PA R T V I I
mebooksfree.net
Body Contouring
63. Principles of Plastic Surgery After Massive Weight Loss
64. Liposuction, Abdominoplasty, and Belt Lipectomy
65. Lower Body Lift and Thighplasty
66. Brachioplasty and Upper Trunk Contouring
mebooksfree.net
C H A P T E R 6 3
mebooksfree.net
Principles of Plastic Surgery After Massive Weight
Loss
Omar E. Beidas and Jeffrey A. Gusenoff, and Ernest K. Manders
Key Points
Massive weight loss patients require comprehensive preoperative evaluation and management of
expectations.
Optimization of patients preoperatively is paramount to minimizing or avoiding complications.
Multiple procedures can be performed simultaneously depending on patient priorities and degree of
deformities.
Staging procedures can minimize operative time and avoid opposite vectors of tension.
Although complications following body contouring for the massive weight loss patient are common,
most are minor and managed as an outpatient basis.
The obesity epidemic in the United States and subsequent popularity in weight loss, whether by means of
bariatric surgery or diet and exercise, echeloned a new subspecialty of plastic surgery. Massive weight
loss (MWL), commonly defined as a loss of greater than 50% of excess weight above ideal body weight
(IBW), has caused an explosion of patients seeking removal of excess skin and fat. This population
deserves special consideration, as MWL has been found to be a predictor for wound complications in
those undergoing body contouring surgery. 1 A comprehensive evaluation must take a multitude of
factors into account to safely and effectively care for the patient. Every patient presents an interesting and
unique challenge; therefore, approaches must be tailored to the individual. Attention to detail keeps both
surgeon and patient out of trouble. This chapter focuses on the overall assessment and management of
the weight loss patient, with procedural details described in Chapters 64–66.
mebooksfree.net
Preoperative Planning
MWL leads to various deformities in all regions of the body, resulting in excess loose skin and fat.
Although many medical diseases are improved or even cured by means of weight loss, the redundant
skin is a constant reminder of the patient’s former self when looking in the mirror. Common complaints
from patients include inability to properly fit in clothing, buildup of moisture in skin folds leading to
intertriginous rashes and recurrent infections, and social stigma. Regardless of the weight loss method,
patients should be congratulated on their tremendous achievement and reminded that their visit with the
plastic surgeon ushers the beginning of the end of their journey. It is imperative that the surgeon
performs a careful assessment of any patient who presents for body contouring after MWL to optimize
the patient and minimize complications.
mebooksfree.net
Weight Loss Method
Most patients undergo weight loss surgery, some achieve weight loss via diet and exercise, whereas a few
resort to medication-induced methods of weight loss. If surgery was performed, it is important to note
the type of procedure, whether laparoscopic or open, need for revisions or adjustments, and presence of a
subcutaneous port. Weight loss by pharmacologic methods can be risky and unpredictable given the lack
of long-term data. Dietary supplements or drugs may not have Food and Drug Administration approval
and can have serious untoward effects. Similarly, fad diets do not have enough evidence to substantiate
them. Interestingly, complications from body contouring in this population are similar independent of
weight loss method. 2
mebooksfree.net
Weight History
History should include the timeline of weight gain and subsequent loss, with particular attention paid to
the method of weight loss. Bariatric surgery typically causes a precipitous drop in weight for the first
year, thereafter a slow decline. A patient often reaches a nadir then climbs to within 10% of this value
before plateauing at this new level. Additional information to obtain at the initial visit is maximum,
minimum, and current weights. MWL patients have an almost three-fold increased risk of wound healing
complications compared to non-MWL patients, and the risk is highest in those who have lost over 100
pounds. 1
Before enlisting a patient for body contouring after weight loss, weight should remain stable—within 5 kg
—for at least 3 months. 3 If a patient is still actively losing weight, or intends to, then he or she should be
reevaluated at 3 to 6 month intervals until down to the desired weight. Ideally, patients should be at or
close to their goal weight, as results are significantly improved when weight is shed before surgery rather
than after.
mebooksfree.net
Nutritional Assessment
Because most patients presenting to the plastic surgeon for body contouring achieve MWL by means of
bariatric surgery, it is vital to perform a comprehensive nutritional assessment as part of the evaluation.
