Phẫu Thuật Tạo Hình Đường Nét Cơ Thể Và Hút Mỡ (Body Contouring and Liposuction)

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Chapter | 51  High intensity focused ultrasound and non-invasive body contouring
FIG. 51.7  The LipoSonix System.
FIG. 51.8  Treatment head with cover removed. The ultrasonic
transducer and movement apparatus is seen.
FIG. 51.9  The abdomen is marked with numbered 3 × 3 cm grids
before treatment.
FIG. 51.10  Water is used to couple the treatment head to the skin
for HIFU transmission.

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PART | 8  Body contouring with HIFU or injectables
FIG. 51.11  The graphical user Interface touch screen controls the
LipoSonix device.
chemistry, including serum lipids. Necropsy specimens
detailed the biologic response of SAT to HIFU, that cell
debris and free lipids in the tissue were removed by mac­
rophages and that there was a thermal effect on collagen.
Subsequently, preclinical safety and dose–response
studies were performed on human volunteers who were
treated and underwent elective abdominoplasty for tissue
analysis. Laboratory studies did not show alterations in
clinical chemistry or blood lipids.
The LipoSonix device was evaluated in a prospective,
randomized, single blinded, sham-controlled study at
energy levels of 0 (sham), 47 J/cm2, and 59 J/cm2 for the
pivotal study to treat localized fatty deposits in the abdomi­
nal area. Patients (n = 180) were screened for inclusion/
exclusion criteria (BMI < 30 and adipose tissue >1 cm
thicker than focal depth of the HIFU transducer) and
consented for the study. All groups had three passes of the
treatment head over the abdominal area. Patients tolerated
the mild discomfort without the need for analgesics. Mild
to moderate ecchymosis was noted in treatment areas
that resolved. Patients were evaluated for their outcomes
using a standardized measurement system and clinical
photography.
The cohort treated with 59 J/cm2, three passes, lost an
average of 2.44 cm off their waist circumference at 12
weeks; the 47 J/cm2 cohort lost an average of 2.06 cm (per
protocol population). These results were statistically sig­
nificant for both groups. Global Aesthetic Outcome Scales
(GAIS) were rated by investigators as improved over the
sham group. Blood chemistry studies remained normal in
all areas. Both patients and investigators rated the outcomes
as improved over baseline. Approximately 67% of subjects
who were treated with HIFU reported mild or no pain
during treatment.9 Representative clinical outcomes at 24
weeks are noted in Figs 51.12–51.17.
THE LIPOSONIX PROCESS
A new procedure for noninvasive body contouring will be
attractive to patients seeking improvement in body areas
where localized fat deposits are located. With the addition
of a reliable noninvasive procedure, along with surgical
lipoplasty, and excisional body contouring procedures, it is
possible to literally have something for everyone. For those
plastic surgeons and surgical dermatologists who have
developed a systematic approach for patient evaluation,
treatment, and aftercare within the framework of surgical
procedures, the addition of a noninvasive body contouring
option should be fairly straightforward. There is the pos­
sibility of treating off-label other body areas including
gluteal, bra rolls, and cellulite, according to the specific
needs of a patient.
The noninvasive area of cosmetic medicine and esthetic
procedures has become very popular for a variety of
reasons. Surgical lipoplasty remains an excellent choice,
yet patients are willing to opt for procedures that have less
downtime and are less complex. Patients will seek out non­
surgical procedures that can be performed within a reason­
able treatment time, such as a person would spend having
their teeth cleaned. They are willing to undergo multiple
sessions in order to achieve improvement instead of having
to deal with the downtime of surgical lipoplasty. In this
context, it is important to calibrate patient expectations that
relate to outcomes seen with surgical lipoplasty to a nonin­
vasive procedure.
The LipoSonix system fits nicely into a process-oriented
approach for its safe and effective use. Excellent outcomes
and patient satisfaction generally can be achieved if you
surround yourself with a great process for the use of this
device. In reality, the technical details of the safe operation
of this device are straightforward; the process for its
use should be developed by physician and staff, as it
involves a variety of interrelated, sequential steps that will
reproducibly result in satisfying, safe outcomes for your
patients. Additionally, everyone involved will appreciate
that this treatment process is designed to not require
hands-on aftercare with regards to surgical dressings,
sutures, or exposure to body fluids. This device does not
require adjunctive, time-consuming lymphatic massage to
produce an outcome.
You may want to consider a service mapping exercise
with staff to define the entire LipoSonix process from start
to finish in your clinic. By doing this, you will be able
to understand what resources are needed, what staff is
involved, and how much time will be required for a treat­
ment session. This exercise will also help define the
other requisite components of patient evaluation and treat­
ment templates, informed consent, objective measurements
of body dimensions, and photography. The importance of

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Chapter | 51  High intensity focused ultrasound and non-invasive body contouring
FIG. 51.12  Forty-seven Joule cohort, three passes, 3.85 cm waist circumference reduction. (Courtesy Mark Jewell, MD.)
A
B
C
D
FIG. 51.13  Forty-seven Joule cohort, three passes, 4.0 cm waist circumference reduction. (Courtesy Mark Jewell, MD.)
A
B
C
D

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PART | 8  Body contouring with HIFU or injectables
FIG. 51.15  Fifty-nine Joule cohort, three passes, 3.10 cm waist circumference reduction. (Courtesy Mark Jewell, MD.)
A
B
C
D
FIG. 51.14  Forty-seven Joule cohort, three passes, 5.35 cm waist circumference reduction. (Courtesy Mark Jewell, MD.)
A
B
C
D

567
Chapter | 51  High intensity focused ultrasound and non-invasive body contouring
B
FIG. 51.16  Fifty-nine Joule cohort, three passes, 4.00 cm waist circumference reduction. (Courtesy Mark Jewell, MD.)
A
C
D
FIG. 51.17  Fifty-nine Joule cohort, three passes, 2.4 cm waist circumference reduction. (Courtesy Mark Jewell, MD.)
A
B
C
D

568
PART | 8  Body contouring with HIFU or injectables
Patient Selection
Everyone involved needs to have a clear understanding of
the “ideal” LipoSonix patient in terms of their physical
characteristics (BMI, hip/waist ratio, SAT location/thickness,
and skin tone) and representative results from treatment.
Adherence to defined values of tissue thickness as deter­
mined by caliper or ultrasound measurements between skin
and deep fascia is necessary in order to deliver HIFU to the
collagen-rich MLM that includes Scarpa’s fascia in the
lower abdominal region. Alternatively, other options for
body contouring surgery should be available if the patient
does not fit the defined criteria for the LipoSonix device.
Some individuals will not be a candidate for body con­
touring because of medical conditions, mental health issues,
or body morphology (intra-abdominal fat deposits, morbid
obesity, hernia or deficient skin tone). While it may be pos­
sible in the future to treat individuals with medical condi­
tions who otherwise fit the patient selection criteria, this has
not been studied. Other individuals may seek more immedi­
ate gratification or require multiple body areas treated.
These are better treated with surgical lipoplasty or exci­
sional procedures. Most patients can benefit from a review
of their nutritional and physical fitness activities as part of
their overall wellness program. Patient selection criteria are
summarized in Table 51.1.
It is important that patient expectations be well-managed
with regards to the anticipated result and the events that
will occur following treatment. While ecchymosis, swell­
ing, and discomfort are part of surgical procedures, these
will also occur following HIFU body contouring. It is
recording patient expectations and satisfaction metrics
within the templates in addition to lifestyle and nutritional
background information is emphasized.
There exist a variety of approaches for process develop­
ment such as the Toyota Production System or Lean Manu­
facturing. Both approaches are adaptable to the health care
environment as it relates to operational excellence, patient
satisfaction and safety.10 Choose to familiarize yourself
with these approaches that enable you to develop a process
for the LipoSonix device that you can trust will deliver its
intended outcome. At the same time, patients can trust that
they will receive value and satisfaction in the ultimate result
when they are educated about the nuances of the procedure,
what happens following treatment, and exactly how long it
takes to produce an outcome following treatment, and what
is required of them afterwards.
When you design your process for the LipoSonix device,
consider the application of an electronic medical record
(EMR) and its ability to import paper templates used for
patient evaluation and treatment. Spreadsheet programs like
Microsoft Excel® are helpful in tracking data collected
during patient visits (physical measurements, BMI, patient
satisfaction, adverse events (AE)). Data analysis for pur­
poses of assessment of outcomes (safety, quality, and
patient satisfaction) is facilitated in this fashion.
Staff Training and Qualifications to Operate
HIFU-Emitting Devices
HIFU-emitting devices used for noninvasive body contour­
ing can be operated by subordinate staff, according to their
scope of practice, qualifications, and training. This would
include individuals such as registered nurses, nurse practi­
tioners, physician’s assistants, ultrasonic technicians, and
physical therapists whose licensure permits the operation
of ultrasonic devices used for therapy or diagnosis. It is
important that only qualified individuals operate HIF-
emitting devices under the direct supervision of a physi­
cian. Noninvasive body contouring with HIFU is a
therapeutic treatment that could produce serious adverse
events if used improperly by untrained, unqualified opera­
tors. The physician is ultimately responsible for the conduct
and safe operation of medical devices by subordinates.
The use of treatment templates and staff checklists will
help “mistake-proof” treatments. It is important that subor­
dinate staff adhere to the treatment plan that has been elabo­
rated for each patient. Equally important is the clear
understanding of what not to do with HIFU devices, such
as using them when tissue is too thin, over bony areas,
hernias, and scars. In all situations, there must be adequate
space for the treatment head to be in touch with the skin
(coupling). Additionally, precise measurements are required
to document waist circumference and patient body weight.
TABLE 51.1  Selection Criteria for Noninvasive HIFU
Body Contouring
BMI optimally
27 or less
>2.5 cm tissue on
caliper pinch in
area to be treated
with HIFU
Absence of surgical
scars in treatment
area
Absence of skin
folds or
hanging skin
Absence of hernia
in treatment zone
Skin tone adequate
for liposuction
Presence of
localized fatty
deposits
abdomen and
waist
No medical or
psychiatric
contraindications
Realistic expectations
for outcome; not
motivated for
purpose of weight
loss
Absence of
intraabdominal
fat (i.e.,
metabolic
syndrome)
Motivated to
maintain fitness and
diet and weight;
willing to return for
follow up visits
Willing to consider
additional HIFU
treatments or surgical
lipoplasty

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Chapter | 51  High intensity focused ultrasound and non-invasive body contouring
During the procedure patients should have the option of
blankets to keep them warm and comfortable. The use of
water to couple the HIFU-emitting transducer to pass
through the skin and the cold treatment head can make
some patients feel chilled. Care should be given not to
excessively wet the treatment area as this may produce
tissue cooling and diminish the effect of the HIFU.
Aftercare
Aftercare following LipoSonix treatment is fairly straight­
forward. As discussed earlier in this chapter, there is no
need for compressive garments or binders that are used in
traditional surgical lipoplasty of excisional body contouring
procedures. The use of foam pads and a shaper garment for
a few days to limit ecchymosis may be a consideration as
in surgical lipoplasty, if you think it necessary. Patients
should be counseled regarding timelines for recovery that
relate to resolution of ecchymosis and post-procedural dis­
comfort. Some individuals may have transient dysesthesias
that gradually resolve over time, just like what is encoun­
tered in ultrasonic surgical lipoplasty. Improvements in
body contour may be noted as soon as 4 weeks post-
treatment, but patients should be advised that full results
should not be expected before 12 weeks post-treatment.
Patients should be seen in follow up visits to monitor
their progress and for purposes of coaching. This is a
novel type of nonsurgical treatment that produces results
over time as ablated tissue is removed. It is important
to help patients maintain enthusiasm while change is
occurring. The use of objective measurements such as
precise weight, waist circumference, and photography is
helpful in the post-treatment period to document progress
in contour change following treatment. Patient counseling
regarding the maintenance of weight and fitness-promoting
activities is important as weight gain can confound
measurements.
The investigational studies performed with the LipoSo­
nix device were single-sessions where three passes (fixed-
depth treatment zone) with the treatment head were
performed. It may be possible to consider other approaches
of serial sessions, variable treatment depth, and even “main­
tenance” procedures.
Adverse Events
In most situations, the incidence of adverse events is low.
The occurrence of discomfort during/after treatment and
ecchymosis are normal events and should be described as
part of the pre-procedural teaching process. Transient dys­
esthesias have been noted, with resolution over time.
Patients will feel attended to if they experience problems
or have questions following treatment. If adverse events do
important to accurately represent what is involved with the
LipoSonix treatment and afterwards. Similarly, aftercare,
patient coaching/support are essential in helping maintain
enthusiasm during recovery. The role of data from objective
measurements and standardized photography is very helpful
when reviewing results and fine-tuning treatment regimens.
Patients should keep accurate logs of dietary intake, exer­
cise and weight in order to assess that there are no exoge­
nous factors that can impact their outcomes.
At this time, it appears that the ideal patient is an indi­
vidual with a BMI of 27 or less, who has localized fatty
deposits and good skin tone. Individuals who are obese, or
have primarily intraabdominal fat generally should be
excluded from LipoSonix treatment because they would not
achieve a satisfactory therapeutic result from treatment.
Predictably, a noninvasive body contouring device will
attract individuals who fall out of precisely-defined selec­
tion criteria. Such individuals may be suitable for surgical
lipoplasty, excisional body contouring, or referral to a
medical weight loss clinic.
Patient Comfort
Most patients are able to comfortably receive treatment with
the LipoSonix device without the need for analgesics or
sedation. Generally, energy ranges in the 35–45 J/cm2 are
tolerated very well on the second-generation Liposonix
device. Occasionally, there may be some areas of discomfort
encountered in the sub-costal, inguinal, or periumbilical
regions. Patients will also report discomfort when HIFU is
applied to fascia such as in the region of a midline diastasis
of the abdomen where tissue depth may be thinner. HIFU
should not be applied over scars, hernias, implanted devices,
or when body contour does not permit coupling between the
treatment head and the skin. Bony areas such as the lower
rib cage and iliac crest of the pelvis become uncomfortable
with HIFU application. It is possible to utilize a half treat­
ment zone on the device’s control panel when treating next
to bone. Areas that contain defined sensory nerves such as
in the sub-costal and inguinal (ilioinguinal nerve) may be
more uncomfortable during treatment.
Patient comfort during the procedure may also be
enhanced with techniques of distraction (gate theory of
pain) that involve application of a vibratory massager
device to the feet during treatment.
Most patients do not require post-procedural analgesics.
They should be counseled to expect discomfort and
instructed on how to manage it with analgesics and cold
packs. Some individuals report discomfort from the ecchy­
mosis that occurs, but this is limited to a few days. Unlike
surgical lipoplasty or excisional body contouring, there
is no requirement for compressive garments following
LipoSonix treatments.

