the migration of the scar. (d) Two years after the body lift and 18 months after revision, type 3 medial thigh lift. A vertical
component was added, extending to the junction of the knee with the thigh. In addition to the improvement in the contour of her thighs,
she had notable correction of the thigh perineal scar migration.
a
b
c
d

487
Chapter 31 Body and Extremity Contouring after Massive Weight Loss
bands are more commonly seen in women who formerly
had a very high BMI and who are relatively short in stature.
The bands are found on the anterior distal one third of the
arm and anatomically appear to be an area lacking in any
subcutaneous fat. The bands become more prominent with
flexion at the elbow. Patients will often note this to be one
of their concerns and are eager to have it corrected. Over the
years, we have attempted several approaches to correct this
deformity with minimal success. Some improvement has
been achieved with liposuction on either side of the area of
constriction, but we have been unable to eliminate the de­
procedure alone will satisfy patient’s thigh concerns (Fig.
31.10). We reserve the vertical medial thigh lift to correct
only the horizontal vector of the soft tissue excess. Efforts to
correct the horizontal excess with a scar limited to the groin
crease will often lead to labial distortion, scar migration,
and inadequate correction of the deformity (see Fig. 31.9).
Brachioplasty
Brachioplasty presents many challenges. One of greatest is
correction of constrictive bands (Fig. 31.11). Constrictive
a
b
c
d
e
f
Fig. 31.10 (a–c) A 27-year-old woman who lost 163 lbs. through lifestyle changes. Her current weight was 117 lbs. and her body mass
index (BMI) was 19.5. Her peak weight and BMI were 280 lbs. and 47, respectively. The medial thigh deformity was one of her primary
concerns. (d–f) Eighteen months after a body lift. The body lift provided sufficient improvement of her medial thighs for her to forgo any
further surgery to this area.

SECTION IV AESTHETIC SURGERY
488
in determining future scar quality and, for the most part,
how patients have scarred in the past is the best indicator
of how they will scar in the future. We also note that scars
continue to improve over time, both in color and thickness,
and that most scars approach the adjoining skin color be­
tween 12 and 18 months.
We do not make recommendations regarding ancil­
lary scar therapy, because data regarding the efficacy these
modalities is limited and the products are often expensive.
Rather, we advise all patients to minimize ultraviolet light
exposure to scars while they are still red to prevent hyper­
pigmentation and offer scar revision at no cost 1 year post­
operatively when needed.
formity completely. Preoperatively, every effort should be
made to highlight the presence of these bands and to note
that they are unlikely to be corrected. A failure to do so will
create the perception of an unfavorable outcome.
Scars
Scars represent a great concern to both patient and sur­
geon in post–bariatric-surgery body contouring. Avoiding
an unfavorable outcome related to scars involves an ele­
ment of patient screening, education, and surgeon choice.
In our practice, a preoperative discussion of scars begins by
noting that patient genetics is the most important variable
Fig. 31.11 Left, A 31-year-old woman 4 years after bariatric surgery and a weight loss of 203 lbs. Her current weight was 195 lbs. and her
body mass index (BMI) was 35. Her peak weight and BMI were 398 lbs. and 71, respectively. Right, Three months after brachioplasty with
concomitant liposuction and scar placement along the posteromedial arm. Although the results are dramatic, the aesthetic level achieved
is not the same as the ideal candidate (Fig. 31.12). The band along the left arm could not be eliminated. (Reproduced from Nahai F, ed. The
Art of Aesthetic Surgery: Principles and Techniques, Vol 3. Breast and Body Surgery. 2nd ed. New York: Thieme Medical; 2011.)

489
Chapter 31 Body and Extremity Contouring after Massive Weight Loss
The surgeon’s choice in scar placement may also be a
very effective tool in avoiding an unfavorable result. Al­
though there are many options for scar placement in bra­
chioplasty and valid arguments to support them, over the
years we have received more favorable patient feedback
from scars placed in a posterior medial arm position (Fig.
31.12). We previously placed scars in the classic bicipital
sulcus location. In this position scars are well hidden when
patients have their arms at their sides and viewed from any
perspective; however, with external arm rotation, scars may
Patients are also informed that tension at the time of
skin closure is perhaps the second most important variable
affecting scar quality. At 1 year postoperatively, poor scars
can be excised and the skin edges approximated under mini­
mal tension, resulting in most cases in less perceptible scars.
If after this discussion candidates continue to express signifi­
cant reservations toward embarking on procedures with ex­
tensive scars and have a history of poor scars, surgery should
be avoided. A very acceptable result may still be perceived
as a poor outcome in this patient population.
Fig. 31.12 Left, A 25-year-old woman 4 years after bariatric surgery and a weight loss of 128 lbs. Her current weight was 137 lbs. and her
body mass index (BMI) was 25. Her peak weight and BMI were 265 lbs. and 48, respectively. Right, Six months after brachioplasty with con­
comitant liposuction and posteromedial scar placement. (Reproduced from Nahai F, ed. The Art of Aesthetic Surgery: Principles and Tech­
niques, Vol 3. Breast and Body Surgery. 2nd ed. New York: Thieme Medical; 2011.)

SECTION IV AESTHETIC SURGERY
490
Fig. 31.13 (a,b) A 35-year-old woman 1 year after brachioplasty with the scar positioned in the bicipital sulcus. (c) The scar becomes vis­
ible with slight external rotation of the arm.
a
b
c
Fig. 31.14 (a,b) A 42-year-old patient with a hypertrophic scar in the posteromedial position approximately 6 months after brachioplasty.
(c) The scar is minimally perceptible from the posterior perspective.
a
b
c
Fig. 31.15 A posteromedial scar position mimics the position of
the seam in a dress shirt.
become visible (Fig. 31.13). The posterior medial arm posi­
tion, our preferred location for nearly a decade, minimizes
scar perceptibility with external arm rotation and when pa­
tients are viewed from a posterior perspective, even in the
case of hypertrophic scars (Fig. 31.14). This position mimics
the location of a seam in a dress shirt (Fig. 31.15).
Truncal Deformity
The truncal deformity is often the greatest compared with
other areas of the body after MWL. Preoperative patient
screening and education are critical to avoid an unfavorable
outcome in this region, and the surgeon’s choice for proce­

491
Chapter 31 Body and Extremity Contouring after Massive Weight Loss
tion of the planned scar location by traction. Other common
complaints include standing cones and a complete failure
to address the deformities of the buttocks, thighs, and back.
Patients very commonly note that the deformities not ad­
dressed by the abdominoplasty are actually accentuated by
this procedure. Our preference is to perform circumferential
lower body lift procedures on most post–bariatric-surgery
patients. Issues of poor scar placement, standing cones, and
incomplete management of the torso can be eliminated with
dure may be the most important variable in defining the
result. Unlike the postpartum deformity, the effects of MWL
extend throughout the torso. Attempts to manage a MWL
patient with a traditional abdominoplasty may lead to very
disappointing results (Figs. 31.16 and 31.17).
A common complaint of MWL patients after abdomi­
noplasty is a high suprapubic scar. This can be explained
by preoperative markings that did not account for the soft
tissue excess of the mons pubis and the subsequent eleva­
Fig. 31.16 A 50-year-old man after massive weight loss and after abdominoplasty. The patient was disappointed with the outcome because of
the high lower abdominal scar, the standing cones at the hips, and the failure to address hip, thigh, and buttock concerns. (Reproduced from
Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques, Vol 3. Breast and Body Surgery. 2nd ed. New York: Thieme Medical; 2011.)
Fig. 31.17 A 45-year-old women with concerns regarding the remaining deformities along her hips, thighs, and buttocks after massive
weight loss and abdominoplasty.

SECTION IV AESTHETIC SURGERY
492
weight gain. Documenting a patient’s weight immediately
before surgery and the weight of the tissues removed creates
objective guidelines for what a patient’s weight should be at
3 months and beyond. A patient who returns for follow-up
at 6 months and weighs the same as on the day of surgery
but had 20 lbs. of tissue removed has gained considerable
weight. The extensive quality of the MWL deformity and
diminished elasticity of these tissues will often make proce­
dures that were well performed appear suboptimal. Patients
need to be informed preoperatively as to what areas will be
improved by the planned surgery and what other procedures
may be needed in the future to reach their goals. In addition,
patients (in particular women age 40 years and older) must
be informed that some early recurrence of skin excess as a
result of poor tissue elasticity is to be expected.
Conclusion
The relatively high complication rates associated with
post–bariatric-surgery body contouring and the significant
potential for unfavorable outcomes can make this area of
plastic surgery somewhat unappealing for surgeons. Fortu­
nately, these challenges are counterbalanced by the enor­
mous functional and aesthetic benefits that can be provided
to these individuals. Although it may be impossible to elim­
inate complications altogether, careful patient screening
and education help minimize the number of complications
and improve the experience of those who do experience a
problem. Similarly, the incidence of unfavorable results can
be diminished by thoughtful patient screening and educa­
tion. Above all, however, the most important variable in
avoiding an unfavorable outcome is a well-informed choice
by the surgeon in formulating a surgical plan.
this technique. Furthermore, after this procedure, patients
are in a much better position for subsequent upper body and
lower extremity contouring.
Patients often request that a lower body lift be performed
at the same time as a vertical medial thigh lift to economize
operative time and minimize time off from work and other
commitments. This option is particularly attractive for pa­
tients traveling considerable distances for surgery. Our expe­
rience with this combination of procedures has led to a high
rate of unfavorable outcomes. As described previously, the
lower body lift addresses excess tissue in a vertical, superior
vector, whereas the vector of traction from a vertical medial
thigh lift is horizontal and medial. When the procedures are
performed concomitantly, the opposing vectors produce sub­
optimal results along the proximal medial thighs (Fig. 31.18).
More than 30% of our patients who had this combination
performed requested revision of the proximal thighs. Disap­
pointing results can be avoided by performing vertical medial
thighs lifts at least 3 months after lower body lifts.
Many of the characteristics common to most MWL pa­
tients predispose to unfavorable outcomes:
•• Higher than normal BMI
•• A history of MWL
•• A deformity that affects most areas of the body and
tissues with poor elasticity
Many patients with a history of weight loss have attempted
a multitude of diets and lifestyle changes throughout their
lives, often with periods of great success. Nevertheless, it is
not unusual for post–bariatric-surgery patients to gain or
lose weight after body contouring procedures. An otherwise
satisfactory result can appear unfavorable with significant
Fig. 31.18 (a) A 35-year-old woman after massive weight loss and (b) 6 months after concomitant body lift and medial thigh lift. The pa­
tient was disappointed with the remaining excess tissue along the proximal medial thighs. (c) The excess tissue was the result of conflicting
vectors of tension between the body lift and the medial thigh lift.
a
b
c