Diet, including daily protein and liquid intake, should be documented. The American Dietetic
Association (ADA) recommends a daily protein intake of 1 to 1.5 g/kg of IBW, or approximately 60 to 80 g
for most adults. ADA guidelines suggest 2 L (8 cups, or 64 ounces) of fluid intake per day. It is best that
patients eat a healthy-balanced diet and exercise regularly.
Given that the stress of surgery can increase energy expenditure up to 25%, 4 patients should be
accordingly counseled to increase their daily protein consumption to 75 to 100 g in the perioperative
period. This increased protein intake should be maintained for at least 2 weeks preoperatively and
4 weeks postoperatively.
Symptoms of chronic malnutrition range in form and severity, including but not limited to fatigue,
muscle aches, and peripheral neuropathy. A history of dumping syndrome should be elicited,
characterized by postprandial symptoms of abdominal pain, nausea, emesis, and diarrhea. Dumping
syndrome is seen mostly in gastric bypass patients and is caused by a rapid emptying of stomach
contents into the small intestine. Generally, the solution is to avoid foods with a high sugar content as
these are not well-tolerated by the postbariatric surgery patient. If any concerns arise from the patient or
physician perspective, the patient should be referred to their bariatric team to address these issues before
proceeding with body contouring.
As many as 50% of postbariatric surgery patients have at least one elemental or nutritional deficiency as a
result, with a greater risk after procedures with a malabsorptive component such as Roux-en-Y gastric
bypass surgery. 5-7 Many of these nutrients and vitamins are necessary cofactors for general metabolism
and wound healing.
8 Patients who achieved weight loss by surgical means often require
supplementation. 9 Therefore, nutritional assessment should include screening of iron, albumin, and
vitamins A, B, and D. Iron-deficiency anemia is the most common preoperative deficiency found in the
MWL population 10 and is most prevalent in women of childbearing age. 11 Referral to a hematologist to
optimize hemoglobin before surgery can avoid need for perioperative transfusion. Not only are low
albumin levels associated with poor wound healing, but also levels below 2.1 g/dL are predictive of
increased mortality rates postoperatively. 12,13 Vitamin B (thiamin) deficiency should be suspected in any
patient with intractable emesis, as late recognition can lead to serious consequences 14,15 (Table 63.1).
TABLE 63.1
Common Vitamins and Elements That Require Supplementation After Bariatric Surgery a
Vitamin/Mineral
Deficient
Patients
(%) 10,16-19
Etiology of Malabsorption
Symptoms/Complications of
Deficiency
Supplementation
Recommendations b
Calcium
40%-50%
Absorption sites (duodenum and jejunum)
bypassed
Muscle
weakness/tetany
Osteoporosis
Calcium citrate 1500 mg
PO daily
Iron (Fe)
25%-50%
Decreased gastric acid
Microcytic anemia
Fatigue
Generalized weakness
Iron sulfate 325 mg PO
daily
Vitamin B1
(thiamin)
20%-30%
Decreased oral intake; persistent
nausea/vomiting
Neurologic
manifestations
Wernicke
encephalopathy
Beriberi
12 mg PO daily
mebooksfree.net
Vitamin B9
(folate)
30%-50%
Poor dietary intake
Thrombocytopenia
Changes
in
pigmentation
or
ulceration of skin or
mucosa
500 µg PO daily
Vitamin B12
10%-15%
Decreased intrinsic factor (produced in
antrum of stomach) required for absorption in
terminal ileum
Megaloblastic anemia
Peripheral neuropathy
PO: 500 µg daily
IM or SQ: 1000 µg
injection monthly
Vitamin D
20%-40%
Poor sun exposure
Osteoporosis
Increased
risk
of
infection,
chronic
disease
Ergocalciferol (D2) or
cholecalciferol (D3) 3000
IU PO daily
Zinc
20%-40%
Absorption sites (duodenum and jejunum)
bypassed
Decrease
immune
system function
Poor wound healing
Hair loss
Folate deficiency
10 mg PO daily
aSigns of deficiency should be screened for at any visit to allow for correction before serious complications arise.