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PART | 8  Body contouring with HIFU or injectables
individuals that know and trust you. You may want to con­
sider preferred pricing for established patients (“frequent
fliers”). Web resources allow for you to post large amounts
of information regarding the procedure, develop accessory
web sites, and help patients prescreen themselves for the
procedure. Web sites can be robust with video and before/
after descriptive photos. It is important that you detail what
you offer in terms of both noninvasive and surgical types
of body contouring in your marketing communications.
Men have traditionally had a keen interest in improving
areas of fullness in the waist and abdomen, yet have shied
away from surgical procedures. This group of potential
patients appears to be interested in the noninvasive, minimal
downtime approach that accompanies the HIFU body con­
touring devices. There is an excellent opportunity to grow
a market for noninvasive body contouring in males. Mar­
keting communications need to be oriented towards attract­
ing male patients.
Within your office, you may want to use a looped slide
show that plays on large screen LCD flat screens or tablet
devices, which highlights this new procedure. Prospective
patients will appreciate seeing representative results that
you have produced. Esthetic plastic surgery and cosmetic
medicine has the need for visual explanation of outcomes
in order to help patients understand what their results may
be after treatment.
THE FUTURE
HIFU-emitting body contouring is an emerging technology
and improvements in technique and technology are expected
to occur over time. As this is the first textbook chapter ever
published on HIFU body contouring, the authors acknowl­
edge that this technology will continue to evolve and
improve over time with regards to efficacy and adaptability
to other body areas. This is a technology that involves a
device driven by software. It has the option of many differ­
ent power levels, focal depth, and patterns that can be
optimized to produce nonsurgical improvements in body
contour. There is still much discovery to be accomplished
in order to optimize this technology as an integral part of
body contouring.
CONCLUSION
Thermal HIFU as delivered by the LipoSonix device (Medicis
Technologies) is capable of producing improvement in
body contour through a noninvasive process. This device,
according to investigational studies, offers safe, predictable
outcomes for patients seeking modest improvements in
body contour without surgery. Patient selection and man­
agement of expectations regarding outcome are of para­
mount importance. The LipoSonix system appears to be an
occur, be certain to document them and note resolution of
the problem.
THE BUSINESS OF NONINVASIVE
BODY CONTOURING
The business model for the use of noninvasive ultrasonic
lipoplasty devices involves both the cost of physician/staff
time and equipment/space/consumables/marketing. It is
possible to set prices for body contouring based on area to
be treated, dimensions (broken down into 5 × 5 cm grids)
or number of HIFU shots fired through the transducer or
treatment sessions. Currently, a single treatment, generally
a three or four pass session, can be accomplished in about
an hour’s time from start to finish, with an earlier consulta­
tion session. While it may be possible to perform HIFU
lipoplasty with higher energy levels and fewer passes,
patient discomfort seems to increase with higher energy
levels. It is better to consider lower energy settings and
patient comfort over expediency.
In most cases, the treatment itself can be performed by
a subordinate staff member who is working within their
scope of practice. Although this is a noninvasive treatment,
it still remains a medical procedure that is being adminis­
tered under the direction and oversight of a physician. It is
impossible with this or any medical procedure to guarantee
an outcome or warrant a result.
Establish office pricing for the procedure based on costs
of equipment (fixed costs + cost of usage), labor, space, and
marketing. I have found that a “fee-simple” approach for
pricing works best because patients know what will be their
costs ahead of time. If additional treatment sessions are
contemplated, a package price may be a consideration. In
situations of patients requiring additional treatment, develop
pricing and policies in this area in order to avoid having to
give away services. Your staff may be interested in under­
going the procedure and costs need to be established for
them also.
It is a good idea to develop a log book or spreadsheet
that details transducer usage, patients treated, number of
HIFU shots fired by the transducer during treatment session,
and transducer inventory. This gives accountability for the
usage of the device and prevents it from being used by staff
after hours without collecting revenue for the office.
Marketing of Noninvasive HIFU
Body Contouring
There are many different ways to market a new service
such as noninvasive body contouring, whether through
web-based resources, social media, or print. It has been said
that the best source for individuals interested in procedures
such as this one is your current patient base of satisfied

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Chapter | 51  High intensity focused ultrasound and non-invasive body contouring
5. Silberg B. The technique of external ultrasound-assisted lipoplasty.
Plast Reconstr Surg 1998;101(2):552.
6. Duck F. Hazards and safety of diagnostic ultrasound. Med Eng Phys
2008;30(10):1338–48.
7. Ablaza V, Gingrass MK, Perry LC, et al. Tissue temperatures during
ultrasound assisted lipoplasty. Plast Reconstr Surg 1998;102(2):
532–48.
8. Gadsden E, Aguilar MT, Smoller BR, Jewell M. Evaluation of a
novel high-intensity focused ultrasound device for ablating subcuta­
neous adipose tissue for noninvasive body contouring: safety studies
in human volunteers. Aesth Surg J 2011;31(4):401–10.
9. Jewell M, Baxter RA, Cox SE, et al. Randomized sham-controlled
trial to evaluate the safety and effectiveness of a high-intensity
focused ultrasound device for noninvasive body sculpting. Plast
Reconstr Surg 2011;128(1):253–62.
10. Spear S. The High Velocity Edge. New York: McGraw Hill; 2009.
excellent fit with existing forms of body contouring surgery
(surgical lipoplasty and excisional body contouring). It has
the potential to expand the marketplace for individuals
seeking improvement in body contour who are willing to
accept a noninvasive approach in return for modest
improvements.
REFERENCES
1. Odo M, Cucé L, Odo L, et al. Action of sodium deoxycholate on
subcutaneous human tissue: local and systemic effects. Dermatol
Surg 2007;33:178–88.
2. ter Haar G, Coussios C. High intensity focused ultrasound: Physical
principles and devices. Int J Hyperthermia 2007;23(2):89–104.
3. Jewell M, Desilets C, Smoller B. Evaluation of a novel high-intensity
focused ultrasound device: preclinical studies in a porcine model.
Aesth Surg J 2011;31(4):429–34.
4. Wilkinson TS. External ultrasound assisted lipoplasty. Aesth Surg J
1999;19:124–9.

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© 2013 Elsevier Inc
Chapter 52 
Key Points
●
Mesotherapy is a specialty that is practiced worldwide
by over 18 000 physicians for cosmetic applications
such as cellulite, spot weight reduction and facial
rejuvenation.
●
Mesotherapy uses combinations of homeopathic and
pharmaceutical medications as opposed to injection
lipolysis, which uses a single substance.
●
Patient selection is key for success.
●
Medication used must be isotonic, biocompatible and
sterile, with a pH between 5 and 7.
●
Number of treatments is determined by patient’s
severity of symptoms and how they respond to
therapy.
●
Absence of double-blind studies has caused the United
States medical community to be slow in its
acceptance.
Mesotherapy for body contouring
and cellulite
Neil S. Sadick and Marion Shapiro
INTRODUCTION
Mesotherapy is a nonsurgical cosmetic treatment invented
by Michael Pistor in France in 1952 after he completed
research in intradermal therapy and research in treating
disorders in the mesoderm layer.1 By choosing mesother­
apy, the patient is not subjected to oral or intravenous medi­
cation, as it treats the problem at its source by local action.
The French Academy of Medicine recognized mesotherapy
as a specialty of medicine in 1987. The International Society
of Mesotherapy has members in 14 countries throughout
Europe and South America. Over the past 50 years, in
excess of 18 000 physicians worldwide have used meso­
therapy on a daily basis for a variety of purposes, including
treatment of cellulite, spot weight reduction, overall weight
loss, hair loss, facial rejuvenation, correction of liposuction
errors, pain management, and sports injuries. This chapter
will only deal with the cosmetic applications of mesother­
apy for body contouring and cellulite.2
Mesotherapy employs multiple injections of a combina­
tion of homeopathic and pharmaceutical medication, plant
extracts and vitamins that are injected into the mesoderm
layer targeting the adipose fat cells, dermal vasculature, and
connective tissue septae. The medications selected for use
are based on the intent of the treatment. Injection lipolysis
(Fig. 52.1) using a single substance like Lipodissolve™
should not be confused with mesotherapy that uses combi­
nations of medications.3 The injections are performed with
a special needle that varies from 0.4 to 0.6 cm, spaced
approximately 1.5–2.5 cm apart. Sometimes the technique
of Nappage is used; this is a series of injections of small
amounts of substance into superficial concentrated areas of
the skin with a longer needle up to 13 mm used occasion­
ally to target deeper fat.3
Mesotherapy has spurred some controversy in the
American medical community even though it has been very
well accepted in Europe and South America.4 Unlike rec­
ognized FDA-approved cosmetic procedures, the medica­
tions used are off-label and no double-blind studies have
been completed to support mesotherapy as an effective
nonsurgical alternative to liposuction. Success rates vary on
the formulas used, and most users keep their formula pro­
prietary. It is safe to say that mesotherapy should only be
utilized by practitioners that are licensed to use injectable
medications, and have studied the techniques and complica­
tions of the procedure.5
SELECTION OF PATIENTS
FOR MESOTHERAPY
Proper selection of patients for mesotherapy is paramount
for the treatment. Both men and women respond equally to
mesotherapy, as do patients of all skin color. Patients who
have a BMI > 30 should not be treated, as their results will
not be adequate. Patients with very loose skin will not have
significant results, nor will patients with extremely hard
fibrous fat. The fat must be in the mesoderm layer, and not
beyond the reach of the mesotherapy needle. Breast, ankles
Part 8  Body contouring with HIFU or injectables