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Chapter 31 Body and Extremity Contouring after Massive Weight Loss
5. Capella JF, Travato M, Woehrle S. Upper limb contouring.
In: Warren R, ed. Plastic Surgery, 4th ed. New York, NY:
Elsevier; 2012
6. Capella JF. Body lift. Clin Plast Surg 2008;35(1):27–51,
discussion 93
7. Capella JF, Travato M, Woehrle S. Screening and safety is­
sues in the massive-weight loss patient. In: Nahai F, ed.
Art of Aesthetic Surgery: Principles and Technique, 2nd
ed. St. Louis, MO: Quality Medical Publishing; 2010
8. Capella JF, Capella RF. An assessment of vertical banded
gastroplasty-Roux-en-Y gastric bypass for the treatment
of morbid obesity. Am J Surg 2002;183(2):117–123
References
1. Buchwald H. Obesity comorbidities. In: Buchwald H,
Cowan G, Pories W, eds. Surgical Management of Obesity.
Philadelphia, PA: Saunders Elsevier; 2007:37–44
2. Nemerofsky RB, Oliak DA, Capella JF. Body lift: an account
of 200 consecutive cases in the massive weight loss pa­
tient. Plast Reconstr Surg 2006;117(2):414–430
3.
tics/2014/cosmetic-procedure-trends-2014.pdf
4. Capella JF. The vertical medial thigh lift. In: Rubin P,
ed. Clinics of Plastic Surgery. New York, NY: Elsevier;
2014:727
Discussion by Dennis Hurwitz
Replacing sagging tissues after massive weight loss
(MWL) with form-fitting skin and gender-specific con­
tours is a daunting task that entails comprehensive
planning, multiple stages, extensive scars, and frequent
wound-healing complications. This time-consuming
and expensive surgery challenges both the patient and
plastic surgeon. A total body approach with a clear un­
derstanding of the objectives and risks yields optimal
results. This discussion offers some variations on the
quest to reach the optimal result with the least hassle.
Moreover, the unique issues related to upper body lifts
and the muscular male are explored.
Avoiding the Unfavorable Result
in Body Contouring After Massive
Weight Loss
Patient Evaluation and Selection
Regardless of patient-imposed limitations, the plastic
surgeon is obliged to evaluate all aesthetic deformities,
motivation, past disease, past surgery, psychiatric dis­
orders, social history, and nutrition. These findings and
their implications are reported to the patient with treat­
ment recommendations. The aesthetic consequences of
an agreed treatment plan that ignores some recognized
deformity is explained. Informed consent elaborates on
the proposed techniques, staging, costs, and reasonable
risks. A generously illustrated patient-oriented book,
complete with testimonials, assists in this education.1
With such complex treatment, the probability for revi­
sion surgery is high.2 A commitment from the patient is
requested to not only accept risk, but also to work with
the surgeon to treat complications, including revisions
to improve the results.
Underweight Patients
Normal and slightly overweight patients are likely
to obtain the best outcomes. Both underweight and
overweight patients are informed of their increased
risk and are offered individualized preparatory pro­
grams. A patient who is under ideal weight suggests
malnutrition, prompting a focused history, physical
examination, and extensive laboratory studies. Their
bypass procedure, such as a gastric partition, duode­
nal switch, or lengthy small intestinal bypass, may be
too restrictive and/or malabsorptive. Intake restric­
tion, social habits, bulimia, induced vomiting, or food
intolerances may limit their diet. These candidates
not only look too thin, they can manifest dry mucous
membranes and skin and poor skin and muscle tur­
gor. Their faces look wasted with deep-set eyes. They
may be weak, with muscular wasting. Regardless of
the presenting weight, a chemistry profile may reveal
deficient levels of protein, albumin, prealbumin, vita­
mins, and trace minerals.3,4
The plastic surgeon should consult with the bariat­
ric team for their appraisal of the patient’s medical and
psychiatric condition, nutrition, and treatment options.
Radical bypass procedures that led to excessive weight
loss may need to be reversed. More often treatment is
directed toward modifying food-related inappropriate
behaviors. Supplements are selected to treat laboratory-
proven metabolic deficiencies.
Untreated, these patients respond poorly to lengthy
anesthesia, have inadequate immunity, and a poor met­
abolic response. As such, they may experience altered
mentation, prolonged recovery, delays in healing, and
life-threatening infection. If adequate weight gain is
not achieved despite proper treatment, or the medical
condition is suboptimal, I tend to offer a single conser­

SECTION IV AESTHETIC SURGERY
494
vatively performed “test” operation. That sometimes
results in an ordeal that the patient does not wish to
repeat.
Overweight Patients
Clearly obese individuals experience compromised aes­
thetic results and higher risk. When the patient is un­
able to reduce to an appropriate preoperative weight,
I offer an effective short-term weight loss program.5
Daily small-dose injections of human choriogonadotro­
pin hormone (HCG) along with a 500-calorie diet over
6 weeks usually results in a 20- to 30-pound weight
loss, mainly from core abdominal adiposity. To prevent
delays in wound healing, surgery should be scheduled
no sooner than 2 weeks after completing this or any
other starvation weight loss program. Persistently
overweight patients are offered only one or two proce­
dures at a stage, usually with considerable concurrent
liposuction. Nevertheless, abdominoplasty in a patient
with prominent epigastrium of intra-abdominal adi­
posity is avoided because of the potential poor healing
and unaesthetic result.
Patient Expectations
Although generally realistic about the extent of their
deformity, MWL patients are not immune to body dys­
morphic syndrome. Unreasonable requests for major
procedures or extensive revisions for a minor deformity
such a subtle scar malposition should not be honored,
because they inevitably fail to satisfy and encourage
demands for further unfulfilling operations. Unreason­
able intense negativity to prior well-intentioned repu­
table surgeons is a red flag for future discontent.
Managing Unfavorable Results and
Complications in Body Contouring
After Massive Weight Loss
Scarring
Cognizant of the enormity of the task, MWL patients
tend to accept whatever scars are deemed necessary.
Nevertheless, they welcome opportunities to reduce
the scar burden, whether by shorter closures or place­
ment in inconspicuous locations. This is especially true
for correction of upper body and breast deformities.
Despite declarations of ready acceptance,6 my patients
prefer to avoid circumferential scars across the central
back. This long scar not only tends to hypertrophy, but
the disruption of distinctly normal feminine midpos­
terior back contours is disfiguring. Except for the most
severe deformity, midback transverse excisions should
stop well short of the midline, forcing the dog-ear exci­
sion along the lateral breast and not across the poste­
rior midline.
A technique to avoid the transverse bra-line exci­
sion for mild to moderate back laxity is to loop extend
a midlateral chest excision toward the midback to cre­
ate the J torsoplasty.5 With harvest of a deepithelialized
lateral thoracic vertical flap, a J torsoplasty is routinely
combined with spiral flap breast reshaping (Fig. 31D.1).
Similarly, as described later, male upper body contouring
usually combines J torsoplasty with boomerang-pattern
correction of gynecomastia.
Seromas
Seromas are a common problem for both extremities
and the trunk that nearly vanishes with optimal pres­
a
b
Fig. 31D.1 (a) Presurgical markings for a combined L brachioplasty with spiral flap breast reshaping in a 42-year-old woman whose
body mass index went from 38 to 27 after gastric bypass surgery. VASERlipo (Valeant Pharmaceuticals) was used for the brachio­
plasty excision site before removal of the skin. Both the rotated vertical lateral thoracic and flipped-up epigastric deepithelialized
flaps contribute to the augmentation and suspension of the breast. (b) The 6-month result demonstrates the desired changes.