bThese are recommendations for supplementation in a person with already-established normal levels of micronutrients based on the
American Society for Metabolic Surgery. 20 In a patient with lower than reference range levels, patients require larger doses and closer
monitoring. Recommendations for women attempting to get pregnant or currently pregnant are generally higher. This table is not all-
encompassing, and there are several other doses and routes of administration for many of these supplements.
IM, intramuscular; IU, international units; PO, per os (oral); SQ, subcutaneous.
mebooksfree.net
Medical Comorbidities
It is important to document a patient’s medical comorbidities before and after weight loss, as many
conditions will improve if not resolved after achieving a more IBW. Medical diseases such as diabetes,
hypertension, hyperlipidemia, gastroesophageal reflux disease, and obstructive sleep apnea, among
others, are improved or possibly entirely eliminated. However, these and others may be present and must
be optimized before any operative procedure. Principles outlined in Chapter 16 should guide
management options, and referrals to specialists made accordingly. It is recommended that a complete
blood count be obtained on all patients who have experienced MWL.
Although all patients will experience some degree of amelioration in medical conditions, not all will be
completely alleviated. Therefore, surgeons treating these patients should be familiar with common
disease states with which they may present. The three most common diseases patients present with after
MWL are depression (53%), arthritis (41%), and anxiety (27%). 10
mebooksfree.net
Body Mass Index
A crucial factor in determining a patient’s suitability for surgery is body mass index (BMI). Although no
threshold exists, BMI should be under or as close to 30 kg/m2 preoperatively, because there is an
increased risk of complications in patients who have a BMI above this threshold. Specifically, in the body
contouring population, higher BMI at time of presentation is associated with increased complications. 17
Deformities can vary after weight loss so distribution of residual obesity is best evaluated on an
individual basis. An example could be performing a patient with a BMI above 40 kg/m2 who has
difficulty ambulating secondary to a heavy, hanging panniculus that ulcerates and makes exercise
difficult. Patients such as these should be optimized and offered a panniculectomy to motivate further
weight loss. Such procedures should be focused and expedited to minimize complications in this patient
population.
mebooksfree.net
Medical, Surgical, and Social History
The surgeon must be conscientious that body contouring after weight loss is elective and should remind
the patient as such. Even though surgery may be life-changing, it will likely never be life-saving as these
patients are unlikely to suffer a mortality if they do not undergo surgery. With that in mind, modifiable
risk factors should be maximally optimized before signing a patient up for these operations.
Use of nicotine products, as discussed in Chapter 16, is the single most easily modifiable risk factor. It is
not advisable to operate on patients actively using any form of nicotine product as these procedures often
have lengthy incisions that are at high risk for wound dehiscence or delayed healing.
History of previous surgeries should be elicited, and scars in the anatomical region of the procedure
should be sought to avoid complications secondary to vascular compromise. Planned surgery on the
abdomen should include a thorough examination of the abdominal wall and any potential hernias.
Patients who have undergone adjustable gastric band (AGB) procedures should have a subcutaneous
port on the abdominal wall, and this may need to be relocated intraoperatively.
Given that many of these procedures have a significant scar burden, patients must be willing to accept a
trade-off of aesthetic result for a scar. Patients need to understand that there is a delicate balance between
scar burden and aesthetic outcome, but certain deformities can only be corrected with a greater scar load.
mebooksfree.net
Medications
Guidelines for management of medications for the body contouring patient in the perioperative period is
akin to most patients, and is covered in Chapter 16. Additional care should be taken if patients are
actively taking weight-loss drugs. Surgeons must ask about birth control or other hormone medications,
as this is pertinent for calculating a Caprini score.