573
Chapter | 52  Mesotherapy for body contouring and cellulite
improve lymphatic and venous drainage, improve the con­
nective tissue characteristics, and reduce adipose deposits
that result in the dimpled look of the skin.9 Although fat
reduction is important in the treatment, usually the appear­
ance is of most concern to the patient, rather than a size
change of the area.
Cellulite is also graded as follows: Grade 1 is cellulite
that is only perceptible on pinching of the skin; Grade 2 is
cellulite that is visibly apparent but disappears on lying flat;
Grade 3 is cellulite that is apparent in any position.
Patients should be given full counseling on adding
exercise and nutritionally sound diets to their daily routines
if they are not already adhering to them. Alcohol consump­
tion should be at a minimum, as should UV exposure for
suntanning. Sun burn, concurrent skin treatments in the
area, or skin infection will contraindicate treatments.
Patients should not expose their skin to tanning, jacuzzis
or steam following their treatments. Hot showers or baths
should also be avoided for 48 hours. Exercise also should
be avoided for 8 hours if excessive sweating occurs
(Table 52.1).10
FORMULATIONS
The selection of medications, herbal extracts and vitamins
is generally at the discretion of the practitioner, and is
learned in a course on mesotherapy. It is important to
choose medication based on the reason for the treatment
(Fig. 52.2). The formula for each patient will differ and
medications and volume of each “cocktail” will vary from
FIG. 52.1  Lipolysis. β-AR stimulates lipolysis; α-AR inhibition of
lipolysis; the α2-AR/β-AR ratio is higher in the thigh/gluteal region
leading to increased adipocity. (Courtesy Dr. Marion Shapiro.)
Beta receptor
Gs
GI
Adenylate cyclase
Adenylate cyclase A-kinase
Hormone-sensitive lipase
Cyclic AMP
Phosphodieterase
5’ AMP
GI
Gs
Fat cell
Glyerol and
fatty acids
Adenosine
receptor
Alpha-2
receptor
TABLE 52.1  Liposuction Versus Mesotherapy
Liposuction
Mesotherapy
Surgical procedure
Noninvasive procedure
Removes fat cells
Removes fat from fat cells
Cannot be used where
there is cellulite
Used wherever there is cellulite
Down time (2 weeks)
No down time
Wear restrictive garments
afterwards for weeks
Wear loose clothing after
treatment
Weight gain back in
abnormal places
Weight gain back where it was
lost
Significant bruising & pain
Minimal bruising and pain
Causes divots and scarring
Reduces divots and scarring
Takes up to 3 months to
see results
Results seen in weeks
Causes loose and weak skin
Tightens and strengthens skin
and lower legs (except the calves) should never be treated.
The face must be treated with caution as facial fat is gener­
ally cosmetically desired. The areas that respond the best
are areas of soft pinchable fat with tighter skin, such as the
abdomen, “love handles”, and legs, submental fat, and
asymmetrical areas following liposuction or fat grafting.
Cellulite can also be treated with mesotherapy. Cellulite
refers to the appearance of dimpled skin referred to as
“orange peel”, on the thighs, buttocks, and sometimes
lower abdomen of otherwise healthy patients; 90% of cel­
lulite cases occur in women.6 Cellulite is most common in
areas of fat deposits and is the result of the unevenness of
this fatty tissue beneath the skin surface. Since cellulite is
largely due to a structural aberration below the skin, people
who have more fat deposits have more pronounced cellu­
lite. Most structural changes include vertical orientation of
the septae with increased septal thickness, while those with
less fat and more muscular definition tend to have less
visible cellulite. There is still much controversy over the
etiology and pathology of cellulite. Most theories postulate
this condition with abnormal connective tissue organi­
zation, alterations in fat metabolism, microcirculatory/
lymphatic derangements, and venous insufficiency.7
According to studies conducted using magnetic reso­
nance imaging and sonography,8 female fat lobules are
larger than males’ and compartmentalized by fibrous septae
that form radial and archlike structures. The uppermost
layer of subcutaneous fat has been described as “standing
fat-cell chambers” separated by connective tissue. From
these fat-cell chambers, small projections of fat cells pro­
trude into the dermis. This unevenness and irregularity of
the subcutaneous fat give the skin the appearance we call
cellulite.
Mesotherapy treatments for cellulite attempt to improve
these four pathological aspects. Medications are selected to

574
PART | 8  Body contouring with HIFU or injectables
FIG. 52.2  Treatment protocol. Disinfect skin with alcohol, mark areas to treat, complete markings on skin (A, B, C). Prepare syringes (D, E) – needle
depth 6–13 mm (F). (Courtesy Dr. Marion Shapiro.)
A
B
C
D
E
F

575
Chapter | 52  Mesotherapy for body contouring and cellulite
one body region to another and may change each time.
Treatment for fat alone will utilize medication for lipolysis,
vasodilation and perfusion, while treatments for cellulite
will also include dissolution of septae and banding. Some­
times multiple medications will be used together that
cause lipolysis, because they have different physiological
actions. All mesotherapy mixtures must adhere to ensure
patient safety. The medications used must be isotonic, bio­
compatible and sterile, with pH between 5 and 7. In Europe,
theophylline tends to be the drug of choice for lipolysis,
whereas in the Americas it is usually phosphotidylcholine.11
Usually 20–30 ml of formula are injected in each session,
with the formula varying in each syringe if necessary.
PREPARATION FOR MESOTHERAPY
Consultation with the patient should include a thorough
medical history and physical exam of the areas to be treated.
Note should be made of any prior surgical procedures,
stretch marks, or unusual pigmentation in those areas. The
patient’s cellulite should be evaluated and classified as to
the grade of severity. Photographs of the patient should be
made against a neutral background, without utilizing flash.
The patient’s areas of treatment should be measured with a
measuring tape and recorded. BMI should be recorded and
a starting weight if possible. Consent for the procedure
should be signed by both the patient and practitioner. A
progress sheet should be placed on the patient’s chart,
where the patient’s information can be recorded on a weekly
basis. Drawings of the areas treated should be placed on
this sheet. A weekly progress note should notate each visit,
medication used, and any adverse side effects or comments
the patient has made regarding their progress.
INJECTIONS
Once the formula is selected, the frequency of treatments,
needle selection, and technique of injections must be deter­
mined. The use of a mechanical injector such as a Pistor,
or injection by hand is determined by the training of the
mesotherapist. The use of a mechanical injector is more
precise as it can deliver an exact amount of medication and
to the desired depth each and every time an injection is
given. There are many types of mechanical injectors avail­
able, and the type that use single needles have the fewest
side effects.
The number of treatments and frequency is determined
by the severity of the patient’s symptoms and how they
respond to the therapy. In general, treatments are usually
given at least 1 week apart, but this can be longer if the
patient has lingering swelling or reactions to the medica­
tions used. To be most effective, the time between treat­
ments should not usually be longer than 4 weeks. Most
patients will begin to see results after the third treatment,
but this can be longer if they are slow responders to the
medications. The number of treatments is based on the
response of the patient to the medication and the goals set
by the patient.
Needle selection is based on the treatment of fat and
cellulite in relation to the depth of fat in the mesoderm
layer. Traditionally, a size 0.4 cm needle is used for cellulite
and scar reduction, a size 0.6 cm needle for superficial fat
loss, and a 13 cm needle for deeper fat deposits. As with
the variation of medication, needle sizes can be changed
each time the patient has mesotherapy. For lipolysis, a
minimum of 0.6 cm needle is used. Mesotherapy needles
are also created for multiple sticks, and must be discarded
after 50 injections are made.
Techniques of mesotherapy injections include proper
spacing with a grid-like pattern between injections 1.5 cm
apart. When the face is injected, the spacing falls to 1 cm
between injections. A 0.6 cm needle is used to create skin
retractions and care must be taken to avoid injecting into
the musculature. The area is first cleaned with alcohol, and
the area to be treated is marked in a grid-like pattern. With
mesotherapy “cocktails”, approximately 0.1 ml is injected
into every site, so that the medication can spread evenly in
the treated area. This differs significantly from fat lipolysis
using only mixtures of phosphatidylcholine/deoxycholate,
where up to 0.5 ml are injected into individual areas
treated.12
Nappage technique can also be used for scarring, espe­
cially when it is a result of surgery or liposuction. Usually
a 0.4 cm needle is used and the scar is pricked, 0.1 cm apart
along the entire length of the scar tissue, to break the fibrous
bands both in the dermis and mesoderm layer. Because this
can be painful, lidocaine is always added to the formula for
pain relief. Also, collagenase and hyluronidase are both
essential additives. A very small amount of medication (one
drop) is administered with each injection in a linear fashion.
Nappage can also be used for very superficial cellulite and
divots.
SIDE EFFECTS AND TREATMENT
Most side effects of mesotherapy occur from the trauma of
injection. After treatment, the patient usually develops tran­
sient redness at the injection sites. They may complain of
site tenderness or pruritus, which usually dissipates within
10 minutes of the treatment. Some patients may develop
transient urticaria that also resolves on its own. These issues
can also be avoided by placing arnica gel on the skin after
treatment.
By far the greatest side effect of mesotherapy is bruis­
ing. This occurs because small blood vessels are inadver­
tently pierced by the needle, causing small subdermal

576
PART | 8  Body contouring with HIFU or injectables
prescribed and used twice daily on the affected area. Hyper­
pigmentation may be treated with a bleaching cream.
Although this complication is rare, it must be addressed or
the patient can have long-lasting problems.
After several treatments, there may be clusters of small
blood vessels originating from the needle injection site.
This neovascular response usually occurs distal to the knee.
If this side effect is seen, mesotherapy should be discontin­
ued indefinitely, as this change may not resolve. Using the
vascular laser, or IPL, may help eliminate the neovascular
response.
Patients may develop an allergic reaction, such as wheal
and flare in response to one of the components of the
medication. Patch testing should be done 1 week after the
hematomas. Unfortunately, those vessels that are non-
visible cannot be avoided; however, although that general
area can be treated, the visible blood vessels should not be
injected. Patients will complain about the bruising.
However, the actual bruises are not tender, as are those
created by trauma. The bruising will usually last for several
days and resolves on its own. When the bruises are persis­
tent, proper care needs to be given. For larger bruises, ice
can be placed on the area for 10 minutes on, 10 minutes off
following treatment. After 48 hours, warm compresses may
be applied. Compounds such as arnica montana and brome­
lain can be taken before and after treatments as a preventa­
tive treatment. For bruising that persists for more than 2
weeks, a strong hydrocortisone cream like Pandel may be
FIG. 52.3  Mesotherapy for liposuction before (A, C) and after (B, D). (Courtesy Dr. Marion Shapiro.)
A
B
C
D

577
Chapter | 52  Mesotherapy for body contouring and cellulite
A
B
C
D
FIG. 52.4  Mesotherapy for liposuction complications before (A, C, E, G, I) and after (B, D, F, H, J). (Courtesy Dr. Marion Shapiro.)
Continued

578
PART | 8  Body contouring with HIFU or injectables
E
F
G
H
I
J
FIG. 52.4  Continued

579
Chapter | 52  Mesotherapy for body contouring and cellulite
reaction has occurred. Usually this will respond to Benadryl
and topical cortisone cream; however, if the reaction
persists or becomes painful, a Medrol Dosepack should be
prescribed.13
Other adverse reactions reported are cutaneous granu­
lomas, atypical mycobacterial infections, lichenoid erup­
tions, ulcerations and exacerbation of psoriasis. To avoid
these complications, patients need to choose physicians
who have been trained in mesotherapy and perform it under
sterile conditions with properly formulated sterile compo­
nents14 (Fig. 52.3A–D).
CONCLUSION
Although mesotherapy has attracted wide acceptance in the
medical community in Europe and South America, the
absence of double-blind studies has caused the United
States medical community to be slow in its acceptance of
mesotherapy. Nonetheless, those practitioners of it who
have been properly trained have consistently observed
highly successful results in their patients (Fig. 52.4A–J). As
a result, various pharmaceutical companies have recently
conducted trials using mesotherapy medications with an
expectation that FDA approval will be obtained and the
medical community will be more likely to perform research
on and practice mesotherapy.
REFERENCES
1. Pistor M. What is mesotherapy? Chir Dent Fr 1976;46:59–60.
2. LeCoz J. Traite de mesoterapie. Paris: Masson; 2004. p. 7–9.
3. Rotunda AM. Mesotherapy and phosphatidylcholine injections: his­
torical clarification and review. Dermatol Surg 2006;23:465–80.
4. USA TODAY August 4 2004.
5. Rotunda AM. Cellulite: Is there a role for injectables? J Cosmet
Laser Surg 2005;7:147–54.
6. Kligman AM. Cellulite: facts and fiction. J Geriatr Dermatol
1997;5:136–9.
7. Rosenbaum M, Prieto V,Hellmer J, et al. An exploratory investiga­
tion of the morphology and biochemistry of cellulite. Plast Reconstr
Surg 1998;101:1934–1939.
8. Rossi ABR, Vergnanini A. Cellulite: a review. J Eur Acad Dermatol
Venereol. 2000;108:51–8.
9. Curri SB. Cellulite and fatty tissue microcirculation. Cosmet Toilet
1993;108:51–8.
10.
11. Rittes PG. The use of phosphatidylcholine for correction of local fat
deposits. Aesth Surg J 2003;27:315–8.
12. Duncan DI. Fat reduction using phosphatidylcholine/sodium deoxy­
cholate injections: standard of practice. Aesthetic Plast Surg 2008;
32:858–72.
13. Urbani C. Urticarial reaction to ethynediamine in aminophylline
following mesotherapy. Contact Derm 1994;31:198–9.
14. Gokdemir G. Cutaneous granulomatous reaction from mesotherapy.
Dermatolog Surg 2009;35:291–3.