495
Chapter 31 Body and Extremity Contouring after Massive Weight Loss
ervation of lymphatic circulation and reducing dead
space. For the torso that means a series of safeguarding
maneuvers.
A limited undermining lipoabdominoplasty is per­
formed. The operation starts with the infusion of sev­
eral liters of saline including xylocaine and epinephrine
throughout the anteriolateral abdomen. Liposuction of
the epigastrium removes excess fat and initiates the un­
dermining. Fat suctioning can be more aggressive to the
point of desired thinness if preliminary VASER (Valeant
Pharmaceuticals) ultrasound is applied to disrupt the
adipose. The superior incision and preparation of the
epigastric flap are performed next. Direct undermin­
ing of the epigastrium is limited to a 6- to 10-cm width
over the midline fascia, depending on the location of the
trans–rectus fascia perforating vessels. Spreading over­
sized forceps, such as LaRoe dissectors (Sontec), are used
to complete epigastric flap mobilization through stretch­
ing of the subcutaneous layer, leaving most perforators
visibly intact.7 Pulling inferiorly on the defatted and re­
leased epigastric flap confirms the lower abdominal in­
cision line, usually at the previously marked ideal loca­
tion. Following the lower abdominal skin incision, the
knife skates over Scarpa’s fascia for 6 to 8 cm over the
groins. Lower abdominal subscarpal fascia adipose and
the supramuscular areolar layer are retained to reduce
injury to emanating lymphatics. Only then is the iso­
lated abdominal excess skin and fat expeditiously re­
moved. When well preserved, Scarpa’s fascia is suture
suspended to the muscular fascia to retain the length of
underlying draining vessels and reduce tension on the
abdominal closure.
By completing the epigastric dissection first and re­
moving the pannus last, the time of cold exposure and
possible desiccation of the lower abdomen is limited.
The dissected debris and clot are wiped away, obviat­
ing room temperature saline irrigation with dilution of
salutary fibrin and platelets. When imbrication of the
midline fascia is indicated, a rapid No. 2 PDO Quill hori­
zontal mattress closure is secured with a J-return over-
and-over stitch. Small three-flap midline deepithelial­
ized cutouts are made several centimeters superior to
the umbilicus on the released epigastric flap. These flaps
are sutured to the rectus fascia around the umbilicus
under central high tension to the epigastric flap, which
relieves tension to the distal and relatively ischemic
portion of the flap. This is the lone area of progressive
tension, dead space–limiting epigastric flap suturing.
Consequently, vascular-compromising tension to the
lower central flap is eliminated. With the table flexed,
double-armed No. 1 or No. 2 barbed sutures secure a
rapid subcutaneous tissue closure over two No. 10 sili­
cone vacuum tube drains. Syringe aspirations and local­
ized foam rubber and elastic garment compression treat
the rare seroma. Failure of several aspirations necessi­
tates percutaneous needle insertion of an indwelling se­
roma catheter for 5 to 10 days.
Lymphatic and Vasculature Concerns
Both arm and thigh longitudinal skin reduction surgery
overlie medial major lymphatic subdermal pathways.
As such, full-thickness skin and subcutaneous tissue
resection disrupts considerable lymphatic and venous
return, leading to a high rate of lymphoceles and pro­
longed distal edema. For the most part that problem
can be avoided by radical excision-site liposuction
(ESL). Within the medial arm or thigh skin excision, all
the subcutaneous fat is suctioned free until the dermis
nearly contacts the muscular fascia. Preliminary VASER
application appears to improve preservation of delicate
neurovasculature. After the perimeter incision is made,
the overlying skin is then avulsed from the defatted bed
with the assistance of scalpel cuts against the dermis.
Cosmetic ultrasound-assisted liposuction of surround­
ing oversize adipose is performed with care to avoid
disrupting the perimeter closing tissue. An elastic gar­
ment reduces upper arm swelling and discourages se­
roma. If distal edema becomes a problem, the garment
is removed. No suction drain is placed, because the
negative pressure encourages lymphatic egress from
lacerated channels. With the advent of radical ESL, se­
romas, lymphoceles, and prolonged distal edema of the
extremities have not occurred.
Both ESL and deepithelialized spiral flap breast re­
shaping mandate precise preoperative estimation of the
width of resection. Excision of extremities with exces­
sive adipose cannot be accurately estimated; these pa­
tients should probably should undergo preliminary lipo­
plasty. Otherwise, lax tissue can be grasped and rolled
together to form conservative parallel incision lines. Be­
fore wound closure these lines are temporarily approxi­
mated to determine whether additional borderline skin
excisions need to be done. With experience the excisions
can be reliably designed, which expedites surgery and
facilitates team surgery. Multiple concurrent operations
under the direction of the responsible surgeon is part of
the efficiency that makes minimal staging total body lift
surgery possible.4,7,8
Skin and Fat Necrosis
Skin and/or fat necrosis over the sacrum and some­
times posterior iliac crests may appear some weeks

SECTION IV AESTHETIC SURGERY
496
after a lower body lift. In thin, smoking patients, this
is a likely occurrence. This delayed healing results from
intraoperative pressure while lying several hours su­
pine for the abdominoplasty on just-completed high-
tension wound closure over bony prominences. Neither
intraoperative silicone gel pads nor air floatation mat­
tresses and postoperative air flotation beds have elimi­
nated this wound-healing problem. In an alternative
approach, anterior torso surgery such as the abdomi­
noplasty is performed first, then the patient is turned
prone into a slightly jackknife position for the lower
body lift surgery. The anesthetized patient thus does
not lie on a high-tension wound closure. Furthermore,
care is taken to avoid direct pressure on the wound clo­
sures over these bony prominences in the early postop­
erative period. Since implementing this modification,
posterior bony-prominence closure necrosis and dehis­
cence has not occurred.
Because of the ubiquitous high-tension closures of
undermined flaps and perhaps the poor quality of the
tissues after MWL, minor wound breakdowns are com­
mon. Their management varies with etiology and mag­
nitude. Width of skin resection, undermining, closure
technique, and nearby surgical scars are factors. I agree
with the judicious use of electrosurgery. Indirect un­
dermining with preservation of perforators is also good
practice. VASERlipo flaps better tolerate tight closures.
Large-bite helical 6 barb/cm Quill closure evenly dis­
tributes proper tension across the subcutaneous tissues.
Major skin necrosis is potentiated by extensive di­
rect undermining. Impending wound edge necrosis is
relieved by cutting the suture closure. When the patient
has been sent home, the surgeon may depend on timely
transmission of digital photographs taken by caretak­
ing family members. The opened wound is covered by
saline-moistened wound dressings, vacuum-assisted
sponges, or temporary skin grafts until the wound is
ready for secondary closure. For borderline truncal clo­
sure pressure, greater care is taken with movement. Ex­
tension across the joint is reduced and flexion increased.
Compression elastic garments may have a brief role in
expelling infused saline.
Excessive closure tension is magnified by postopera­
tive swelling, which could cascade into edgewise skin
necrosis and lead to major wound dehiscence. To fore­
stall this disaster in worrisome tight brachioplasties and
thighplasties, firmly wrapping with 6-inch–wide elastic
bandages may inhibit aggravating postoperative swell­
ing. During the first 24 hours, distal vascularity of the
extremity is monitored; if compromised, the extrem­
ity wrapping must be removed. In the few instances
when these wraps have been implemented, there have
been no instances of venous congestion or arterial in­
sufficiency that require removal of the elastic wraps or
sutures. Not only has swelling been impeded, but the
closures healed primarily. The bandages are less tightly
wrapped the next day to minimize distal extremity
swelling.
Surgical scars left on undermined flaps may lead
to distal skin necrosis. There should be a wide, well-
vascularized skin bridge between the scar and the clo­
sure. Otherwise the surgeon should attempt to leave the
scars in the excision, which may necessitate a broad ver­
tical limb to the abdominoplasty or limit superior un­
dermining beyond a subcostal scar.
Gender Differences
Traditional body contouring surgery in men can be
disappointing. Whereas body contouring surgery in
women should narrow the waist and enhance the
breasts and buttocks, in men the skin and subcutane­
ous tissue resection needs to be adequate to reveal un­
derlying prominent superficial muscles and thorough
enough in the flanks to restore upper body dominance.
For moderate to severe gynecomastia after MWL, tra­
ditional transverse chest excisions correct the vertical
excess skin but fail to significantly reduce horizontal
excess. Hence postsurgical flexing at the waist shows
disturbing hanging skin that looks like ptotic breasts.
The residual loose skin also obscures the contour sub­
tleties of the pectoralis and latissimus dorsi muscles.
The upper body and gynecomastia can be corrected
along with the loose upper torso skin through a boo­
merang and J torsoplasty pattern.8–10 Muscle show is
improved, and there is no sagging skin when leaning
over.
The typical beltlike lower body lift that hugs the
pelvic rim, even with liposuction of the flanks, leaves
too full a waist and thus persistent lower body domi­
nance (Fig. 31D.2). In addition, a low-lying belt lipec­
tomy tends to depress contours along the lateral gluteal
closure, leading to an unnatural low hourglass-like nar­
rowing. Lateral gluteal thinning combined with residual
flank bulges result in an abnormal body contour that
thwarts comfortable positioning of the pants belt. These
deficiencies of traditional male lower body lift can be
avoided by a determined effort to create a narrow waist
through direct oblique excision between the posterior
iliac crests and the 12th rib as posterior extensions of
an abdominoplasty (Fig. 31D.3). These lower and upper
body oblique and vertical excisions combine well with
a traditional abdominoplasty to optimally reveal mas­
culinity (Video 31D.1).10

497
Chapter 31 Body and Extremity Contouring after Massive Weight Loss
Conclusion
Although there are variations to the successful ap­
proach to treating the surface changes after MWL,
proper patient selection, preparation, and organized
skillful surgery and follow-up care will reduce and
ameliorate the annoying and life-threatening compli­
cations. Delayed wound healing is synonymous with
compromised aesthetics.
a
b
Fig. 31D.2 Lower body lift failure. (a) Oversized and sagging hips and flanks with sagging buttocks before lower body lift. (b) Eight
years after an abdominoplasty with transverse lower body lift, the patient has residual flank and hip fullness, iatrogenic lateral
gluteal depressions, and minor saddlebag deformity. The markings are for lipoaspiration from the flanks and lipoaugmenation of
the lateral gluteal depression. The correction was partially successful.
a
b
Fig. 31D.3 Correction of severe flank bulging. (a) Oblique flank excisions are marked for reduction of severe bulges. (b) The
4-month result shows correction of the flank bulges with fading oblique lower back scars.