The surgeon must be aware of restrictions on postoperative medications in bariatric surgery patients.
Patients who have undergone AGB must take oral medications in crushed, liquid, chewable, suspension,
or sublingual forms. In those who have had Roux-en-Y gastric bypass, nonsteroidal antiinflammatory
drugs are contraindicated due to the perceived risk of ulceration, 21 although this has not been studied.
mebooksfree.net
Staging
Patients presenting after MWL usually have many areas in need of body contouring. It is best to have the
patient prioritize the regions they desire corrected and, together with the surgeon, create a plan. Variables
that may influence the timing and staging include the number of surgeons, procedure setting, regional
laws, and the patient’s financial resources. Procedures may have to be staged to minimize operative time
and avoid opposite vectors of skin tightening. Some procedures may be combined safely, whereas certain
procedures should not be combined in the same operative setting. 22,23 Given that many of these
procedures are not covered by health insurance carriers, patients may space surgeries due to financial
implications. Staging may not be a bad option, however, because it allows for minor revisions and
corrections of areas previously operated on. Finally, patients generally desire new areas contoured after
initial stages and may return to have other body regions corrected. 24
For global body contouring, including procedures on the chest or breast, trunk, upper and lower
extremities in a healthy patient without financial constraints, a two-stage approach may be used. A
common two-stage practice involves a circumferential trunk procedure and upper body procedure such
as either mastopexy or brachioplasty, followed later by the second stage to encompass the other upper
body procedure and thigh lift. Unless extraordinary circumstances dictate a more accelerated timeline,
surgeries should be spaced with a minimum of 3 months in between to allow for the tissues to heal,
assessment of skin relaxation, and improved patient recovery.
mebooksfree.net
Markings
Preoperative markings serve for surgeons either as an estimate that is verified intraoperatively or as the
final cutting guide. Therefore, it is critical that the patient understand the markings and final scar
placement. An easy approach is to mark the patient in clinic the day before surgery in front of a mirror
and show the patient the expected scar location. This allows ample time for marking without
interruptions, is less invasive and more comfortable for the patient than the holding area, and provides
time for questions.
mebooksfree.net
Special Considerations
Despite being already covered in Chapter 16, perhaps in no other patient is attention to certain
perioperative factors as important as the MWL patient, namely venous thromboembolism (VTE)
prophylaxis and intraoperative body temperature. For truncal reshaping procedures, some surgeons
prefer to prep the patient while in the standing position, then have him or her move onto a sterile draped
operating room table. Extremities should be prepped circumferentially for easy movement and access to
all areas, permitting liposuction of other regions of the extremity or the excision site itself.
mebooksfree.net
VTE Prophylaxis
Worthy of mention in the patient population is proper management of VTE prophylaxis. Risk of VTE in
the post-MWL patient is around 3%, and the risk in those with a BMI over 35 kg/m2 triples to
approximately 9%. 25 Although no consensus guidelines exist for the post-MWL patient, the 2005 Caprini
score should be used as a reference. At a minimum, either compression stockings or intermittent
pneumatic compression devices should be applied throughout the patient’s stay, and patient should be
encouraged to ambulate on the evening of surgery.
mebooksfree.net
Body Temperature
Given that hypothermia can increase complications postoperatively and body-contouring procedures
often require exposure of a large body surface area, it is critical to take all possible precautions to avoid
hypothermia. 26,27 Hypothermia is easier to treat before rather than after it sets in, so appropriate measures
should be in place to prevent its occurrence. In addition to the methods described in Chapter 16, certain
techniques can be employed in the MWL patient to decrease the risk. One technique involves making a
sterile warming blanket sandwich, using a forced air heating pad interposed between two sterile drapes.