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© 2013 Elsevier Inc
Chapter 53 
Key Points
●
Weight loss patients present with anatomic deformities
that are distinctly different from those encountered in
nonbariatric esthetic surgery patients.
●
It is useful to group these deformities by body area:
the mid-body, breasts, arms, back, thighs, and face
and neck.
●
Mid-body contouring frequently requires
circumferential abdominoplasty due to the
circumferential excess of skin that involves the anterior
abdomen, hips, outer thighs, lower back, and buttocks.
●
Back deformities are consistent in their presentation
and have been named according to their location:
breast fold, scapular fold, lower thoracic fold, and hip
fold.
●
Patients younger than 45 years of age typically
demonstrate enough skin contraction and elasticity
that surgical correction of the face and neck is not
needed.
Describing the deformities
Berish Strauch and Charles K. Herman
INTRODUCTION
The burgeoning field of bariatric surgery has introduced a
new subset of patients to the plastic surgeon. Patients
present after massive weight loss with unique anatomical
deformities that are particular to each area of the body.
Weight loss surgery results in drastic changes in patients’
physiology and blood supply that must be taken into account
before successful body contouring surgery can be per­
formed. Weight loss surgery itself is often effective in cor­
recting obesity as well as improving many comorbid
conditions, including hypertension and diabetes. On the
other hand, the surgery results in a multiplicity of both
esthetic and functional problems. Overhanging folds of skin
and areas of skin overlap and friction create issues with
hygiene, infection, and cosmesis. The folds of skin can be
deforming and of as great concern to patients and have as
much impact on self-image as had their former obesity.
Alterations in anatomy and physiology include increased
blood supply that was previously required to support the
patient’s excess fat and skin, in addition to issues with
macronutrient and micronutrient absorption. While the
vascularity of the patient’s tissue may cause issues with
hemostasis during and after surgery, it alternatively can be
used to support much larger and longer soft tissue flaps than
those possible in the nonbariatric population.
ANATOMIC CONSIDERATIONS
We have grouped the body into six unique anatomic areas
that require surgical attention.
Mid-body Excision
The mid-body is usually addressed with circumferential
abdominoplasty. In contrast to the nonbariatric patient,
these patients typically present with skin excess that extends
onto the hips and lateral thighs and posteriorly to the back
and buttocks. In patients with limited posterior excess, a
near-circumferential abdominoplasty that extends to the
posterior axillary lines may be indicated. In the era before
laparoscopic bariatric surgery, up to 20% of patients pre­
sented with ventral hernias after open bypass surgery. These
abdominal wall defects are frequently addressed at the time
of body sculpting.1
Surgery of the Breast
We have described a variety of deformities of the female
breast as well as a classification of these deformities
(Table 53.1).2
The anatomic innervation to the breast has been
described in multiple articles, dating back to Sir Astley
Cooper’s description in 1840.3 Craig and Sykes identified
the role of the third, fourth, and fifth anterior cutaneous
nerves, and the fourth and fifth lateral cutaneous nerves, in
supplying sensation to the nipple–areola complex.4 The
importance of the lateral cutaneous branch of the fourth
intercostal nerve as innervation to the nipple–areola complex
was documented by Courtiss and Goldwyn.5 In light of these
anatomic considerations, we generally employ a superolat­
eral dermoglandular pedicle in our reduction mammaplasty
and mastopexy cases.
In the female patient, the skin envelope, degree of
nipple ptosis, and deficiency in volume must all be
Part 9  Special considerations for the massive weight loss patient

581
Chapter | 53  Describing the deformities
contrary, consistent deformities of the upper back are
encountered. These deformities usually take the shape of
four folds in distinct anatomic positions along the back. We
have named the folds by region in order to standardize their
nomenclature: breast fold, scapular fold, lower thoracic
fold, and hip fold (Fig. 53.2).9 The lower two folds also are
used to mark the superior line of excision during circum­
ferential abdominoplasty surgery.
Surgery of the Thighs
Patients often request contouring of both the medial and
lateral thighs. Deformities take distinct shapes. Many
patients present with thighs that are cone-shaped (Fig.
53.3), whereas others present with cylinder-shaped thighs
(Fig. 53.4). Cone-shaped thighs present with greater verti­
cal skin excess than horizontal and, thus, may require only
a transverse excision; cylinder-shaped thighs, however,
typically present with both vertical and horizontal excess
that may require both vertical and transverse excisions.10
Surgery of the Face and Neck
The degree of skin excess and soft tissue ptosis observed
varies with the patient’s age and amount of weight loss.
FIG. 53.1  Classification of deformities of the arm is useful for surgi­
cal planning.
I
I
II
II
III
III
IV
IV
TABLE 53.1  Classification of the Deformities of the
Female Breast
Type I: Superolateral dermoparenchymal pedicle using the
modified Wise pattern
Ia: Reduction mammaplasty of 1200 g per patient
or more
Ib: Mastopexy for ptosis with minimal to no
reduction of breast parenchyma
Ic: Reduction mammaplasty with free nipple graft
Type II: Superolateral dermoparenchymal pedicle using the
vertical pattern
IIa: Reduction mammaplasty of 1200 g per patient
or less
IIb.i: Mastopexy for ptosis
IIb.ii: Mastopexy for ptosis with mammary prosthetic
implant
considered in selecting the appropriate technique. In
patients with excess residual volume as well as ptosis, a
standard reduction mammaplasty may be effective. Many
patients, however, have a deficiency in volume, particular
in superior pole fullness, combined with excess ptotic skin.
In these patients, mastopexy alone may be indicated, or
mastopexy with “autologous augmentation” using a dermo­
glandular flap in continuity with a pedicle that is rotated
into the superior pole of the breast, or a mastopexy com­
bined with augmentation using a mammary prosthesis. The
male breast generally requires a reduction of excess skin,
typically with an inferior pedicle reduction.
Brachioplasty or Recontouring of the Arm
and Axilla
Excess skin in the upper extremity can extend from the
chest wall distally to the elbow. We have described ana­
tomic zones that are useful in planning the surgical approach
(Fig. 53.1):6
● Zone 1: forearm
● Zone 2: elbow to axilla
● Zone 3: axilla
● Zone 4: lateral chest wall.
Liposuction alone is rarely suitable in addressing the
upper extremity deformity. Excision of the excess skin from
the elbow to the axilla is generally the most effective
approach. Authors have described a variety of incisions,
including ones located posteromedially,6 inferiorly,7 and in
the bicipital sulcus.8
Surgery of the Back
In the nonbariatric patient, back contouring is infrequently
indicated or considered. In the weight loss patient, on the

582
PART | 9  Special considerations for the massive weight loss patient
Patients younger than 45 years often have enough skin
elasticity to allow skin contraction after weight loss and
avert noticeable deformity of the face and neck. Patients
older than 45 years present with skin excess along the
face and neck as well as variable degrees of soft tissue
ptosis, including midfacial descent, that require surgical
attention.11
SURGICAL CONSIDERATIONS
Mid-body Excision
In the majority of our patients, complete circumferential
excision is accomplished. Generally, the procedure can be
completed in 3 to 3.5 hours using our technique.12 This
necessitates rotating the completely prepped patient directly
on the operating room table, maintaining sterility. The pro­
cedure commences along the anterior abdomen and is con­
tinued as far posteriorly as possible. The patient is then
rotated into a prone position. All tissue between the lower
thoracic fold and the hip fold is marked for excision. No
undermining of the back flaps is performed, which has
FIG. 53.2  We have named four anatomic folds along the back that
are remarkably consistent in location in the weight loss patient: breast
fold, scapular fold, lower thoracic fold, and hip fold.
Breast fold
Scapular fold
Lower thoracic fold
Hip fold
FIG. 53.3  The cone-shaped thigh presents predominantly with verti­
cal excess and can be addressed with a transverse excision.
drastically reduced the rate of skin flap necrosis and seroma
formation. Drains are removed when output is less than
30 ml per day per drain. Pain control is assisted through
use of a pulsed electromagnetic frequency (PEMF) device
applied over the dressings.13
Breast Reconstruction after Weight Loss
As described above, weight loss patients demonstrate an
augmented blood supply to the soft tissues, allowing the
use of long de-epithelialized dermoglandular flaps. Given
this anatomic feature unique to this patient population, we
typically rotate dermoglandular flaps in continuity with a
superior or superolateral pedicle to provide an autologous
augmentation of the superior pole of the breast.14 Placement
of a breast prosthesis may further increase projection and
fullness.
Brachioplasty
As described in the “Anatomic Considerations” section,
excess skin is observed from the elbow through the pos­
teromedial arm and across the axilla onto the lateral chest
wall. Our approach involves excising the excess tissue with
a posteromedial incision in an S-shaped pattern. This
accomplishes two goals: the posteromedial scar is more

583
Chapter | 53  Describing the deformities
Face and Neck
Patients younger than 45 years tend to demonstrate enough
skin contracture that surgical correction is not indicated.
Over age 45 years, both skin excess of the face and neck
as well as soft tissue descent require surgical attention.
CHRONOLOGY
Authors differ not only in the individual techniques
employed to correct the anatomic deformities encountered
in weight loss patients, but also in their timing. Many sur­
geons favor staging the surgeries by anatomic area, while
some surgeons prefer to accomplish as much surgery as
possible in fewer stages.15 Patient preference, of course, is
paramount in determining the order and timing of these
surgeries. Some patients may be most concerned with the
appearance of their arms or face, as these areas are more
difficult to conceal with clothing. In these cases, we have
started with a facelift or brachioplasty as the first stage. On
the other hand, the majority of patients defer to the recom­
mendations of their surgeon. We favor dividing the surger­
ies in multiple stages, given consideration of blood loss and
anesthesia time.
In general, we attempt to limit the length of each stage
to less than 6 hours. Patients usually present with most
concerns related to their large abdominal pannus, with both
functional and esthetic concerns. Therefore, circumferential
abdominoplasty is the first stage in most cases. After 3
months, we frequently perform concomitant surgery of the
breast and upper arms. The anatomic proximity of the arms
and breasts facilitates this staging and the patient can
remain supine during the entire stage. After the ensuing 3
months, surgery of the thighs, followed by surgery of the
upper back 3 months later, are typically performed. The
older patient may request facial rejuvenation, which is per­
formed in the final stage. Our staged approach incorporates
the advantages of combining select surgeries to reduce
anesthesia risk as well as cost to the patient, while maintain­
ing patient safety as the prime consideration by reducing
the time under anesthesia and blood loss.
CONCLUSION
The weight loss patient presents with unique anatomic
deformities that must be taken into consideration by the
surgeon in order to achieve the optical outcome. These
deformities are distinct from those encountered in the non-
bariatric cosmetic surgery patient. Therefore, the surgical
techniques must be tailored to the needs of these patients.
Our staged approach allows combining surgeries on differ­
ent anatomic regions as feasible, but resists the temptation
to perform too much surgery in one setting in order to
concealed with the arms adducted and the S shape redis­
tributes the tissue over a longer length and decreases the
potential for linear scar contracture. A Z plasty across the
axilla reconstitutes the natural domed shape to the axilla.6
Surgery of the Back
The posterior portion of the breast fold and the scapular
fold can be flattened by removing an ellipse encompassing
the breast fold and one-half of the scapular fold, elevating
the residual scapular fold to close the defect. The lower
thoracic and the hip folds are eliminated with the posterior
portion of the circumferential abdominoplasty, as described
above.
Thigh Surgery
Depending on the extent of the excess skin, namely whether
or not the excess extends inferior to reach the knee, this
area may be addressed with only a superior transverse exci­
sion. Otherwise, in thighs that are more cylinder-shaped
with excess extending inferiorly, a medial vertical scar to
the knee generally is needed.
FIG. 53.4  The cylinder-shaped thigh presents with both vertical and
horizontal excess and, thus, frequently requires both transverse and
longitudinal excisions.

584
PART | 9  Special considerations for the massive weight loss patient
reduce the risk-to-benefit ratio as much as possible. It is
important to discuss with patients that their body contour­
ing journeys after weight loss may require a year or longer
until completion.
REFERENCES
1. Herman CK, Hoschander A. Combination abdominal wall hernia
repair and mid-body contouring. In: Strauch B, Herman CK, editors
Encyclopedia of Body Sculpting after Massive Weight Loss. New
York: Thieme; 2011. p. 103–8.
2. Strauch B, Elkowitz M, Baum T, et al. Superolateral pedicle for
breast surgery: An operation for all reasons. Plast Reconstr Surg
2005;115(5):1269–77.
3. Cooper A. The Anatomy of the Breast. London: Longman; 1840.
4. Craig RDP, Sykes PA. Nipple sensitivity following reduction mam­
maplasty. Br J Plast Surg 1970;23:165.
5. Courtiss E, Goldwyn RM. Reduction mammoplasty by the inferior
pedicle technique. Plast Reconstr Surg 1977;59:500.
6. Strauch B, Greenspun D, Levine J, et al. A technique of brachio­
plasty. Plast Reconstr Surg 2004;113:1044.
7. Cannistra C. Brachioplasty with an inferior scar. In: Strauch B,
Herman CK, editors. Encyclopedia of Body Sculpting after Massive
Weight Loss. New York: Thieme; 2011. p. 155–62.
8. Rubin JP, Michaels J. Correction of Arm Ptosis. In: Strauch B,
Herman CK, editors. Encyclopedia of Body Sculpting after Massive
Weight Loss. New York: Thieme; 2011. p. 163–74.
9. Strauch B, Rohde C, Patel MK, et al. Back contouring in weight loss
patients. Plast Reconstr Surg 2007;120(6):1692–6.
10. Strauch B, Herman CK. Medial thigh contouring: cones and cylin­
ders. In: Strauch B, Herman CK, editors. Encyclopedia of Body
Sculpting after Massive Weight Loss. New York: Thieme; 2011.
p. 265–71.
11. Herman CK, Diaz JF, Strauch B. Facial rejuvenation: indications and
analysis. In: Strauch B, Herman CK, editors. Encyclopedia of Body
Sculpting after Massive Weight Loss. New York: Thieme; 2011.
p. 281–6.
12. Strauch B, Herman C, Rohde C, et al. Mid-body contouring in the
post-bariatric surgery patient. Plast Reconstr Surg 2006;117(7):
2200–11.
13. Strauch B, Herman C, Dabb R, et al. Evidence-based use of pulsed
electromagnetic field therapy in clinical plastic surgery. Aesth Surg
J 2009;29(2):135–43.
14. Strauch B, Herman CK. Superolateral pedicle for reconstruction of
the female breast. In: Strauch B, Herman CK, editors. Encyclopedia
of Body Sculpting after Massive Weight Loss. New York: Thieme;
2011. p. 175–85.
15. Hurwitz DJ. Single stage total body lift after massive weight loss.
Ann Plast Surg 2004;52(5):435–44.