SECTION IV AESTHETIC SURGERY
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References
1. Hurwitz DJ. Total Body Lift: Reshaping the Breasts,
Chest, Arms, Thighs, Hips, Back, Waist, Abdomen
and Knees After Weight Loss, Aging, and Pregnancies.
New York, NY: MD Publish; 2005
2. Hurwitz DJ, Agha-Mohammadi S, Ota K, Unadkat J. A
clinical review of total body lift surgery. Aesthet Surg
J 2008;28(3):294–303, discussion 304–305
3. Agha-Mohammadi S, Hurwitz DJ. Nutritional defi­
ciency of post-bariatric surgery body contouring pa­
tients: what every plastic surgeon should know. Plast
Reconstr Surg 2008;122(2):604–613
4. Agha-Mohammadi S, Hurwitz DJ. Potential impacts
of nutritional deficiency of postbariatric patients
on body contouring surgery. Plast Reconstr Surg
2008;122(6):1901–1914
5. Hurwitz DJ. Refinements in body contouring surgery
the torso. Plast Reconstr Surg 2014;134(6):1185–
1195
6. Hunstad JP, Repta R. Bra-line back lift. Plast Reconstr
Surg 2008;122(4):1225–1228
7. Hurwitz DJ. Comprehensive Body Contouring: Theory
and Practice. New York, NY: Springer Verlag; 2016:81
8. Hurwitz DJ. Single-staged total body lift after massive
weight loss. Ann Plast Surg 2004;52(5):435–441, dis­
cussion 441
9. Hurwitz DJ. Boomerang pattern correction of gyne­
comastia. Plast Reconstr Surg 2015;135(2):433–436
10. Hurwitz DJ. Enhancing male features after massive
weight loss. Aesthetic Plast Surg 2016;40:245–255

499
CHAPTER
32

Gluteal Augmentation
Ashkan Ghavami and Joubin S. Gabbay
Gluteal augmentation has been performed with increas­
ing frequency for nearly 5 decades. The first reported
case, described by Bartels in 1969, used a breast implant
to treat gluteal idiopathic atrophy.1 Over the ensuing years,
augmentation of the gluteal region has been performed
using implants designed specifically for the purpose, au­
toaugmentation with local flaps, and, increasingly, with
autologous fat transfer.1–7 All modalities of gluteal augmen­
tation have undergone an evolution of technique resulting
in greater predictability with an improved complication
profile. This refinement is perhaps most notable in gluteal
augmentation with fat transfer. This is by far the most com­
monly performed method for gluteal contouring and aug­
mentation today. We have seen an explosion in buttock-
enhancing procedures since 2010. Popular media, social
media, and Internet popularity of certain female icons of
modern beauty have placed a large focus on buttock shape
and curvier body silhouettes.
There are several advantages of gluteal augmentation
with fat transfer compared with other methods.2,3,6 The pro­
cedure uses entirely autologous tissue, avoiding the compli­
cations associated with an implant (capsular contracture,
implant migration or rotation, wound-healing complica­
tions, thinning of native tissues, and implant-associated in­
fectious complications). It allows for detailed contouring of
the entire gluteal area, allowing focused augmentation of
specific areas of the region as dictated by anatomic need and
patient preference (unlike implant-based augmentation or
autoaugmentation using flaps, which have a more limited
region of augmentation). The harvesting of fat by liposuc­
tion allows for comprehensive or focused torso contouring
with a more profound global result. The reduction of fat in
the lower back, flanks, thighs, and even more distant sites
provide a powerful global body contouring effect combined
with augmentation of the gluteal region. The subtraction
of fat from the lower back and adjacent torso, with simul­
taneous addition of fat graft to the buttocks superiorly and
medially, provides the 360-degree “curve” visual enhance­
ment that is desirable. The result is an overall body silhou­
ette in which concavities flow to adjacent convexities cre­
ating a pleasing and sensual S curvilinear body reshaping
(Fig. 32.1).
S curve (posterior)
S curve (lateral)
Convexity
Transition
Concavity
Convexity
Transition
Concavity
Fig. 32.1 “S-curve” body silhouette.

SECTION IV AESTHETIC SURGERY
500
evolved to one with a more consistent and predictable re­
sult and a dramatically reduced complication profile that is
arguably superior to other modalities of gluteal augmenta­
tion. This chapter provides an overview of our approach to
patient selection, surgical technique, and postoperative care,
with special attention to details that optimize results and
help avoid complications. It also discusses the management
of complications that may arise from gluteal augmentation
with fat grafting. Box 32.1 reviews the overall pitfalls that
can lead to undesirable aesthetic results, poor patient satis­
faction, or true surgical complications.
Avoiding Unfavorable Results
and Complications in Gluteal
Augmentation
Despite its advantages, gluteal augmentation using fat
transfer has its limitations. Without sufficient fat for aug­
mentation, the procedure may provide less than desired aug­
mentation.6 In addition, fat grafting may be unpredictable or
subside to less than desirable volume over time. Other com­
plications noted with gluteal fat transfer include fat necrosis,
infection, erythema, abscess, hematoma, seroma, contour ir­
regularities, asymmetry, sciatic nerve injury, fat embolism,
thromboembolism, and death.8–10
Over the past decade, refinements in patient selection,
surgical technique, and postoperative management have
dramatically improved the short- and long-term results as­
sociated with gluteal fat augmentation. The procedure has
Box 32.1
Preoperative
•• Poor patient analysis
•• Inadequate patient consultation
•• Unrealistic expectations
•• Poor understanding of fat graft outcomes and
limitations
•• Patient factors
○
○Smoking (tobacco use)
○
○Suboptimal donor fat volume
○
○Soft tissue and bony morphology
Intraoperative
•• Poor liposuction technique
○
○Donor site irregularities
○
○Inadequate fat graft acquisition
○
○Excess trauma to fat graft lobules
•• Improper handling of fat grafts
○
○During processing
○
○During lipoinjection
○
○Lack of sterility
○
○Poor fat graft injection technique
•• Excess compression
•• Fat compartment blowout
•• Pooling of large fat aliquots
•• Neurovascular trauma
Postoperative
•• Compression or pressure of fat graft recipient
sites
•• Thromboembolic complications
○
○Tobacco use
○
○Poor hydration and calorie intake
○
○Weight loss
○
○Early or excessive exercise
○
○Unrealistic patient expectations
Pitfalls in Gluteal
Augmentation with Fat
Transfer
Summary Box
Complications Associated with Gluteal
Augmentation
•• Capsular contracture
•• Implant migration
•• Implant rotation
•• Improper wound healing
•• Thinning of native tissues
•• Implant-associated infection
•• Fat necrosis
•• Erythema
•• Abscess
•• Hematoma
•• Seroma
•• Contour irregularities
•• Asymmetry
•• Sciatic nerve injury
•• Fat embolism
•• Thromboembolism
•• Death
Patient Selection
Appropriate patient selection and education is critical to
the success of any cosmetic operation. The ideal patient for
gluteal fat augmentation should have sufficient donor fat
to allow for an appreciable gluteal augmentation. Very thin
patients are generally considered poor candidates for the
procedure; however, in some cases, thinner patients can
have a dramatic global torso transformation simply as the
result of a modest liposuction and fat augmentation to very
select zones of the gluteal region. In some cases, when pa­
tients have marginal or insufficient quantities of fat for glu­
teal augmentation, they can be instructed to gain weight
with a diet focused on gaining and increasing fat lobule size
to improve lipoaspirate yield.

501
Chapter 32 Gluteal Augmentation
Surgical Planning
Proper technical planning and execution are directly re­
lated to preoperative evaluation and thorough discussion
with the patient regarding aesthetic goals. As mentioned
previously, successful outcomes should rely less on volume
of augmentation than on optimal gluteal shape and how
this shape relates to overall body contour. The goal of this
chapter is to discuss possible complications and how to
prevent them; therefore details on aesthetic planning and
classifications of buttock shape are outside the chapter’s
scope and intent. However, it is important to review gen­
eral aesthetic guidelines.
There are four general types of trunk/buttock shapes6
(Fig. 32.2):
1. A-frame
2. V-frame
3. Square
4. Round
Understanding the limitations on how V- and H-frames
can be altered to the more desirable A-frame (or upside-
down heart) shape is paramount to avoiding overzealous
injection, particularly in zones that notoriously have less
fat graft survivability (midlateral and inferolateral areas).
For example, to change a V-frame to a more optimal waist–
hip ratio optimally requires a certain distance between the
12th rib and iliac crest (Fig. 32.3). The deeper the muscular
attachments and the longer the distance, the more liposuc­
tion in this area can excavate the flank and create depth.
In addition, lateral buttock augmentation and expansion
of width is often hardest to achieve in the anatomic region
that may need it most. The lack of neighbor fat cells here,
along with essentially skin, thin subcutaneous fatty depth,
and tensor fascia lata, makes it a challenge to alter the scaf­
fold and establish a favorable environment for fat graft sur­
vival (Fig. 32.4). Excessive fat transfer here often leads to
less graft survival and can lead to cyst and third-space cavi­
ties or frank seromas. However, selective release, grafting,
and precise and limited re-release allows for appropriate
expansion and fat take.
The patient should be marked in the standing position.
Planned areas of liposuction should be marked in a standard
fashion, with emphasis on the zones adjacent to the buttock.
There are many different surgeon preferences in marking
the buttock for gluteal augmentation. Although knowledge
of certain classifications or gluteal zones is helpful, clinical
markings do not need to adhere to these. More simply, areas
requiring both release and different capacity for accepting
fat grafts are marked. Markings are based on several fac­
tors including skin laxity, fat and muscle fullness, and bony
structure. It is important to assess the lateral–trochanteric
region for enhancement, because it can significantly contrib­
ute to the lateral contour of the gluteal profile. The iliac crest
should be noted and serves as the lowest point of liposuction
and the upper edge of the gluteal region. The patient should
It is critical to have a thorough discussion with the pa­
tient and explain what the procedure can and cannot ac­
complish for that individual. As in any plastic surgical proce­
dure, expectation management is of paramount importance.
Reviewing preoperative and postoperative photos of other
patients, particularly with similar body frame and tissue
characteristics, helps demonstrate achievable results and
elucidates limitations of the procedure. The magnitude of
gluteal contour improvement achievable is rooted in the
patient’s anatomic morphology and surgical precision. The
consultation should include a careful discussion of the risks
associated with the procedure along with the inherent un­
predictability of fat graft survival and longevity of the over­
all “new” buttock shape.
It cannot be overemphasized that in the current online
and social media climate, “selfies,” and numerous applica­
tions that help people alter their photographic images, pa­
tient education is becoming more vital. Without a collec­
tive effort by board-certified plastic surgeons in cohesive
dissemination of honest information on long-term “true”
results and limitations and/or risks, there will exist a far
greater challenge in the near and distant future. A lack of
informed decision-making will directly lead to unrealistic
expectations and increased complication rates. Patients will
see postoperative examples taken too early (with much of
the visualized gluteal volume resulting from edema and ulti­
mately nonviable fat grafts) or edited photos on social media
or, worse, on surgeons’ websites, and expect these results.
An honest plastic surgeon may lose that patient to someone
less experienced or less interested in technical acumen and
ethical practice standards. The results in fat grafting, more
than any other aesthetic procedure, require a minimum of
6 months to a year to assess.
Patients with preexisting medical comorbidities or who
are older than 40 years should receive appropriate medi­
cal clearance. It is very important to review all medications,
supplements, herbs, and other substances that the patient
is taking and instruct the patient to cease taking any that
may predispose to perioperative complications (vitamin E,
fish oil, aspirin, nonsteroidal anti-inflammatories, weight
loss supplements, etc.). Thromboembolic risk factors should
be scrutinized and discussed with patients. Smoking and
nicotine use (vaporized or directly consumed) may greatly
compromise fat graft viability by limiting blood flow to the
fat grafts. A lack of proper vasodilation and neovascular­
ization can reduce the delivery of proper nutrients for fat
graft survival. Patients who have unrealistic expectations or
who are psychologically compromised should have repeat
consultation(s), formal psychological evaluation, or refusal
of the procedure (often the wisest course). A classic exam­
ple is someone who desires disproportionately large but­
tock size. As with oversized breast implants, overexpansion
of the surrounding tissue envelope and scaffold will cause
severe deleterious effects. This is even less predictable than
in breast augmentation, because the long-term volume ef­
fect is not fixed as it is with an implant. The surgeon should
not resort to “overcorrection” for this reason.