In this manner, the entire surgical region may be prepped, but any areas not actively being operated on
may be covered and warmed without interrupting the flow of the procedure.
mebooksfree.net
Complications
Even though postoperative complications in the MWL population can be quite frequent, fortunately they
are usually minor and amenable to treatment on an outpatient basis. Most commonly observed are
delayed wound healing and wound dehiscence, underscoring the importance of preoperative nutrition
optimization. Wound breakdown should be presumed to be a result of nutritional deficiency until proven
otherwise. Another common complication is seroma, which can be decreased with drain use. If drain
output continues to preclude removal of drains, chemical sclerosis can be performed. If drains were not
used or a seroma appears after drain removal, percutaneous needle aspiration can be done up to three
times, after which time placement of a seroma catheter is recommended. Rarely, the patient may require
reoperation to excise the seroma cavity.
Systemic complications tend to be more serious and can range from VTE to death. Early serious surgical
site complications that may require intervention include hematoma, which may require operative
drainage; surgical site infection, necessitating oral or intravenous antibiotics; nerve injuries, possibly
needing exploration in the operating room. Late surgical site complications include scar widening or
hypertrophy, as well as chronic draining wounds or sinus tracts. Surgery on the extremities can lead to
lymphedema, with the lower extremities more commonly affected.
Postoperative numbness of the surgical site is normally transient and resolves with time. If a nerve injury
is identified intraoperatively, it should be repaired. If a patient complains of numbness postoperatively, it
is expected to resolve with time, sometimes taking up to a year. However, if a patient reports numbness
in a nerve outside of the zone of operation, such as an ulnar nerve neuropathy during abdominoplasty,
this is more likely to be related to improper positioning or padding of the nerve intraoperatively. These
nerve symptoms generally resolve spontaneously, although patients require reassurance throughout this
period.
The most feared complication of body contouring surgery is resecting so much tissue that closure
becomes impossible with the tissue left behind. This is prevented by use of judicious measuring and
resection of tissue. The best practice to avoid this complication is by verifying the marks several times,
and by committing to only one margin of resection and raising flaps toward the opposite margin until
these edges can be brought together without undue tension.
mebooksfree.net
Outcomes
Studies have shown that, overall, patients who have body contouring after weight loss have better quality
of life (QoL) outcome measures as compared to weight loss patients who do not undergo plastic surgery.
Body contouring after MWL provides patients with improved self-esteem, social life, work ability, and
sexual and physical activity. 28 Specifically, after lower body lift, patients have higher levels of self-
esteem and self-confidence and feel more attractive. 29 These improved QoL measures persisted for years
after plastic surgery.
mebooksfree.net
Questions
1. A 45-year-old woman presents for abdominoplasty. She has two children delivered via C-section
and desires improved abdominal contour. She smokes half a pack of cigarettes a day but is otherwise
healthy. Which of the following is the best approach to her operative management?
a. Ask her to quit and proceed with surgery next week
b. Deny her surgery for her smoking habit
c. Proceed with surgery since half a pack of cigarettes a day is not detrimental
d. Refer her to another physician willing to operate on smokers
e. Wait until she has stopped smoking for 4 weeks and check her urine cotinine before
proceeding with surgery
2. A 37-year-old woman presents to your clinic desiring correction of breast ptosis and abdominal
skin laxity. She underwent laparoscopic Roux-en-Y gastric bypass surgery 6 months ago and reports
her weight has been stable for the past month. Her BMI in your office is 33 kg/m2. She has no other
significant medical problems and she would like both procedures at the same stage. What is the best
management of this patient?
a. Defer surgery until her weight has been stable for a minimum of 3 months
b. Defer surgery until she is 1-year postbariatric surgery
c. Perform the abdominoplasty first to promote further weight loss, then the mastopexy in a
second stage
d. Proceed with surgery as soon as possible
3. A 41-year-old man presents after losing 50 kg through diet and exercise. He has gynecomastia as
depicted in Figure 63.1. On physical examination, there is significant fibrous tissue in the retroareolar
region. What is the best treatment option for this patient?