585
© 2013 Elsevier Inc
Chapter 54 
Key Points
●
Factors contributing to nutritional deficiencies after
surgical weight loss include the type of bariatric
procedure performed, BMI history, current dietary
habits including daily total protein intake, current
nutritional supplementation, and history of regular
follow up with a bariatric program.
●
Body contouring after massive weight loss leads to
relatively high risk of wound complications, much of
which could be contributed to nutritional deficiency.
●
Preoperative evaluation prior to plastic and
reconstructive surgery should be tailored according to
the presence of symptoms and physical findings
suggestive of nutritional deficiency, with the degree of
laboratory testing further guided by a low index of
suspicion.
●
Bariatric patients are at an increased risk for all
psychiatric conditions, particularly mood disorders,
eating disorders and personality disorders. Failure to
diagnose and treat these conditions preoperatively can
negatively impact surgical outcome.
●
Psychological barriers to proper nutrition can include
mood disorder and binge eating disorder. When
nutritional deficiencies are detected in the preoperative
workup, concomitant psychiatric disorders should be
investigated.
Psychological and nutritional evaluation
Madelyn H. Fernstrom, Jeffrey L. Sebastian and Angela S. Landfair
INTRODUCTION
The post-bariatric patient presenting for body contouring
evaluation presents unique challenges for the plastic
surgeon. The field of body contouring plastic surgery for the
post-bariatric patient is rapidly evolving and has mirrored
the growing popularity of surgical weight loss procedures.
Even as the operative experience in this population of
patients has grown, the complication rates of body contour­
ing procedures after massive weight loss remain significant.1–3
Wound-related complications including dehiscence,
necrosis, delayed healing, infection, hematoma, and seroma
formation can be linked to nutritional deficiencies, which
may be subclinical and unmasked by the demands of
undergoing a plastic surgery procedure.4 With the need to
optimize patient safety, there has been greater focus in the
plastic surgery literature on the preoperative evaluation of
the post-bariatric surgery patient, with particular attention
to nutritional assessment.5–8 Weight loss and maintenance
with appropriate supplementation is no small feat after sur­
gical weight loss, and requires compliance and psychologi­
cal wellbeing. Surgical success and patient satisfaction
after body contouring surgery ultimately depend upon a
patient’s mood stability and capability of adopting a healthy
lifestyle.
This chapter outlines the nutritional and psychological
considerations in the evaluation of the massive weight
loss patient. New methods of preoperative assessment and
treatment protocols could materialize through thoughtful
contemplation of the various risks unique to this patient
population.
NUTRITIONAL CONSIDERATIONS FOR THE
POST-BARIATRIC PATIENT
Bariatric Surgery History
The gastrointestinal physiology of post-bariatric patients
differs according to the type of bariatric procedure per­
formed. It is therefore important to obtain a bariatric surgery
history, since this will largely predict the type of nutritional
deficiency for which the patient is at greatest risk.9,10
Bariatric procedures can in general be categorized as
being restrictive, malabsorptive, or a combination of both
(Table 54.1). Malabsorption is achieved by bypassing
a portion of the proximal small bowel, leaving less absorp­
tive surface for ingested nutrients, whereas restriction is
achieved by either reducing the size of the stomach or
by placing a mechanical device to restrict food intake.
Although purely restrictive procedures do not alter the
normal digestive pathway, nutritional deficiencies may
develop nevertheless due to restriction of caloric or nutrient
intake, maladaptive eating behavior and digestive symp­
toms. The Roux-en-Y gastric bypass (RYGB) is considered
the gold standard procedure and remains the procedure
Part 9  Special considerations for the massive weight loss patient

586
PART | 9  Special considerations for the massive weight loss patient
to occur within 1–3 years with stabilization of metabolic
derangements,10 the post-bariatric surgery patient remains
at risk for both macronutrient and micronutrient deficien­
cies. Furthermore, many post-bariatric surgery nutritional
deficiencies tend to worsen over time.5,19,20 Although bariat­
ric surgery has been in practice for at least several decades
now, evidence-based guidelines regarding optimum nutri­
tional supplementation following surgery are still lacking.9
Despite empiric vitamin and mineral supplementation
(Table 54.2), deficiencies are prevalent in post-bariatric
surgery patients presenting for plastic surgery.5
Protein
Protein deficiency is a significant risk for bariatric patients
and should be of concern for plastic surgeons, since ade­
quate serum protein levels are necessary for normal wound
healing.21 Importantly, protein malnutrition after weight
loss surgery cannot be excluded by history alone and serum
concentration should be measured. Bariatric surgery can
produce a combination of catabolism, malabsorption, and
intolerance to protein-rich foods, leading to depletion of
total body proteins.22 Protein malnutrition, in turn, may lead
to increased inflammation and decreased tensile strength of
surgical wounds as they heal. Large wounds from major
surgery can increase protein demands for healing by 25%
during the postoperative period.23 Furthermore, low serum
albumin has been shown to be a strong predictor of increased
morbidity and mortality, in particular due to sepsis and
major infections.24 Greater decreases in BMI following
most commonly performed in the United States. This pro­
cedure has components of both restriction and malabsorp­
tion. Worldwide, experience with placement of the purely
restrictive laparoscopic adjustable gastric band (LAGB) is
greatest.11 Approved by the FDA in 2001, the LAGB has
quickly become the second most common bariatric proce­
dure in the US, with favorable longer-term results and
public perception that it is the least invasive of surgical
procedures.12–14
Weight Loss History
In general, gastric bypass patients will undergo rapid weight
reduction in the first 3 months, reaching a stable plateau
within a 12 to 18 month period.15 Patients with the LAGB
have a much slower rate of weight loss, which may not peak
until 3–4 years following placement of the device.10,12,14
Even though many post-bariatric surgery patients will have
lost in excess of 45 kg (100lbs), quite a few will plateau
with a body mass index (BMI) that remains high at the time
of presentation for plastic surgery. Furthermore, a signifi­
cant percentage will still be classified as obese at the time
of plastic surgery.6,16 Wound-related complications that may
be due to pre-existing micronutrient deficiencies found with
obesity17 may therefore be further compounded by the
effects of bariatric surgery, which may produce malabsorp­
tion of nutrients, bile salts and electrolytes, as well as intol­
erance of particular foods.
Ideally, post-bariatric patients should be within 10–15%
of their goal weight at the time of evaluation for plastic
surgery, fluctuating no more than a few kilos over a 3–6
month period.18 A greater decrease in BMI following bar­
iatric surgery, increasing age, and the presence of dumping
syndrome may indicate a greater risk for nutritional defi­
ciency.5 Although intestinal adaptation can be expected
TABLE 54.1  Common Types of Bariatric Surgery
Procedures Performed in the United States
Restriction
Malabsorption
Roux-en-Y gastric
bypass (RYGB)
Standard
+ +
+
Long-limb
+ +
+ +
Laparoscopic adjustable
gastric band (LAGB)
+ + +
Biliopancreatic
diversion (BPD)
+
+ + +
BPD with duodenal
switch (BPD/DS)
+
+ +
TABLE 54.2  Routine Vitamin and Mineral Supplements
Following Bariatric Surgerya
Supplement
Dosage
Multivitamin
1–2 daily
Calcium citrate with
vitamin D
1200–2000 mg/d + 400–800 U/d
Folic acid
400 µg/d in multivitamin
Elemental iron with
vitamin Db
40–65 mg/d
Vitamin B12
≥350 µg/d orally
or 1000 µg/month intramuscularly
or 3000 µg every 6 months
intramuscularly
or 500 µg every week intranasally
aPatients with preoperative or postoperative biochemical deficiency.
bFor menstruating women.
From Mechanick et al10
states are treated beyond these recommendations.

587
Chapter | 54  Psychological and nutritional evaluation
of time, in particular in the post-bariatric surgery patient
with protracted nausea and vomiting. Subclinical deficiency
can be quickly unmasked by the routine administration of
glucose-containing intravenous fluids,4 whereby impaired
glucose metabolism may precipitate central nervous system
deterioration.29 A low index of suspicion should be main­
tained for patients presenting with vague neurologic symp­
toms, including weakness, numbness, forgetfulness, or with
subtle signs of peripheral neuropathy on physical exam.
Although adequate daily requirements are typically met
with a multivitamin, patients with persistent vomiting
should be screened for deficiency.10 Patients who develop
neurologic signs and symptoms suggestive of Wernicke–
Korsakoff encephalopathy should receive aggressive
parenteral supplementation with thiamine (100 mg/day)
for 1 to 2 weeks, with subsequent oral supplementation
(100 mg/day) until neurologic symptoms resolve.10
Calcium and Vitamin D
Calcium and vitamin D deficiency are predominantly seen
following procedures involving malabsorption. This occurs
because ingested calcium and fat-soluble vitamin D can no
longer be absorbed in the bypassed proximal small bowel,
in addition to maldigestion from loss of acid action. A sig­
nificant number of patients become intolerant to dairy prod­
ucts as well. Postmenopausal women in particular are at
longer-term risk for developing secondary hyperparathy­
roidism and metabolic bone disease, including osteoporosis,
osteopenia, and osteomalacia.30–32 Following malabsorptive
bariatric procedures, calcium and vitamin D deficiency have
been reported in 25–48% and 50–63%, respectively,10 of
patients at 4 years. Low serum albumin is a strong predictor
of metabolic bone disease,33 and rapid or extreme weight
loss also contributes to bone loss outside of nutritional and
hormonal influences.10,34 Patients who have had a malab­
sorptive procedure should receive regular monitoring of
bone metabolism and mineral homeostasis. Markers of
increased bone turnover such as bone-specific alkaline
phosphatase and osteocalcin may be the most sensitive in
detecting metabolic bone disease.10 With increased aware­
ness of the prevalence of metabolic bone disease following
bariatric surgery, routine supplementation with elemental
calcium containing vitamin D in the range of 1200 to
2000 mg daily is recommended. Vitamin D can be further
supplemented with ergocalciferol, 50 000 IU one to three
times per week, with parenteral vitamin D reserved for
severe deficiency.10
Other Nutritional Deficiencies
Deficiencies of the fat-soluble vitamins A, E and K are seen
following procedures resulting in malabsorption of fat,
bariatric surgery and the presence of dumping syndrome
are found to be significant predictors of hypoalbuminema
in bariatric surgery patients presenting for plastic surgery.5
Quantitative assessment of daily protein intake is impor­
tant, since many patients will fall below 50% of the recom­
mended daily intake of protein. Low prealbumin levels have
been reported in up to 38% of post-bariatric surgery
patients.6,10 Daily protein intake for the post-bariatric surgery
patient is recommended in the range of 60–120 g/day,10,25
with those preparing to undergo major body contouring or
reconstructive surgery advised to consume no less than 1 g/
kg/day,5 typically by way of supplementation. In severe
cases of protein calorie malnutrition, hospitalization for
hyperalimentation may become necessary.
Iron
All bariatric surgery patients are at risk for developing iron
deficiency, in large part due to an intolerance to red meat,
which may lead to microcytic anemia.10,20 In a population of
patients presenting for plastic surgery, the most common
deficiency of vitamins and minerals tested was iron at
39.7%.5 Menstruating women are at greatest risk and will
often receive oral supplementation by way of ferrous sulfate,
fumarate, or gluconate (320 mg twice a day). Vitamin C can
help iron absorption and increase ferritin levels. Intravenous
iron may be necessary for severe or recalcitrant deficiency.
Vitamin B12 and Vitamin B9 (Folate)
The gastric bypass patient population is at greatest risk for
developing vitamin B12 deficiency, due in large part to
maldigestion.26 This deficiency tends to increase over time,
despite oral supplementation with crystalline vitamin B12,27
and may lead to macrocytic anemia and neurologic sequelae.
Supplementation with oral crystalline vitamin B12
(350 µg/day) or intranasal vitamin B12 (500 µg/week) is
typically provided. In cases where adequate levels cannot
be maintained, parenteral supplementation (1000 µg/week
or 1000 to 3000 µg every 6–12 months) may be necessary.10
Vitamin B12 status should be evaluated on an annual basis.
Folate deficiency may be seen in up to 38% of gastric
bypass patients, which can lead to megaloblastic anemia
and an increased risk for neural tube defects during
pregnancy.28 In most cases, folate supplementation
(400 µg/day) is adequate with the amount contained in a
multivitamin preparation.
Vitamin B1 (Thiamine)
Thiamine deficiency can lead to severe neurologic com­
promise, including Wernicke–Korsakoff encephalopathy.
Deficient states can be reached in a relatively short period