SECTION IV AESTHETIC SURGERY
502
A
C
B
a
A
C
B
b
A
C
B
c
A
C
B
A′
C′
B′
d
Fig. 32.2 Mendieta’s frame shapes to evaluate overall bony frame and the consequent buttock–body relationship. (a) A-frame. (b) V-frame.
(c) Square. (d) Round. A, Upper lateral hip; B, midbuttock; C, lateral leg. (Reproduced from Mendieta CG. The Art of Gluteal Sculpting. New
York: Thieme; 2011:11.)
Fat recipient site
Fat excess
Distance
between 12th rib
and iliac crest
Fat transfer
Depth and distance
determined potential
for S curve
Post liposuction
Fig. 32.3 Flank shape potential. The distance between the caudal ribs and iliac crest along with iliac crest height and shape influence the
potential depth of the flank and waist excavation and degree of waist–hip ratio possible.

503
Chapter 32 Gluteal Augmentation
we do not believe this allows for good visualization of gluteal
symmetry and creates abnormal buttock contour and tissue
splaying. It is critical that all pressure points are protected,
particularly with the patient in the prone position (axillary
rolls, facial padding, elbow padding, and a horizontal cush­
ioning of the iliac crests, etc.).
Liposuction is performed in the standard fashion us­
ing the surgeon’s preference for tumescence and cannulae.
We prefer high-oscillation cannula-tip aspiration (power-
assisted) lipoaspiration. The main layer targeted is the sub­
scarpal layer, with large (4 and 5 mm) cannulas that allow
for adequate fat removal and comprehensive redraping of
the tissues postoperatively. A 4- to 5-mm cannula diame­
ter allows the fat lobules in this large volume grafting to be
minimally traumatized and more viable. Smaller cannulas
are used to target superficial cellulitic areas and for more su­
perficial lipodystrophy. Sometimes vibration is used without
suction to release superficial and deeper bands before per­
forming liposuction. Pretunneling and posttunneling are a
highly effective way to mobilize the fat layer to be aspirated,
and helps even out the remaining tissue layers during post­
operative healing.11,12 As with all liposuction, it is critical to
use multiple access incisions with crisscrossing passes at
multiple depths to avoid contour irregularities. We believe
special attention should be paid to aggressive liposuction
of the lower back, central fat pad (sacral area), and flanks. It
is the area just above the central gluteal border that can of­
ten blunt the degree of upper pole gluteal projection. With
removal of this area of lipodystrophy, there is an apparent
greater lower back lordosis with an appearance of greater
superior gluteal projection. This is what is colloquially called
a “shelf.” Excessive liposuction in the sacral area can destroy
the lymphatics similar to the mons pubis area, leading to an
increased prevalence of seromas in this region.
Seromas are more common in these two locations and
typically resolve with simple one-time or serial aspirations
in the office. Not adhering to the basic liposuction tech­
niques listed previously may result in donor site irregulari­
ties or inadequate fat graft acquisition, both of which are
undesirable.
Fat Preparation
Fat preparation is a critical step; the surgeon must not de­
viate from protocol and must be meticulous in every stage.
There are many approaches to processing of the lipoaspi­
rate, with an increasing number of devices (often expen­
sive) used for it.13,14 Although the details may differ, the
principles remain the same: the goal is to separate the vi­
able fat in a sterile fashion from the aqueous component
and prepare it for transfer to the buttock.
Our approach to fat preparation is to drain or aspirate
out the aqueous component of the lipoaspirate once the fat
has decanted in the liposuction canister (Fig. 32.5). The fat is
then strained through a commercial strainer, without touch­
ing the fat, removing further aqueous components and ob­
be assessed to determine whether elevation of the gluteal
contour or additional fullness in the iliac crest are needed.
There are often areas of dimpling throughout the gluteal
region or an oblique fascial band at the inferomedial border
of the buttock; these should be noted and marked, because
they require “selective” release intraoperatively.
The preoperative marking session is the last, and argu­
ably best, time to clearly delineate to the patient what areas
are planned for reduction and augmentation. It is helpful
to discuss with the patient which areas they feel strongest
about augmenting, particularly in cases where there may
not be enough fat to augment all areas of the buttock. The
patient should be offered the opportunity to prioritize sev­
eral zones, such as upper buttock fullness, posterior projec­
tion, posterolateral buttock fullness, or lateral hip–trochan­
teric fullness.
Intraoperative Considerations
Liposuction
The patient may be prepped for surgery with a standing
prep or in multiple steps throughout the operation. Se­
quential compression devices must be used, and the patient
should be given a dose of preoperative or perioperative an­
tibiotics within an hour of incision (and should be redosed
after 4 hours if the surgical duration allows for that). Per­
forming the procedure with general anesthesia allows for
greater flexibility in the operation.
There are many approaches to patient positioning dur­
ing surgery. We prefer to begin the operation with the pa­
tient in the supine position and turn the patient prone to
complete the procedure. The procedure may also be per­
formed with an alternating lateral decubitus position, but
Fig. 32.4 In the midlateral and inferolateral gluteal region it is usu­
ally more challenging to ensure great fat graft survival secondary to
a poor native scaffold and inadequate “neighbor” fat cells. The skin
and subcutaneous layer are typically adherent to tensor fascia lata
with less room for expansion. This patient has a lack of native scaf­
fold, poor capacitance, and poor osseous morphology.

SECTION IV AESTHETIC SURGERY
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The single most important component to ensure suc­
cess of fat transfer is to lay multiple small aliquots of fat so
that the injected fat is surrounded by healthy, well-vascular­
ized tissue and surrounding native fat cells. It is important
to avoid pooling of fat into large aliquots, because they may
progress to areas of fat necrosis or liquefaction. We use 3.7-
mm cannulae to inject the fat and do so during advancement
and retraction of the syringe (Video 32.1). Strokes should
be rapid, in a fanning motion, not staying in one location
for long. Typically no more than 5 to 10 cc of fat per pass is
injected.
As with liposuction, it is critical to perform multiple
passes in multiple directions to ensure an even and homog­
enous distribution of fat. We inject fat into the subcutane­
ous and superficial muscular layers only, beginning deep and
moving more superficial. Avoidance of the deeper muscular
layers is critical to avoid intravascular injection and injury
to the sciatic nerve (Video 32.2).10
Fat lobules placed in syringes should not be excessively
aqueous nor contain ligamentous and fibrous tissue. Revi­
sion and secondary liposuctioned zones will contain scar
and fibrous tissue, which will be aspirated and require re­
moval from injected aliquots. These both complicate the
necessary tension feedback required to optimally judge in­
jection volume required or possible per area. Some tissue
resistance should be felt with every pass to avoid inadver­
tent pooling of fat lobules. This third spacing can cause fu­
ture cyst formation and potential saponification of sterile
fat (Fig. 32.7).
Overcorrection is not recommended, because exces­
sive injection may result in greater pressure placed on the
transplanted fat—a potentially cytotoxic event.13 Excessively
aqueous fat grafts will overestimate actual volume of vi­
able fat cells injected. This may make the patient feel good,
because many want a certain amount of volume and deter­
mine success on this number. However, this will lead to un­
realistic expectations. A viable fat ratio is approximately 30
to 50% of aspirate volume. For example, if 3 L are aspirated,
up to 1,500 mL may be usable fat grafts. The factor that de­
termines this is the density of fat cells per area. Volumes
may be less in secondary cases or weight loss patients. Ar­
eas of gluteal dimpling may be released with percutaneous
aponeurotomy using an 18-gauge needle. We often use a
small pickle-fork cannula to release a lower central fascial
band of the buttock.
Access incisions are closed using a layered technique.
The nature of sterility and viability of fat grafted sites re­
quires watertight closure of incisions, particularly those of
the buttock and lumbar area. Open drainage should not be
used. Compression of the areas of liposuction is important to
prevent seromas and ensure good adherence of the skin and
superficial fat layers to the musculoskeletal framework. We
place one or two layered Topifoam adhesive pads (Mentor
Aesthetics) over the area of the lower back central (sacral/
suprasacral) fat pad to help enhance the desired lower back
lordosis. We then place Topifoam foam over the areas that
have undergone liposuction and place the patient into a
compression garment.
taining a greater content of more purified fat lobules. The
fat is mixed with a total of 300 mg clindamycin solution for
each strained batch. The fat is then transferred into 60-mL
Toomey syringes and prepared for injection to the gluteal re­
gion (Fig. 32.6). The strainers are covered with towels or pa­
per to avoid theoretical contamination in this open, exposed
part of processing. Although proponents of closed systems
claim contamination is an issue, there has been no evidence
to suggest that infection rates are increased or viability rates
are reduced with this processing technique. In more than
1,000 buttock fat transfers using the simple technique de­
scribed here, I (A.G.) have seen only three infections, and all
resolved with simple incision and drainage, with no need for
further revision or regrafting.
Gluteal Fat Transfer
Fat transfer is the most technically unforgiving component
of the procedure. The fat is susceptible to injury or death
from shearing, nutritional depletion, excessive pressure,
and other factors.13 Great care must be taken to place the
fat properly into the appropriate anatomical regions and to
avoid neurovascular complications to the patient and cyto­
toxic complications to the transplanted fat.
Fig. 32.5 Decanting after “low suction” aspiration into a closed can­
ister system.
Fig. 32.6 Fat graft transferred into 60-mL Toomey syringes.