mebooksfree.net
FIGURE 63.1
a. Inframammary fold excision with free nipple graft
b. Liposuction only
c. Periareolar incision, direct excision
d. Wise-pattern reduction
4. What is the appropriate antibiotic and dose for preoperative prophylaxis in a 50-year-old man who
has no known drug allergies and weighs 128 kg?
a. Cefazolin 2 g
b. Cefazolin 3 g
c. Clindamycin 600 mg
d. Clindamycin 900 mg
e. Vancomycin 1500 mg
1. Answer: e. Smoking is a modifiable risk factor that can reduce complications after surgery.
Nicotine can lead to vasoconstriction and reduced oxygenation of healing tissues, leading to
mebooksfree.net
increases in wound healing problems and infection. The best option is to counsel the patient to stop
and check her urine for smoking 2 weeks before surgery. Urine cotinine tests can take up to 10 days
to get the results, so it should not be used close to the surgical date. Many surgeons advise smoking
cessation for 4 weeks before and after surgery. Having a smoking policy in place can avoid
postoperative complications.
2. Answer: a. Patients who present after MWL, regardless of weight method, should have a stable
weight for at least 3 months before undergoing a body contouring procedure. Patients often lose
weight and reach plateaus at several points in their weight loss cycle then go on to lose again;
therefore, a one-month period is of insufficient length to deem stable. In addition, further weight loss
will surely improve this patient’s BMI, perhaps even bringing it below 30 kg/m2, reducing her risk
substantially.
3. Answer: a. In a patient with excess bulk and a long nipple to inframammary fold distance such as
the one pictured, a direct excision with free nipple graft is needed to remove the tissue and move the
nipple-areola complex (NAC) to the proper location on the chest wall. Liposuction only or direct
excision would be insufficient to treat the excess tissue or move the NAC to the correct location, or
both. A pedicled reduction would be too bulky to fit the pedicle under the skin envelope.
4. Answer: b. The correct dosing for a patient who has no allergy to penicillin or cephalosporins is
2 g in patients under 120 kg of weight and 3 g in patients over 120 kg of weight. Clindamycin 600 mg
is no longer recommended, and the standard dose for patients with a true cephalosporin allergy is
900 mg. In special circumstances, including a history of methicillin-resistant Staphylococcus aureus
infection, vancomycin 1500 mg should be used.
mebooksfree.net
References
Constantine, RS, Davis, KE, Kenkel, JM. The effect of massive weight loss status, amount of weight loss, and method of weight loss on body
contouring outcomes. Aesthet Surg J. 2014;34(4):578-583.This study examined the differences in complication rates between MWL and non-MWL
patients undergoing the same procedures. Results from 450 patients showed that those who lost more than 100 lb of weight were in the highest risk
category.
Chetta, MD, Aliu, O, Tran, BA, et al. Complications in body contouring stratified according to weight loss method. Plast Surg (Oakv).
2016;24(2):103-106.
Bond, DS, Phelan, S, Leahey, TM, et al. Weight-loss maintenance in successful weight losers: surgical vs non-surgical methods. Int J Obes
(Lond). 2009;33(1):173-180.
Van Way, CW III. Nutritional support in the injured patient. Surg Clin North Am. 1991;71(3):537-548.
Halverson, JD. Metabolic risk of obesity surgery and long-term follow-up. Am J Clin Nutr. 1992;55(2 suppl):602S-605S.
van der Beek, ES, Monpellier, VM, Eland, I, et al. Nutritional deficiencies in gastric bypass patients; incidence, time of occurrence and
implications for postoperative surveillance. Obes Surg. 2015;25(5):818-823.
Stein, J, Stier, C, Raab, H, Weiner, R. The nutritional and pharmacological consequences of obesity surgery. Aliment Pharmacol Ther.
2014;40(6):582-609.
Agha-Mohammadi, S, Hurwitz, DJ. Potential impacts of nutritional deficiency of postbariatric patients on body contouring surgery. Plast
Reconstr Surg. 2008;122(6):1901-1914.