588
PART | 9  Special considerations for the massive weight loss patient
the postoperative period with support group meetings,
which are often organized by bariatric programs, as well
as by a growing number of centers dedicated to excellence
in the post-bariatric plastic surgery patient.41 This can be
very instrumental in helping the patient maintain healthy
dietary choices by providing regular feedback from nutri­
tion experts, psychologists, guest speakers and a forum
for sharing experiences with fellow post-bariatric surgery
patients.
predominantly the BPD procedure. Vitamin A deficiency can
lead to ocular xerosis and night blindness. Oral supplementa­
tion with 5000 to 10 000 IU/d is recommended until Vitamin
A levels normalize. Vitamin K deficiency may lead to easy
bruising, bleeding, and metabolic bone disease. Supplemen­
tation with vitamin K is recommended when international
normalized ratio value increase above 1.4. Vitamin E defi­
ciency can be associated with anemia, ophthalmoplegia, and
peripheral neuropathy. Oral supplementation is with 800–
1200 IU/d until vitamin E levels normalize.10
Other mineral and trace element deficiencies are uncom­
monly reported. Zinc deficiency occurs most commonly
following the BPD procedure, with hair loss and rash the
most common symptoms. Although zinc plays a role in
wound healing, caution should be exercised with aggressive
supplementation, since this may lead to a copper defi­
ciency,35 which in turn can cause anemia and neutropenia.36
The antioxidant selenium has been shown to be deficient in
a small percentage of BPD patients without clinical
sequelae.37 Hypomagnesemia can produce neuromuscular,
intestinal and cardiovascular symptoms, as well as abnor­
mal secretion of parathyroid hormone.10 Magnesium defi­
ciency is usually seen following the BPD procedure in the
setting of persistent diarrhea.37
PERIOPERATIVE CONSIDERATIONS
The timing of plastic surgery is important when evaluating
the post-bariatric patient. Ideally, evaluation for body con­
touring surgery should take place no sooner than the 12 to
18 month period required for weight stabilization.10 Patients
who have either failed to lose weight or have regained a
substantial amount of weight might benefit from further
evaluation by the bariatric multidisciplinary team. Prob­
lems may include maladaptive eating behavior associated
with a psychological disorder, loss of integrity of the gastric
pouch, or need for band adjustment.9,10
It is clear that life-long surveillance for nutritional defi­
ciencies is important for all bariatric surgery patients.38,39
Continued multidisciplinary evaluation is important, since
a significant proportion of patients may be noncompliant
with regard to nutritional supplementation or lack ongoing
evaluation of their nutritional status. Ideally, evaluation
of the post-bariatric patient prior to any major plastic
surgery should include workup by a dietician familiar
with bariatric surgery patients to help assess adequacy of
protein intake and deficiency with regard to vitamins and
minerals,40 since proper nutritional supplementation can
significantly reduce complications in this population of
patients.6 Current guidelines for regular laboratory evalu­
ation of the bariatric surgery patient are extensive (Table
54.3). Ongoing education of the patient regarding the
importance of nutrition can be further reinforced during
TABLE 54.3  Recommended Long-Term (>1 Year)
Biochemical Surveillance of Nutritional Status
Following Malabsorptive Bariatric Surgery
Proceduresa,c
Procedure
RYGB
BPD, BPD/DS
Frequency
Annually
3–6 months depending
on symptoms
Laboratory
tests
CBC, platelets
Same as RYGB,
including the following:
Electrolytes
Albumin, prealbumin
Glucose
Fat-soluble vitamins
(6–12mo)
Iron studies, ferritin
Vitamin A
Vitamin B12
25-Hydroxyvitamin D
Liver function
Vitamin E
Lipid profile
Vitamin K and INR
25-Hydroxyvitamin
D
Metabolic bone
evaluationb
Optional:
Intact PTH (6–12mo)
Intact PTH
Urine N-telopeptide
(annually)
Thiamine
Osteocalcin (as
needed)
RBC folate
Trace elements
(annually or as needed)
Zinc
Selenium
Miscellaneous (as
needed)
Essential fatty acid
chromatography
aCBC = complete blood cell count; PTH = parathyroid hormone;
RBC = red blood cell; INR = international normalized ratio.
bDual-energy X-ray absorptiometry should be performed annually to
monitor bone density.
cAdapted from reference 10.

589
Chapter | 54  Psychological and nutritional evaluation
incidence of anywhere from 4% to 50% in the bariatric
population, although the true incidence is likely closer to
10%.47,55,56 Patients with BED had more depressive symp­
toms and associated minor disturbances of eating behavior
such as grazing and night eating.57 Although some studies
reported that nonbinge eaters had a significantly higher
excess body mass index loss than binge eaters,58,59 other
long-term studies determined no difference in ultimate
weight loss impact between patients in the BED and
non-BED groups.57,60 However, binge eaters had more eating
disturbances such as less restriction, more disinhibition,
more hunger, as well as more psychopathological traits
(passive-aggressive, aggressive-sadistic, manic, ethanol
dependence, major depression).61 One study found that 46%
of patients who had undergoing bariatric surgery reported
loss of control over eating marked by objective or subjective
bulimic episodes.62
Body image dissatisfaction is significantly greater in
the morbidly obese compared with normal-weight control
subjects. Body image dissatisfaction is more prominent in
women and is associated with a higher incidence of depres­
sion, low self-esteem, and perfectionism.63–65 After under­
going bariatric surgery and weight loss, patients improved
in self-image and self-satisfaction, sometimes into pub­
lished normal range.66,67 However, self-disparagement and
preoccupation with body shape remained significantly dif­
ferent from control subjects, suggesting that some nega­
tively charged aspects of body image remain, regardless of
weight loss.68 Body contouring surgery after weight loss
also further improved body image and was independent of
mood.69
Overall, the psychology of the morbidly obese influ­
ences perceived and real outcomes of massive weight loss.
Mental health tends to improve in the first couple of years
after weight loss surgery, but the positive transformation
may not be enduring.46 Massive weight loss can lessen
depression, anxiety symptoms, paranoid ideation, and
improve interpersonal relationships.70,71 The literature sug­
gests, though, that improvements in mood deteriorate over
time49 and that psychiatric abnormalities, negative person­
ality profiles, detrimental eating patterns, and negative
body image attitudes persist to some degree despite overall
improvements in psychological profiles.
DISCUSSION
The patient who has undergone bariatric surgery undergoes
a tremendous physical transformation, as well as a com­
plete nutritional and lifestyle overhaul. It is only natural that
during this same period patients also undergo a psychologi­
cal upheaval. Improvements in body image, social activity,
social satisfaction, and satisfaction with life are seen in
conjunction with massive weight loss.
PSYCHOLOGICAL CONSIDERATIONS FOR
THE BARIATRIC PATIENT
Psychological issues related to morbid obesity incontro­
vertibly impact bariatric surgery outcomes. Before surgery,
about two-thirds of patients appear to have at least one
psychiatric diagnosis.42,43 In one large study, 66% of patients
had a lifetime history of at least one Axis I diagnosis (clini­
cal disorders including major mental disorders), with 38%
meeting Diagnostic and Statistical Manual criteria at the
time of preoperative evaluation. Moreover, 29% of this
group had one or more Axis II disorders (underlying per­
vasive personality disorders), whereas 27% had a lifetime
incidence of binge eating disorder.43 Similar rates of diag­
noses of Axis I and II disorders are reported elsewhere.44,45
A dominant finding is a high incidence of mood and per­
sonality disorders, destructive eating behaviors, and poor
body image in the morbidly obese patients. Although
massive weight loss improves some of these issues, the
improvement appears to be transient. The patient’s psycho­
logical profile appears to have a significant impact on suc­
cessful weight loss, but weight loss appears to have a more
transient impact on the psychology.
Depressive disorders are the most common diagnoses
in the bariatric population, followed by anxiety disorder.46
The incidence of depressive disorder in bariatric surgical
patients ranges from 4.4% to 53% in the literature.47,48
Depressive symptoms negatively impacted physical func­
tion and increased eating in response to negative emotion
and impaired appetite regulation.49,50 Although female
patients were more depressed than their male counterparts,
their postoperative psychological improvement was also
more significant.51
While depression and anxiety disorders are the most
prevalent, other diagnoses are also noteworthy. High inci­
dences of somatization (29.3%), social phobia (18%),
hypochondriasis (15%), and obsessive–compulsive disor­
der (13.6%) were found in the bariatric population.47
A series of patients treated at a bariatric surgery clinic
demonstrated a 72% incidence of personality disorders,
including histrionic, borderline, schizotypal, and passive-
aggressive.52 Compared with published norms, the patients
undergoing bariatric surgery were consistently found to
be psychopathically deviant or disordered in their personal­
ity traits.53,54 Interestingly 32.6% had lifetime diagnoses
of substance abuse disorder, suggesting that substance
abuse and weight problems may share some common
foundation.43
Binge eating disorder (BED), marked by consumption
of an objectively large quantity of food in a brief period
during which time a person experiences subjective loss of
control, has been extensively studied in the morbidly obese
presenting for weight loss surgery. BED has a reported

590
PART | 9  Special considerations for the massive weight loss patient
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Although many of the outcomes of bariatric surgery are
quite positive, it would be inaccurate to paint a rosy picture.
Nutritional complications are not only common, they are
the norm among patients who undergo bariatric surgery.
Patient noncompliance is the most important factor in the
development of postsurgical nutritional deficiencies, with
noncompliance with oral supplementation estimated at 33%
to 64%.72 Some personality traits among the morbidly
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are believed to preclude adjusting to demands imposed by
bariatric surgery.73 After surgery, patients who undergo bar­
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exercise, and vitamin intake. Perhaps these demands are
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Many patients have a psychological relationship with
food that extends beyond nutritional needs. In many patients
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vacancy rather than physical need. It’s not surprising, then,
that even after physiological and anatomic alteration,
patients who undergo bariatric surgery should reinitiate
their prior relationship with food, maladaptive or not. In
a time of stress, individuals often turn to comfort foods;
is it so surprising that after a major surgery, patients who
have undergone bariatric surgery have difficulty adhering
to a very foreign regimen of small, protein-rich meals
and vitamin supplementation? Although the nutritional
failures are not to be taken lightly, it is also important
to ensure continued psychological health during this tre­
mendously stressful period. Many of these individuals
eat as a maladaptive coping mechanism for psychological
problems, contributing to obesity.56 Optimization of psy­
chological treatment and social resources can only help
thwart the negative impulses and social stress that revive
old habits.
Ultimately, massive weight loss from bariatric surgery
initiates a remarkable physical transformation that often
moves on into a revolution in personal relationships,
body satisfaction, and social standing. Nutritional compli­
cations of bariatric surgery are, for the most part, correctible
with careful adherence to a protein-rich diet and vitamin
supplementation, as well as frequent monitoring. Proper
identification of pre-existing maladaptive personality,
eating, and thought patterns can assist in identification of
indi­viduals least likely to comply and achieve successful,
healthy weight loss. Consistent, long-term follow up is
also essential to minimize both medical and behavioral
complications.