505
Chapter 32 Gluteal Augmentation
Superior
Inferior
Superior
Inferior
Superior
Inferior
Cross section
Intraoperative
Long term
Denser ligaments/fibrous
bands seen among other
ligaments
Ligaments
Subcutaneous fat
Pooling in 3rd space cavity
created by overrelease
Superficial fat
Compartment blowout
results in contour irregularity
Capsule with
saponified fat
lobules
Deep fat layer
Gluteal muscle
a
b
c
d
Fig. 32.7 Overrelease of deep ligaments and fat compartment borders. Third spacing can result in fat “pooling” and subsequently alter fat
take. (a) Ligament distribution varies in each buttock but is similar to Cooper’s ligaments in the breasts. (b) Cross-sectional relationship of
ligaments from the muscle to the superficial subcutaneous fat layer. (c) Overrelease of ligaments and/or overexpansion with excess volume
can create a pooling of fat cells in the third spacing that is created. (d) Over the long term, “fat compartment blowout” can create a non­
contractile soft tissue envelope and an encapsulated cystic cavity containing saponified fat cells and liquid (usually sterile).

SECTION IV AESTHETIC SURGERY
506
tention is paid to minimizing the amount of time between
the moment fat is removed from the body and the time it
is injected into the buttock. Minimizing this extracorporeal
time reduces potential oxidative and ischemic injury to the
adipocytes. While the fat is out of the liposuction canister, it
is kept covered by a towel as a barrier to contamination and
air exposure. A common topic of discussion at conferences
relates to this critical step. Critics of the “open” technique of
transfer from donor to recipient note a “nonsterile” nature
to strainers. However, the argument is null based on vast ex­
perience and lack of literature. The simplest way to think of
this is that surgeons leave many instruments and materials
(meshes, sutures, and tissue matrixes) exposed throughout
surgical cases and resultant infectious issues do not occur.
There are many details associated with fat injection
that can optimize graft take. It is critical that the fat be dis­
tributed in small aliquots (5 to 10 cc) in multiple passes to
ensure that any implanted fat is completely surrounded by
well-vascularized host tissue. Large aliquots of fat will result
in “lakes” of fat within the buttock tissue, cyst formation,
and fat loss. The central core of these large aliquots will be
too far away from host tissue to receive any nutrients or
oxygen by diffusion, before the graft is vascularized. This
central tissue will be significantly more susceptible to loss.
Another important consideration to optimize fat take dur­
ing the injection process is to pay careful consideration to the
total volume injected with attention to the pressure within the
buttock. There is an upper limit of fat volume that can be in­
jected to the buttock.13 This capacitance should be judged pre­
operatively by tissue palpation and intraoperatively based on
continual and subtle changes in tissue resistance with cannula
passes. Beyond a certain point, the pressure built up within
the gluteal tissues from excessive fat injection can build to a
point that has a deleterious effect on the transplanted fat. The
graft capacity should therefore be evaluated and reevaluated
throughout injection. Increased experience in large volume fat
grafting will help immensely in this and all steps.
Postoperatively, care is taken to nurture the transplanted
fat as it transitions from a diffusion-dependent graft to vas­
cularized tissue that has taken hold in the host environment.
The most important concept in the perioperative period is
to avoid pressure on the newly transplanted fat. Patients are
instructed not to sit or lay on their buttocks for 2 weeks af­
ter the operation except for 20 to 30 minutes at a time on
pillows for eating, toilet use, and other necessary tasks. We
also believe in optimizing the nutritional support to the re­
cently transplanted fat.
We encourage patients to enjoy healthy, complex car­
bohydrates and protein shakes between meals. We also en­
courage our patients to stay well hydrated but consume a
low-sodium diet to minimize postoperative edema. Finally,
as previously mentioned we try to maximize fat retention
by allowing exercise 4 to 6 weeks after the operation but ini­
tially discouraging strenuous “fat-burning” exercises (such
as aggressive cardiopulmonary workouts) in favor of more
anabolic, muscle-building or muscle-maintaining exercises
such as yoga, Pilates, or weight training.
The understanding of factors related to fat retention af­
ter grafting have made significant headway over the past
Postoperative Care
Patients are given antibiotics for 5 days postoperatively. The
Topifoam pads are removed 7 to 10 days after the operation
and are replaced as needed. The patient is instructed to use
the surgical garment for up to 2 months after the opera­
tion, changing from first stage (two zippers) to second stage
(one zipper). Pads are usually not needed when the second
stage compression is used. Because compression on aug­
mented buttocks can result in fat graft death, the patient is
instructed to avoid sitting or lying on the buttocks for the
first 2 weeks and up to 8 weeks as much as feasible. This
includes prone positioning when sleeping and sitting with
pillows underneath the thighs, keeping the gluteal region
off the chair. There are now many commercially available
pillows designed specifically for this purpose. Another ap­
proach some patients take is to sit on an inflatable exercise
ball or sit on the thighs with the buttocks off the edge of a
sitting stool or chair with no back.
A very important caveat to that rule is to have a very low
threshold to see patients if they have any concerns or questions.
The final surgical result is not noted for 3 to 6 months after sur­
gery. After the 6-month mark, contour and volume retention
does not change much further if all conditions remain the same.
Patients should be educated on meticulous hygiene. Pa­
tients are instructed to ambulate immediately after surgery.
Postoperatively, patients are instructed to “feed their
fat.” We recommend a relatively high caloric intake for the
first 1 to 3 months after surgery to ensure better fat nutri­
tion and retention. Patients are allowed to engage in light
exercise 4 weeks after the operation. We recommend that
patients focus on exercises that will build and tone muscle
(yoga, Pilates, weight training, etc.) rather than strenuous
fat-burning exercises.
Avoiding and Managing Specific
Complications in Gluteal
Augmentation
Poor Fat Survival
Poor fat survival is perhaps the most common complaint
associated with gluteal fat transfer. Reasons associated with
all aspects of the operation as well as patient idiosyncrasies
are responsible for why fat take may be less than desired.
Perioperative factors that affect fat survival can be catego­
rized into those associated with fat preparation, fat injec­
tion, or postoperative care (see Box 32.1).6,13,14 Fig. 32.9,
later in the chapter, addresses poor fat graft survival in ar­
eas of overrelease and overexpansion.
We believe that it is normal to lose anywhere from 30 to
40% of transplanted fat over 3 to 12 months. Surgical factors
are reduced as much as possible to minimize this loss. From
the first steps of the operation, great consideration is paid
to maintaining and optimizing fat viability.
The operation is performed with a sense of urgency,
with care taken to minimize any wasted time. Particular at­

507
Chapter 32 Gluteal Augmentation
Preoperative expectations aside, striving to achieve ex­
cellent postoperative symmetry is certainly an important
goal but a secondary one of this procedure. Preexisting
asymmetry must be appreciated before the operation. Dif­
ferent quantities of fat may be injected on either side and in
different subunits of the buttock as needed. As a component
of the preexisting gluteal asymmetry, structural differences
between the buttocks must be recognized; this includes
dimpling, fascial bands, indentations, scar tissue, and skin
laxity. Fascial bands, inter–fat compartment ligamentous
borders, and indentations may be released using a pickle-
fork, vibrating various-tipped cannula, or 18-gauge needle
(superficial) intraoperatively. Indentations and areas of scar
may need more fat, scar release or revision, or reduction of
contralateral gluteal augmentation to match the restriction.
If a patient is noted to have substantial asymmetry post­
operatively, the most important first step is to wait at least 3
to 6 months after the operation to determine the final graft
take. The desire and necessity for revision fat injection to
correct asymmetry as a result of differential fat take is ac­
tually very rare.
If the patient continues to have asymmetry after the 3 to
6 months, the most straightforward approach is to perform
another fat transfer procedure to augment the side with vol­
ume deficiency (Fig. 32.8). This can be undertaken as early
as 6 months, but preferably at 12 months, if donor fat is
available. In performing revision augmentation, the entire
buttock need not be augmented. It is more efficient to only
5 years. In general, this understanding is primarily related
to operative maneuvers and techniques that improve out­
comes. Future direction in research should be directed to­
ward identifying the factors that result in differential fat take
among patients and on how to control these factors.
Asymmetry
Asymmetry is not commonly a source of patient complaint
and is often subtle. Preoperative native bony and tissue
asymmetries in contour, size, shape, and tissue elastic­
ity are most influential on long-term contour asymmetry.
Asymmetries are also related to many factors, including
differential fat viability and “take,” pressure differences
in sitting postoperatively, and different donor site char­
acteristics. However, the most important factor in manag­
ing postoperative asymmetry is preparing the patient for
it preoperatively. It is critical to clearly explain and point
out preoperative asymmetries and variations in iliac crest
height and other bony differences as well as skin and soft
tissue variations and native irregularities. Photographs aid
in this process. Surgical goals can be to improve the asym­
metry with differential fat grafting, but it will be impos­
sible to completely correct, as with all bilateral plastic
surgery. As has been abundantly documented in the breast
augmentation literature, patients who have appropriate
preoperative expectations and informed consent are sub­
stantially happier postoperatively.15
Fig. 32.8 This patient achieved adequate results for postoperative asymmetry. (a–f) Stage 1, before (a–c) and after (d–e) fat transfer
and abdominoplasty with avoidance of midback liposuction and preserving midtrunk perforators to the abdominoplasty flap. (g) Stage 2
(4 months later): Fat transfer and bilateral dogear revision.
a
b
c
d
e
f
g

SECTION IV AESTHETIC SURGERY
508
•• Skin dimpling (re-release and more superficial injection
of smaller fat aliquots)
•• Fat necrosis or oil cysts (treatment noted in the
following section)
Fat Necrosis and Cysts
One of the most important principles of successful fat
transfer is to inject small aliquots of fat with the goal to
have the graft surrounded by healthy, well-vascularized tis­
sue that allows diffusion of nutrients and oxygen to all of
the transplanted fat cells. With injection of too much fat in
one pass and lack of resistance, there is a greater risk that
the large aliquot of fat will pool within the gluteal tissue
and the central core of the aliquot will not receive adequate
nutrition to survive the grafting procedure. This fat death
may result in oil cysts or firm areas of fat necrosis. Small
areas will not pose a clinical problem or one needing cor­
rection. Large areas may cause large cyst formations or cre­
ate regional areas of soft tissue depression or ptosis from
fat graft loss (Fig. 32.9). Complete fat loss and full buttock
ptosis are rare. If they occur, a direct superiorly based but­
tock lift will treat the ptosis, and subsequent secondary fat
injection for volume can be later performed.
Again, prevention is the best approach to fat necrosis
or oil cysts. Box 32.2 lists the recommended treatment if
they do occur.
After appropriate treatment of these areas of fat necrosis
or oil cysts, the patient may have a contour deformity that
will require scar release and/or fat grafting.
Infection
Perioperative intravenous antibiotics and postoperative
oral antibiotics in addition to mixing the patient’s fat with
antibiotics before transfer to the buttock minimize wound
augment the anatomical zone(s) indicated. The alternative
approach of reducing the buttock with greater volume using
liposuction is not recommended, because liposuction of the
buttock is fraught with complications, including significant
contour abnormalities and untoward ptosis. In certain cases,
liposuction may be considered if it is performed in areas that
were augmented outside of the buttock tissue, such as the
lateral hip or supragluteal area, to improve the asymmetri­
cal appearance.
Contour Abnormalities
Management of contour abnormalities takes many cues
from the management of asymmetry discussed in the pre­
vious section: Patient education and prevention are the
most effective approaches. It is very important to note any
preexisting contour abnormalities before the operation
and discuss them in detail with the patient. The patient
is informed that all attempts will be made to improve the
contour abnormality, but guarantees cannot be made. One
of the most challenging aspects of buttock augmentation
with fat is to fully correct cellulite, wavy skin contour, a flat
lower pole, and dimples. Superficial skin contours are very
difficult to reverse or correct completely, as are adherent
lower pole or lateral areas that lack a native fat scaffold to
build upon.
Meticulous surgical technique with an eye toward rec­
ognition and prevention of contour abnormalities is the best
approach. As noted previously, preexisting contour differ­
ences resulting from dimpling, fascial bands, indentations,
scar tissue, and skin laxity should be managed appropri­
ately intraoperatively. Contour changes from liposuction
of the torso, extremity, or other fat donor sites should be
avoided by using good liposuction technique: using appro­
priately sized cannula to aspirate fat from multiple direc­
tions, in multiple passes, at multiple depths (with care to
never be too superficial). Donor site defects may need to be
addressed, as with any liposuction, and may include later fat
transfer, revision liposuction, band release, seroma drainage,
or other procedures.
Iatrogenic contour abnormalities of the buttock may
also be realized postoperatively. As with asymmetry, in most
cases it is prudent to wait 3 to 6 months after the operation
to accurately evaluate the issues and address the defect(s).
Postoperative contour changes of the buttock (with their
treatment) include the following:
•• Superficial fat injection (may be treated by steroid
injection or localized, superficial liposuction using small
cannulas)
•• Inadequate fat injection (may be treated with additional
fat transfer)
•• Tethering from scar (may be treated with percutaneous
scar release and fat injection)
Box 32.2
•• Large oil cysts may need to be drained under
direct palpation or with ultrasound guidance.
Packing may be required to help the dead space
close.
•• Small oil cysts may be allowed to resorb or be
drained with needle aspiration or wall suction
and a small cannula.
•• Large areas of fat necrosis may require surgical
excision (Fig. 32.10).
•• Small areas of fat necrosis (less than
approximately 2-cm diameter) may resolve with
time and can be observed.
Recommended Treatment for
Fat Necrosis and Cysts

509
Chapter 32 Gluteal Augmentation
Fig. 32.9 Buttock ptosis and loss of fat graft because of pooling and overrelease and a resultant fat compartment “blowout” fracture.
(a) Regional overrelease of ligaments, overexpansion with high pressure (excess fat graft volume) and resultant third spacing, poor contour,
and fat compartment blowout. (b,c) Before fat transfer. (d,e) After fat transfer and overrelease and overexpansion in the midbuttocks. This
results in poor contour control and greater loss of fat. This patient also had concomitant breast augmentation.
b
c
d
e
a
Fig. 32.10 A large capsulized cystic cavity with resultant sterile saponified fat
grafts. The capsule was excised, all fat grafts in the cavity were removed, the
area was irrigated, cultures were taken, and grafts were sent for pathologic ex­
amination. The skin was closed at the central gluteal cleft. The cultures were
negative and pathology confirmed calcified necrotic fat cells.

SECTION IV AESTHETIC SURGERY
510
lism has been reported as a macroscopic, mechanical ob­
structive event in which large quantities of fat occlude the
cardiovascular system, or as a microscopic inflammatory
event in which embolism of small quantities of fat result in
a systemic inflammatory response. In all cases, the greatest
care should be placed on prevention of this complication.
Fat should be injected in small aliquots only on advance­
ment and withdrawal of the cannula with constant motion.
Fat should be transferred into the subcutaneous and super­
ficial muscular tissue only. Larger blood vessels have been
noted deeper within the muscle and should be avoided,
because a theoretical partial laceration may allow an entry
for fat grafts. In addition, avoidance of deep injection mini­
mizes the risk of sciatic nerve injury.
Fat embolism presents with acute or progressive cardio­
vascular compromise. In either setting, if there is suspicion
for fat embolism, the patient should be supported with flu­
ids and oxygen and promptly transferred to a hospital for
evaluation and treatment.
Mortality
Recently an Aesthetic Surgery Education and Research
Foundation (ASERF) task force survey study showed a 3%
fatality rate among those surgeons who responded to the
­survey (692 surgeons of 4,843 receiving the survey).16 Out
of 198,857 cases, 32 fatal fat emboli and103 nonfatal emboli
were reported. Furthermore, 25 fatalities were confirmed in
the United States over the last 5 years via autopsy reports
and interviews conducted with surgeons and medical exam­
iners. Four deaths were reported from 2014 to 2015 from
pulmonary fat emboli in American Association for Accredi­
tation of Ambulatory Surgery Facilities (AAAASF) facilities
alone. In my (A.G.) vast experience, which has included no
known cases of fat emboli, deep venous thrombosis, pulmo­
nary embolism, or deaths, several key points have become
evident that require expanded discussion. The ASERF study
is correct in stating that cannula size, angle of injection, and
deep muscular injection should be avoided; I personally de­
scribed these points to one of the lead authors via several
discussions we had before its publication.
The fundamental problem with fat injection in gluteal
augmentation is that, unlike many other aesthetic procedures,
it is not widely taught in residency training. Many graduates
and more senior surgeons are, however, zealous in offer­
ing this procedure, because it has become one of the fastest
growing and most popular procedures requested worldwide.
Surgeons erroneously believe that the learning curve is not
steep and it is simply an easily adopted offshoot procedure
of liposuction. This is not the case. Experience is required
and complications are not necessarily related to volume of
fat injected. It is in “how” it is injected. A bump should be
placed under the iliac bones in the prone position in addition
to “kidney” position extension of the operating table to create
an upward angle from caudal and cephalad injection points.
This makes it more difficult to inadvertently enter the deep
muscular and large vessel, sciatic nerve spaces. The injection
infections. Patients are instructed to perform a chlorhexi­
dine rinse before surgery and are instructed to maintain
good hygiene postoperatively (antibiotic ointment on ac­
cess incisions, regular showers, etc.). Even with the most
careful approach, wound infections can occur.
If a patient develops localized erythema concerning for
cellulitis in the postoperative period, we have a very low
threshold to treat with antibiotics (typically a fluoroquino­
lone for 7–10 days). When patients develop an abscess, it is
promptly cultured and drained and the wound packed. Ide­
ally, we access the abscess through one of the fat transfer or
liposuction incisions (lengthening the incision if necessary),
but in some cases, the abscess must be accessed with a new
incision on the buttock (Fig. 32.11). Cultures are followed
closely, and antibiotics are narrowed appropriately. It is rec­
ommended to take mycobacterial cultures at the time of ab­
scess drainage. Rarely, mycobacterial infections have been
noted in patients undergoing gluteal fat transfer. Referral to
infectious disease specialists for appropriate treatment and
surveillance is important. In these cases, interrogation of
the operating room for a source may be warranted. Fungal
infection is very rare but I (A.G.) have seen it with one case.
Direct excision of the spores was necessary. The aesthetic
and medical consequences quickly resolved with antifungal
medication, obviating the need for a hospital stay or further
intervention.
Fat Embolism
Fat embolism may occur as a result of liposuction of the
donor site or fat transfer to the buttocks.8,10 Microfat and
in some instances macrofat embolism has been noted to
occur with even small liposuction procedures. Fat embo­
Fig. 32.11 This abscess localized to the inferocentral buttocks sym­
metrically began at week 3 postoperatively at the inferior buttock
crease access incisions. Cultures grew Staphylococcus epidermidis, and
the patient was treated with incision and drainage with extensive
clindamycin–saline irrigation of the cavity and subsequent packing.
The patient was prescribed culture-directed oral antibiotics after a
short hospital stay and 48 hours of intravenous antimicrobial ther­
apy. The cause of the infection was unknown but was presumed to
be postoperative contamination of the incision site because the re­
maining sites were nonerythematous and the other fat grafts were
viable.