591
Chapter | 54  Psychological and nutritional evaluation
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25. Gusenoff JA, Rubin JP. Plastic surgery after weight loss: current
concepts in massive weight loss surgery. Aesth Surg J 2008;28(4):
452–5.
26. Brolin RE, Gorman JH, Gorman RC, et al. Are vitamin B12 and folate
deficiency clinically important after Roux-en-Y gastric bypass?
J Gastrointest Surg 1998;2(5):436–42.
27. Provenzale D, Reinhold RB, Golner B, et al. Evidence for dimin­
ished B12 absorption after gastric bypass: oral supplementation does
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28. Mallory GN, Macgregor AM. Folate status following gastric bypass
surgery (the great folate mystery). Obes Surg 1991;1(1):69–72.
29. Salas-Salvado J, Garcia-Lorda P, Cuatrecasas G, et al. Wernicke’s
syndrome after bariatric surgery. Clin Nutr 2000;19(5):371–373.
30. Fitzpatrick LA. Secondary causes of osteoporosis. Mayo Clin Proc
2002;77(5):453–68.
31. Shaker JL, Norton AJ, Woods MF, et al. Secondary hyperparathy­
roidism and osteopenia in women following gastric exclusion
surgery for obesity. Osteoporos Int 1991;1(3):177–81.
32. Parfitt AM, Miller MJ, Frame B, et al. Metabolic bone disease after
intestinal bypass for treatment of obesity. Ann Intern Med 1978;
89(2):193–9.
33. Marceau P, Biron S, Lebel S, et al. Does bone change after biliopan­
creatic diversion? J Gastrointest Surg 2002;6(5):690–8.
34. Gossain VV, Rao DS, Carella MJ, et al. Bone mineral density (BMD)
in obesity: effect of weight loss. J Med 1999;30(5–6):367–76.
35. Willis MS, Monaghan SA, Miller ML, et al. Zinc-induced copper
deficiency: a report of three cases initially recognized on bone
marrow examination. Am J Clin Pathol 2005;123(1):125–31.
36. Todd LM, Godber IM, Gunn IR. Iatrogenic copper deficiency
causing anaemia and neutropenia. Ann Clin Biochem 2004;41(Pt
5):414–6.
37. Dolan K, Hatzifotis M, Newbury L, et al. A comparison of laparo­
scopic adjustable gastric banding and biliopancreatic diversion in
superobesity. Obes Surg 2004;14(2):165–9.
38. Fried M, Hainer V, Basdevant A, et al. Inter-disciplinary European
guidelines on surgery of severe obesity. Int J Obes (Lond) 2007;
31(4):569–77.
39. Buchwald H. Consensus conference statement: bariatric surgery for
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als, and third-party payers. Surg Obes Relat Dis 2005;1(3):371–81.
40. Rubin JP, Toy J. Discussion. Prospective assessment of nutrition and
exercise parameters before body contouring surgery: optimizing
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and postoperative psychological characteristics in morbidly obese
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morbidly obese patients undergoing gastric bypass: a comparison
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215–20.
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vertical banded gastroplasty. Obes Surg 2003;214:394–8.
74. Halmi KA, Mason E, Falk JR, et al. Appetitive behavior after gastric
bypass for obesity. Int J Obes Relat Metab Disord 1981;5:457–64.
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576–80.
76. Fischer S, Chen E, Katterman S, et al. Emotional eating in a mor­
bidly obese bariatric surgery-seeking population. Obes Surg 2007;
17:1778–84.
60. Bocchieri-Ricciardi LE, Chen EY, Munoz D, et al. Pre-surgery binge
eating status: effect on eating behavior and weight outcome after
gastric bypass. Obes Surg 2006;16:1198–204.
61. Guisado Macias JA, Vazleal FJ. Psychopathological differences
between morbidly obese binge eaters and non-binge eaters after
bariatric surgery. Eat Weight Disord 2003;8:315–8.
62. Kalarchian MA, Marcus MD, Wilson GT, et al. Binge eating among
gastric bypass patients at long-term follow-up. Obes Surg 2002;12:
270–5.
63. Dixon JB, Dixon ME, O’Brien PE. Depression in association with
severe obesity: changes with weight loss. Arch Intern Med 2003;
163:2058–2065.
64. Grilo CM, Masheb RM, Brosy MB, et al. Binge eating and self-
esteem predict body image dissatisfaction among obese men and
women seeking bariatric surgery. Int J Eat Disord 2005;37:347–51.
65. Rosenberger PH, Henderson K, Grilo CM. Correlates of body image
dissatisfaction in extremely obese female bariatric surgery candi­
dates. Obes Surg 2006;16:1331–6.
66. Hafner RJ, Rogers J. Husbands’ adjustment to wives weight loss
after gastric restriction for morbid obesity. Int J Obes Relat Metab
Disord 1990;14:1069–78.
67. Hrabosky JI, Masheb RM, White MA, et al. A prospective study of
body dissatisfaction and concerns in extremely obese gastric bypass
patients: 6- and 12-month postoperative outcomes. Obes Surg 2006;
16:1615–21.
68. Adami GF, Meneghelli A, Bressani A, et al. Body image in obese
patients before and after stable weight reduction following bariatric
surgery. J Psychosomat Res 1999;46:275–81.

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© 2013 Elsevier Inc
Chapter 55 
Key Points
●
Patient selection with specific attention to weight loss
history, medical status, and nutritional assessment is
the foundation for deciding when to combine
procedures.
●
Clinical setting and experience of the surgical team
should be considered when planning combined
procedures.
●
Patient safety is paramount, and staging procedures
should always be an option.
●
Certain combinations of procedures complement each
other, while others are best performed in a staged
fashion because of opposing vectors of pull.
●
The lower body lift is the cornerstone truncal
contouring operation for the massive weight loss
patient and often performed first in a staged plan.
Staging and combining procedures
J. Peter Rubin and Jennifer Capla
INTRODUCTION
The key to body contouring surgery after massive weight
loss is to understand which combinations of procedures
can be safely combined in a given case. Patient selection
is of utmost importance. When an individual would like to
target multiple areas, a staged operative plan can be advan­
tageous. Staging allows achievement of optimal esthetic
results while minimizing postoperative complications. The
cornerstone of safe and effective combined and staged pro­
cedures is a thorough patient workup.
UNDERSTANDING BODY IMAGE AND
WEIGHT LOSS
Individuals seeking body contouring surgery after massive
weight loss have changed their lives dramatically. Despite
their significant weight loss, they retain the stigmata of their
obese state in the form of loose hanging skin. It is important
for the plastic surgeon to recognize and appreciate that
patients may still view themselves as obese. Patients look
for a specialist who understands the emotional as well as
physical needs of the massive weight loss patient, and their
comfort with the surgeon will be influenced by perceived
sensitivity to self esteem issues. We often start the interview
by congratulating the patient for the progress they have
made in the process of weight loss and for taking steps to
reclaim their lives.
PREOPERATIVE EVALUATION OF THE
MASSIVE WEIGHT LOSS PATIENT
Evaluation begins with a detailed history. In particular, it is
important to obtain a thorough weight loss history. The
method of weight loss and type of bariatric procedure
provide important data on the potential for nutritional
deficiencies, amount of expected weight loss, and time to
plateau. Other relevant information includes date of bariat­
ric surgery, maximum BMI, current BMI and change in
weight over the past 3 months. This information can aid in
determining if the patient has weight stabilized and is a
good candidate to proceed with body contouring surgery.
A relevant nutritional history should be obtained. The
majority of weight loss patients will have adequate intake
for the unstressed state. Major surgery, however, can
increase the body’s nutritional requirements by 25% and
many weight loss patients may have physical impedance to
increasing oral intake.1 Please see Chapter 54 for further
details.
One area that may be overlooked in the preoperative
evaluation, which is essential to the postoperative recovery,
is the patient’s social support network. It is necessary to
define who will be available to help take care of the patient
at home in the initial postoperative period, especially if
multiple combined procedures are contemplated.
Screening for Medical Problems
The key focus is patient safety, and a history of significant
medical problems, including hypertension, ischemic cardiac
disease, sleep apnea, and diabetes, must be fully delineated
and addressed before body contouring surgery. While most
medical comorbidities of obesity are significantly improved,
if not resolved, following weight loss, the plastic surgeon
must search for residual disease. Inquiring about any recent
changes in medication doses can help determine if the
Part 9  Special considerations for the massive weight loss patient

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PART | 9  Special considerations for the massive weight loss patient
balance are necessary to facilitate the healing process.3
Additionally, a more predictable outcome can be achieved
when the patient is not actively losing weight.
Favorable BMI
A high BMI is associated with increased wound healing
complications.4,5 As the patient’s BMI decreases, we are
able to offer more safe surgical options and expect better
esthetic outcomes.6 The best candidates have a BMI of
28 kg/m2 or less. We are more cautious in our level of
intervention with patients who have a BMI between 29 and
32 kg/m2. Patients with a BMI between 32 and 35 kg/m2
should be selected with great care. If a patient in a high
BMI range desires significant contouring, we recommend
delaying the operation until further weight loss can be
achieved. We work on a weight loss plan with the patient
and nutritionist and schedule a 2–3 month follow up
appointment. This way the patient will remain under your
care and not feel abandoned; moreover, you are able to
serve as a motivating force. Some patients in a high BMI
range may benefit from a first stage breast reduction or
simple panniculectomy if such a procedure would improve
their ability to exercise and progress with further weight
loss. For patients with a BMI greater than 35 kg/m2, our
practice in most cases is to defer operations because of
increased risk of complications and less potential for satis­
fying esthetic results.5,7 Patients in this BMI range may be
offered a functional panniculectomy, with strict indications
of severe panniculitis or a profoundly disabling pannus.
Nutritional Status
The importance of the nutritional status of the post-bariatric
patient cannot be over-stressed.8–11 If the patient has symp­
toms of persistent nausea and vomiting, have them see their
bariatric surgeon to rule out a stricture or a treatable cause.
Because gastric bypass patients have altered gastrointesti­
nal physiology and subsequent dietary issues, nutritional
deficiencies are not uncommon.12 In our center, we require
patients take at least 75–100 g of protein per day before
elective body contouring surgery. A patient who is inca­
pable of consuming 75 g of protein per day is often not a
good surgical candidate and dietary modification is essen­
tial. Please see Chapter 54 on nutritional assessment.
Medical and Psychosocial Stability
Medical and psychosocial issues must also be stable
prior to any operation. Patients with significant medical
comorbidities are routinely sent to an appropriate medical
specialist for further evaluation and clearance. An adequate
social support network should be in place. Active smokers
disease state is in equilibrium or is still in a state of flux.
This is a good indicator as to whether the body is still
working to achieve a level of homeostasis after weight loss.
Exercise tolerance is a useful indicator of surgical risk.
Patients who routinely engage in 45 minutes of vigorous
exercise without shortness of breath or other symptoms will
likely tolerate the stress of surgery. However, beware of the
inactive patient. These patients may have cardiac disease
that will be unmasked by a major surgical procedure. We
advise consultation with medical consultants, as warranted,
for preoperative evaluation and recommendations for
managing chronic disease states. Patients who smoke are
advised to stop at least 4 weeks prior to surgery.
Physical Examination
All aspects of a thorough physical exam should be included
in the initial patient evaluation in order to fully appreciate
the deformities and screen for residual medical problems.
The massive weight loss patient will present with a wide
range of physical anomalies. Body type (truncal versus
peripheral obesity), remaining adiposity, rolls/folds and
rashes should be noted. Body fat distribution will vary
greatly in this patient population and will influence surgical
options. Attention should be given to the patient’s skin tone
and elasticity, as well as regional variations in skin elastic­
ity. On the abdominal exam, make note of previous scars,
the presence of any hernias, degree of diastasis, and overall
laxity of the abdominal wall. To facilitate analysis of defor­
mities in each anatomic region of the body, a four point
rating scale can be applied. The Pittsburgh Weight Loss
Deformity Scale is a tool to delineate the severity of defor­
mities.2 An increased score correlates with a more severe
deformity requiring a more extensive surgical procedure for
correction.
PATIENT SELECTION
Patient selection must be focused on maximizing safety and
minimizing complications. With that goal in mind, the fol­
lowing criteria are desirable: (1) the patient should be
weight stable for at least 3 months; (2) BMI should be
favorable; (3) good nutritional status confirmed; (4) medical
and psychosocial stability determined; and (5) reasonable
goals and expectations communicated.
Weight Stability
Prior to body contouring surgery a patient should be weight
stable for at least 3 months (usually occurs between 12 and
18 months after GBP). We define stability as no more than
2.5 kg (5 lb) change in weight per month over the previous
3 months. Nutritional homeostasis and a positive nitrogen