511
Chapter 32 Gluteal Augmentation
silicone injection can be both acute and chronic and, at the
most severe, have resulted in several deaths.17–22
Complications Associated with Silicone
Implants
Infection
Infection typically occurs early in the postoperative period.
Early antibiotic treatment of cellulitis or suspected cellulitis
is clearly indicated to avoid implant infection. Once implant
infection is established, it is vital to remove the implant,
wash the cavity, and possibly leave the wound packed to
heal by secondary intention.
Wound Dehiscence
Wound dehiscence is noted to be the most common com­
plication associated with implant-based gluteal augmen­
tation. Local wound care may be used to manage minor
wound dehiscence, but implant removal is indicated in
cases of significant wound separation with implant expo­
sure. The incidence of wound dehiscence may be reduced
by the use of implants smaller than 350 cc, placement of
implants in an intramuscular position, and use of adhesion
sutures to tack subcutaneous tissue to the midline inci­
sions.
Seroma
Seroma is less common than wound dehiscence and may
be associated with the use of textured implants. Small se­
romas are typically unrecognized and most often disappear
over time. Early aspiration of fluctuant seromas larger than
100 mL may help prevent more serious complications such
as infection, implant migration or extrusion. Larger sero­
mas (larger than 200 mL) may require serial drainage or
surgical evacuation with drain placement.
Hematoma
Minor hematomas may be observed or aspirated, but larger
hematomas causing bulging or tenderness should be surgi­
cally evacuated to avoid complications such as wound de­
hiscence, infection, or capsule formation.
Capsular Contracture
Capsular contracture is a rare complication that may be
related to infection, hematoma, or seroma. Patients have a
thick capsule that may cause deformity or substantial pain.
Treatments include open capsulectomy or implant removal.
Sciatica
Patients may have transient sciatica that usually resolves
within 2 weeks. Prevention of sciatic injury is technique-
cannula diameter should be 3.7 mm or larger, which is what
I have used since 2007. The plane of injection should always
be altered, starting with deep (supramuscular) and working
more superficial. Manual feedback is necessary throughout
the fat injections; some resistance should always be sensed,
to avoid injecting a large aliquot of fat into an opened third
space (“blowout” of fat compartment; discussed previously).
This is one reason that I (A.G.) do not agree with mechani­
cally guided injection devices, because this tactile feedback
is disrupted and the fat is often more aqueous, allowing for
a higher chance of injection (because of the more watery na­
ture of fat grafts) into the wrong planes. Surgeons are learning
more about fat injection nuances as a whole, and given the
recent survey, more study is required.
Seroma
Seroma can occur in the donor area and should be treated
by needle aspiration and use of compression garments. Se­
romas that are clinically relevant in the recipient site(s) are
rare and can be treated with simple aspiration as well. Re­
peated drainage may be necessary.
Injection of Nonautologous
Materials
Although no filler materials are approved by the U.S. Food
and Drug Administration with a specific indication for
gluteal augmentation, the procedure still is done. In most
cases, patients have the procedure done by unlicensed
practitioners or in a foreign country and can have a vari­
ety of materials injected into the buttocks. Soft tissue fillers
have been associated with significant complications and
are not recommended for gluteal augmentation.
Gluteal Augmentation with Silicone
Implants
Silicone (ADATO-SIL-ol 5000, Bausch and Lomb, Rochester,
NY; Silicon 1000, Alcon Labs, Forth Worth, TX) has the lon­
gest and most controversial history of use in soft tissue aug­
mentation in the body.17–22 Its widespread use beginning in
the 1950s has revealed an unacceptable rate of complica­
tions when used as a large volume soft tissue filler for such
areas as the buttocks or breasts. In many cases, poor qual­
ity or industrial-grade silicone mixed with adulterants is
used by unlicensed practitioners. Although initial aesthetic
results with silicone may be good, complications may arise
years or decades after injection. Complications include lo­
cal skin discoloration and thickening, soft tissue nodular­
ity and granuloma formation, skin and soft tissue cellulitis,
abscess formation and necrosis, and persistent pain. Sili­
cone can compress on local neurovascular structures and
can migrate both locally and to distant sites, resulting in
disfigurement and organ failure. Systemic complications of

SECTION IV AESTHETIC SURGERY
512
Polyacrylamide Hydrogel
Polyacrylamide hydrogel, available by many brand names,
emerged as an alternative to silicone with expectations of
diminished toxicity and complication profiles, but experi­
ence revealed concerning outcomes. Complications noted
with hydrogel usage include inflammation and granuloma,
asymmetry, irregularity, infection and abscess formation,
gel migration, and anaphylaxis. Concerns for carcinogenic
behavior of the material and impedance of mammogra­
phy have resulted in the substance being banned for use in
breast augmentation in China. As with silicone and other
injectable agents, polyacrylamide hydrogel is often mixed
with adulterants or is used from industrial sources.26
Other Fillers
Other pharmaceutical-grade agents have begun to emerge
as candidates for gluteal injection. Stabilized hyaluronic
acid (Macrolane, Galderma, Fort Worth, TX) has been used
in Europe and has been shown to have persistence on
magnetic resonance imaging and good subjective results
after 24 months.27,28 Poly-L-lactic acid (Sculptra Aesthetic,
Galderma) has been also used for gluteal augmentation.
Although these agents have a better safety profile, they
have the disadvantages of requiring large amounts of very
expensive products to often be injected in multiple stages
for an overall augmentation that is limited in effect and
temporary in duration. Macrolane had been used widely
for breast augmentation but is no longer recommended
for this purpose because of complications including blue
discoloration, encapsulated lumps in breast tissue, infec­
tion, and parenchymal fibrosis.29 Concern for similar com­
plications with gluteal augmentation continue to limit its
use.
The most concerning injectable agents used for buttock
augmentation are the often unknown industrial agents that
are injected by nonlicensed practitioners.19,20,30,31 These
products are commonly marketed as legitimate filling
agents, with such names as “Biogel,” or “French Polymer” or
claim to be products mentioned previously (silicone, poly­
acrylamide hydrogel, poly-L-lactic acid) but are actually in­
dustrial or commercially available products that have no
accepted use in soft tissue augmentation.32 At best, these
agents may have slow development of complications, and
at worst they have resulted in the deaths of many patients.
The injections are performed outside of the medical arena
by practitioners who have neither the ability nor concern to
manage complications.
Complications associated with injections from nonauto­
logous soft tissue fillers can be managed based on the nature
of the agent and severity of the complications. We believe
that once an agent is in the patient, the best course of ac­
tion is to leave it alone. In no case should patients who have
already had gluteal augmentation with permanent agents
such as silicone, hydrogel, or unknown or illicit agents have
dependent with the procedure and should be carefully con­
sidered when performing it.
Implant Malposition
Implant malposition can occur early or late after augmen­
tation. Intramuscular placement predisposes to malposi­
tion related to poor placement and inappropriate settling
postoperatively or because of late lateral migration of the
implant. Malposition may also be the consequence of tissue
dissection from seroma or hematoma.
Aesthetic Complications
An unacceptable aesthetic outcome may be the result of
poor implant or placement site selection. Implant mis­
match to buttock size and contour may result in implant
edge visibility or inadequate augmentation. Placement of
an implant in the subfascial position in a thin patient may
result in implant palpability. Excessive or inappropriate
dissection may result in malposition or asymmetry. Man­
agement of implant malposition or a poor aesthetic result
should often be deferred for at least 6 months to allow for
reduction of swelling and formation of a stable capsule.
Maneuvers used in implant revision include implant ex­
change (change of size and shape), position change (sub­
fascial or intramuscular position), capsulectomy, capsu­
lotomy, capsulorrhaphy, implant removal, and infragluteal
fold revision.
Gluteal Augmentation with
Other Fillers
Gluteal augmentation originated with the use of silicone
implants, but in recent years, the preferred choice of mo­
dality of gluteal augmentation has clearly shifted to the use
of autologous fat. Despite that, gluteal augmentation with
silicone implants is performed with increasing frequency
and is more commonly used in South American and Euro­
pean countries. Gluteal augmentation with implants car­
ries a unique indication and complication profile.
In addition to surgeon and patient preference, indica­
tions for implant-based gluteal augmentation include a pau­
city of fat for autologous augmentation and buttock ptosis.
The following variables must be considered23:
•• Use of oval versus round implants
•• Incision pattern
•• Placement of the implant in a subfascial or
intramuscular position
•• Gluteal fold modification before or after the procedure
As with the unique surgical features associated with im­
plant-based gluteal augmentation, the complication profile
is unique to the procedure.1,7,23–25

513
Chapter 32 Gluteal Augmentation
nous antibiotics. Abscesses must be surgically drained. In
cases of significant deformity or intractable pain or com­
pression on neurovascular structures, surgical débridement
may be considered, but the patient must understand the
likelihood of significant deformity after débridement.
Outcomes
Figs. 32.12–32.16 provide examples of our gluteal augmen­
tation results and outcomes (Video 32.3).
further augmentation with fat or other products. Further
gluteal augmentation places the patient at significant risk
of developing infection or other complications.
Medical management should be reserved for cases of
inflammation, infection, intractable pain, and significant de­
formity. In cases of inflammation and erythema, a combina­
tion treatment with oral steroids and antibiotics may be an
acceptable first-line approach. As cases progress in severity
and infection is suspected, surgical management becomes
necessary. Cellulitis should be treated with oral or intrave­
Fig. 32.12 Left, This 22-year-old patient received fat transfer to her bilateral buttocks. Right, Postoperatively, she is very satisfied with the
overall volume and shape.

SECTION IV AESTHETIC SURGERY
514
Fig. 32.13 S-curve. (a) This 32-year-old patient had a fat transfer.
(b) Postoperatively she has deepened lumbar and sacral curves and
improved waist-to-hip ratio. Buttock projection is improved and
the patient is happy with the outcome.
a
b
a
b
Fig. 32.14 S-curve. (a) This 36-year-old patient had some moder­
ate skin laxity. (b) She experienced improved buttock aesthetics via
fat transfer to the bilateral buttocks, resulting in overall improve­
ment of S-curves and overall body silhouette lines. Overall buttock-
to-body balance and improved contour led to a very satisfactory
outcome.
Fig. 32.15 S-curve. (a) This 24-year-old patient had a taut skin en­
velope. (b) Postoperatively, the square contour lines improved to
more S-curve contours and improved, more feminine buttock shape
and projection.
a
b
a
b
Fig. 32.16 S-curve. (a) This patient had a square buttock appear­
ance and was concerned about a masculine body shape. (b) She has
improved buttock and full-body contours after liposuction with fat
transfer to the bilateral buttocks.