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Chapter | 55  Staging and combining procedures
that a 7-hour upper limit of total anesthesia time is reason­
able for selected patients.13,14 In a clinical review comparing
single-stage multiple procedure body contouring cases
versus two-stage procedures, it was found that single-stage
surgery averaged 8.4 hours while two-stage procedures
averaged 7.4 hours for the first stage and 4.6 hours for the
second stage, totaling 11 hours. Complications and wound
healing problems were comparable between the two groups
and the complication rates for the individual procedures
remained constant when procedures were combined.15
Importantly, the majority of complications noted are local
wound complications. Therefore, while the overall compli­
cation rate is higher for multiple procedure cases in well
selected patients, the rate is equal to the sum of the com­
plication rates for the individual procedures.
Surgeon Experience and Setting
While it may be feasible to do two or three procedures in
a single stage, the surgeon should be guided by his or her
level of experience, experience of the OR team, and treat­
ment setting. Pitanguy set forth criteria when combining
multiple procedures into one operation. These include: a
skilled surgeon that is experienced at performing multiple
procedures, anesthesiologists adept at handling these cases,
and an operative team able to assist in the case.16 As men­
tioned earlier, combining procedures in well selected
patients will increase the overall rate of local wound com­
plications (additive based on “per procedure” complication
rates), but the incidence of major complications is
unchanged.17 Caution should be exercised in the surgery
center setting should combined procedures be entertained,
and the length of operative time and/or number of proce­
dures performed in a single anesthetic may be regulated by
legal code.
Patient Preference
It is important to focus on the individual patient’s goals.
Our approach is to ask patients to list the regions of their
bodies that they would like to correct in order of priority.
We then discuss surgical options that would affect changes
in these regions, including the location of the scars and the
extent of recovery. We emphasize the concept of trading
excess skin for scar and assess the patient’s willingness
to accept these scars. We also emphasize that having ade­
quate time available to recover from the procedure is some­
thing that should be addressed before surgery; this will
allow patients to make arrangements with their employer
or, if necessary, delay surgery until a more suitable time.
A patient must have a strong social support network with
particular attention to having someone who can care for the
patient during their recovery time. Lastly, patients are
are encouraged to stop at least one month prior to surgery.
Our preference is to defer surgery for active smokers. If
necessary to operate on an active tobacco user, then the
extent of the procedure performed, especially the amount
of tissue undermining, is limited. Similar caution is exer­
cised with diabetic patients and those treated with steroids.
Patients under the care of psychiatrists or psychologists
should be cleared by their mental health provider prior to
surgery.
Goals and Expectations
The final component is to ensure that the patient has a
reasonable set of goals and expectations. Patients must be
willing to accept extensive scars in exchange for loose skin,
understand both the power and limitations of the intended
procedures, and appreciate which areas of the body will not
be affected by the planned surgery. This last point is impor­
tant because improving one area of the body may highlight
deformities in adjacent areas.
OVERVIEW OF STAGING STRATEGIES
The MWL patient is frequently a candidate for multiple
body contouring procedures. These operations can gener­
ally be described as lengthy, technically demanding, and
time-intensive versions of standard body contouring proce­
dures familiar to most plastic surgeons. Determination of
how many procedures to perform at one operation entails
multiple factors (Table 55.1).
Patient Safety
First and foremost is patient safety. While there is no evi­
dence to support a maximum operative time, some suggest
TABLE 55.1  Considerations in Deciding to
Combine Procedures
Operative setting
Outpatient center
Hospital
Patient medical status
Known medical problems
Cardiac risk
Surgeon comfort with long case
Interplay of adjacent procedures
Are there opposing vectors of pull?
Impact on blood supply
Displacement of intended scar positions
Operative team
Second surgeon
Residents
Extenders

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PART | 9  Special considerations for the massive weight loss patient
examples of staged body contouring cases are shown in
Figs 55.1–55.4.
ABDOMINOPLASTY/MASTOPEXY
This is one of the most common procedural combinations
in the massive weight loss population. Combining a tradi­
tional abdominoplasty with any type of breast operation
including breast reduction, mastopexy, augmentation or
gynecomastia correction can be done safely. This combina­
tion does not require any position changes for the patient
and it can be tackled in a team approach to facilitate expe­
diting the operative time. If a fleur-de-lis (FDL) abdomino­
plasty is combined with a breast procedure, then it is
necessary to consider the vectors of pull from each proce­
dure. Often, the inframammary fold (IMF) in the massive
weight loss patient can have such mobility that the pull
from FDL closure can draw the IMF medially and down­
ward. This can lead to unpredictable results and may drive
the decision for a staged approach.
informed that relapse of skin laxity is unpredictable and can
be severe enough to require operative revision. When a
patient is a good candidate for multiple procedures, what is
the ideal combination of procedures to perform at one
setting? There certainly is no clear answer, and it is impor­
tant to remember that performing multiple stages is never
a wrong answer. As with all our plastic surgery patients, be
guided by what is safe for the patient and what will provide
the optimal outcome while minimizing the postoperative
complications.
Considerations for
Combining Procedures
There are a number of body contouring procedures that can
be combined in one operative setting. Below we will review
some of the more common combinations and caveats to be
aware of when assessing each patient. Detailed technical
aspects of the procedures mentioned below appear in
other chapters addressing the respective topics. Clinical
A
B
FIG. 55.1  A 58-year-old woman following 73 kg (160 lb) weight loss from roux-en-Y gastric bypass who desired dermal suspension mastopexy
and abdominoplasty, a combination of procedures that is generally favorable, and brachioplasty. Preoperative photographs (A–D) and postopera­
tive photographs at 1 year (E–H) are shown. No significant change in buttock or trunk contour is effected form this combination, as expected. The
patient returned desiring additional body contouring of the buttock and trunk. A second stage circumferential body lift was performed and the scars
merged with the abdominoplasty scars, along with a limited lateral chest transverse resection to correct upper trunk contour. If a full transverse upper
body lift was planned, it would have been staged relative to the lower body lift to avoid opposing vectors of tension. Postoperative photos are shown
2 years after the first stage (I–L).
C

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Chapter | 55  Staging and combining procedures
FIG. 55.1  Continued
D
E
F
G
H
I
Continued

598
PART | 9  Special considerations for the massive weight loss patient
J
L
K
FIG. 55.1  Continued
FIG. 55.2  Brachioplasty photographs for the patient in Fig. 55.1 shown preoperatively (A), 1 year (B), and two years (C) postoperatively
demonstrating maturation of the bicipital groove scar.
A
B
C

599
Chapter | 55  Staging and combining procedures
A
B
C
D
FIG. 55.3  A 43-year-old woman after 55 kg (120 lb) weight loss from gastric bypass (A, B). Circumferential debulking liposuction was
employed in first stage with 4 l of aspirate removed from each leg concurrent with circumferential lower body lift and fleur-de-lis abdomino­
plasty (C, D).
Continued

600
PART | 9  Special considerations for the massive weight loss patient
E
F
This was followed 6 months later with a staged vertical medial thighplasty, with 1 month photographs shown (E, F).
FIG. 55.3  Continued
LOWER BODY LIFT/ VERTICAL MEDIAL
THIGH LIFT
The lower body lift (LBL) is one of the cornerstone proce­
dures for the massive weight loss patient. It is commonly
performed in the first stage along with a smaller concurrent
upper body procedure. The LBL targets both the outer thigh
and the gluteal area. The LBL requires the patient to be in
the prone position initially. The patient will then require a
change in position intraoperatively, which adds to the oper­
ative time and complexity. Recovery from a LBL/
abdominoplasty is significant and therefore best combined
with a smaller procedure that does not involve as much
of an impact on the recovery. It is this author’s preference
not to combine a lower body lift with a full-length vertical
medial thigh lift because of the opposing vectors of pull
during the closure and the magnitude of recovery. While
the LBL targets the outer thigh it also impacts the medial
thigh with a lateral displacement of the medial thigh tissues.
This vector opposes the medially directed pull of the verti­
cal medial thigh lift and can lead to suboptimal results of
both the outer and inner thigh without a second opportunity
to correct the laxity that settles over time. If an abdomino­
plasty had been performed in a prior operation and the
LBL performed posteriorly only, then a vertical medial
thigh lift may be performed at the same time. This is
because the opposing vector of tension becomes limited and
the recovery is more reasonable. We will combine a short
scar vertical thigh lift (upper third of thigh) with a lower
body lift because this is a situation in which the thigh vector
of tension is moderate and the recovery is tolerable.
UPPER BODY LIFT/BRACHIOPLASTY
Usually performed at a second stage, the upper body lift
(UBL) targets the mid-back rolls and the lateral axillary
rolls. Performing a brachioplasty with the UBL allows for
a continuity of the scar pattern while minimizing creation
of dog-ears. In the event that the combination of a brachio­
plasty and UBL result in a newly created t-point, then the
procedures should be staged (see lateral view Fig. 55.4). An
upper body lift can be readily combined with a mastopexy
(Fig. 55.4).
UPPER BODY LIFT/LOWER BODY LIFT
An UBL and LBL should rarely be performed at the same
time. These are two procedures with clearly opposing
vectors that, when combined, limit the impact of each pro­
cedure performed individually. The amount of skin that can
be resected from the UBL will be limited by the resection
from the LBL. Although both are performed in the prone
position, tackling these two problem areas at one time will
likely lead to suboptimal results and may require a second

601
Chapter | 55  Staging and combining procedures
A
B
FIG. 55.4  A 46-year-old woman with 100 kg (220 lb) weight loss following roux-en-Y gastric bypass with BMI of 25 kg/m2 and good medical
profile. Multiple procedures were desired to correct deformities throughout the body (A–C). Two stages were planned. In the first stage, a circumferential
lower body lift was performed, along with a fleur-de-lis abdominoplasty and brachioplasty. Postoperative photos from the first stage are shown at 4
months, just prior to the second stage (D–F). At the second stage, a dermal suspension mastopexy, circumferential upper body lift, and vertical medial
thigh lift were performed. Postoperative photos are shown 1 year after first stage (G–I).
C
D
E
F
Continued

602
PART | 9  Special considerations for the massive weight loss patient
G
H
I
FIG. 55.4  Continued
operation to correct the residual skin laxity. It is this author’s
preference to perform the LBL/abdominoplasty at the first
stage and perform the UBL at a second stage (Fig. 55.4).
ABDOMINAL WALL RECONSTRUCTION/
ABDOMINOPLASTY
It is not uncommon for the plastic surgeon to encounter a
massive weight loss patient with an incisional hernia. When
approaching these patients, we first consider whether there
has been sufficient weight loss to avoid excessive pressure
on the repair exerted by a still obese intraabdominal com­
partment. The rates of postoperative wound complications
and hernia recurrence are significant in patients with a BMI
> 35.18 It is reasonable to recommend further weight loss
and use of an abdominal binder for comfort before perform­
ing surgery on a large asymptomatic hernia, if necessary.
If the patient has reached an appropriate body weight
for hernia repair, consideration is then given to the extent
of the procedure. For small or moderate sized hernias, we
will combine the repair with major body contouring proce­
dures such as LBL. Very large hernias may require exten­
sive lysis of adhesions and/or separation of the abdominal
wall components to achieve closure. When such an abdomi­
nal wall reconstruction is anticipated, we limit the body
contouring procedures to a concurrent panniculectomy and
stage any other desired surgeries. We routinely bowel prep
patients with hernias, and seek recommendation from the
patient’s bariatric surgeon regarding the preferred method.
Moreover, the referring weight loss surgeon may want to
be involved with these cases in a team approach.
When combining an abdominal wall reconstruction with
a FDL abdominoplasty, caution should be taken when
undermining the abdominal flaps laterally. A limited dissec­
tion should be performed with preservation of the lateral
abdominal perforators. A separate lateral tunnel can be
created to minimize undermining of the abdominal wall
flaps. This tunnel can allow access for either a lateral myo­
fascial release or more traditional component separation. If
a patient is still obese and needs further weight loss, then
the FDL abdominoplasty should be performed at a second
stage.
In summary, the amount of skin laxity and pattern of
deformities a patient has plays a large role in determination
of the appropriate combination of procedures. When decid­
ing on the correct combination it is helpful to mimic the
pull that the operation will achieve using a pinch or dis­
placement technique – pulling the skin in the vector in
which it will be removed. We find it useful to stand the
patient in front of a mirror and review how areas of skin
laxity might be improved on their body, including a dem­
onstration of how the surgeon pulls on the skin to estimate

603
Chapter | 55  Staging and combining procedures
the amount of resection and the resultant impact on contour.
During this part of the examination, limitations of the pro­
cedures, given that patient’s body type, are discussed. This
often includes an explanation of which anatomic regions
can be changed with a given procedure and, importantly,
which adjacent regions will not be impacted. How existing
scars will be handled and the effect of the procedure on
stretch marks inside and outside the area of planned resec­
tion is explained. The quality of previous scars is noted and
used as a guideline to predict how future scars may appear.
To further emphasize the issue of surgical scars, a skin
marker is often used to draw the location of the scars
directly on the patient’s body. Photographing these prelimi­
nary marks helps to document the discussion.
Overall, the advantages of staging include less anes­
thetic time at a single operation, decreased blood loss,
avoidance of opposing vectors of pull on regions of skin,
and the opportunity to have a “second chance” to correct
any contour irregularities or skin relaxation seen after the
first stage. Disadvantages of staging include multiple anes­
thetics, increased time off work, and expense for the patient.
In the end, the patient must be a partner in the decision
about the best strategy for their individual case.
CONCLUSION
Body contouring is a wonderful adjunct to bariatric surgery
and completes the weight loss process for many patients.
Any plastic surgeon who evaluates patients after massive
weight loss will see the full spectrum of patient subtypes.
The majority of patients that present to the office for con­
touring surgery will be well adjusted and have undertaken
great measures to reclaim their lives. However, there will
be individuals that are not quite prepared for surgery. A
thoughtful and organized approach to the massive weight
loss patient will identify the individuals that are good surgi­
cal candidates. Carefully devised operations for the appro­
priate patient at the right time have the potential to provide
a tremendously rewarding experience for the patient and
surgeon. As their body contour surgeon, you have the capa­
bility to eradicate the hanging skin that serves as a daily
reminder of the obese state they have recovered from.
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