Austin, RE, Lista, F, Khan, A, Ahmad, J. The impact of protein nutritional supplementation for massive weight loss patients undergoing
abdominoplasty. Aesthet Surg J. 2016;36:204-210.
Naghshineh, N, O’Brien Coon, D, McTigue, K, et al. Nutritional assessment of bariatric surgery patients presenting for plastic surgery: a
prospective analysis. Plast Reconstr Surg. 2010;126(2):602-610.A prospective study examining nutritional status of 100 consecutive patients
presenting for plastic surgery after bariatric surgery. Eighty percent of patients had inadequate protein intake. The most common deficiency was iron
deficiency anemia, with almost 40% of patients.
Zimmermann, MB, Hurrell, RF. Nutritional iron deficiency. Lancet. 2007;370:511-520.
Gibbs, J, Cull, W, Henderson, W, et al. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the
National VA Surgical Risk Study. Arch Surg. 1999;134(1):36-42.
Correia, MI, Waitzberg, DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a
multivariate model analysis. Clin Nutr. 2003;22(3):235-239.
Sebastian, JL, V, JM, Tang, LW, Rubin, JP. Thiamine deficiency in a gastric bypass patient leading to acute neurologic compromise after
plastic surgery. Surg Obes Relat Dis. 2010;6:105-106.
Gardiner, S, Hartzell, T. Thiamine deficiency: a cause of profound hypotension and hypothermia after plastic surgery. Aesthet Surg J.
2015;35(1):NP1-NP3.
Carlin, AM, Rao, DS, Meslemani, AM, et al. Prevalence of vitamin D depletion among morbidly obese patients seeking gastric bypass
surgery. Surg Obes Relat Dis. 2006;2:98-103.
Coon, D, Gusenoff, JA, Kannan, N, et al. Body mass and surgical complications in the postbariatric reconstructive patient: analysis of 511
cases. Ann Surg. 2009;249(3):397-401.A study examining differences between body contouring patients undergoing single versus multiple operations
in a single setting. 449 patients were included, and complications were correlated with current and maximum BMIs in the single procedure group, but
with change in BMI in the multiple procedure group.
Gletsu-Miller, N, Wright, BN. Mineral malnutrition following bariatric surgery. Adv Nutr. 2013;4(5):506-517.
Clements, RH, Yellumahanthi, K, Wesley, M, et al. Hyperparathyroidism and vitamin D deficiency after laparoscopic gastric bypass. Am
Surg. 2008;74(6):469-474.
Parrott, J, Frank, L, Rabena, R, et al. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the
surgical weight loss patient 2016 update: micronutrients. Surg Obes Relat Dis. 2017;13(5):727-741.
Mechanick, JI, Kushner, RF, Sugerman, HJ, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American
Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and
nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis. 2008;4(5 suppl):S109-S184.
Coon, D, Michaels, J IV, Gusenoff, JA, et al. Multiple procedures and staging in the massive weight loss population. Plast Reconstr Surg.
2010;125(2):691-698.Looking at 609 patients undergoing body contouring after MWL, the authors showed that the per-procedure complication rate
was the same whether performing one or many procedures in the same stage.
Pascal, JF, Le Louarn, C. Remodeling bodylift with high lateral tension. Aesthetic Plast Surg. 2002;26(3):223-230.
Song, AY, Rubin, JP, Thomas, V, et al. Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver
Spring). 2006;14(9):1626-1636.
Shermak, MA, Chang, DC, Heller, J. Factors impacting thromboembolism after bariatric body contouring surgery. Plast Reconstr Surg.
2007;119(5):1590-1596.The authors looked at their 10-year experience with 129 patients having body contouring after MWL. BMI was the leading risk
factor, and recommendations for prophylaxis are discussed.
Kurz, A, Sessler, DI, Lenhardt, R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten
hospitalization: study of wound infection and temperature group. N Engl J Med. 1996;334(19):1209-1215.
mebooksfree.net
Coon, D, Michaels, J IV, Gusenoff, JA, et al. Hypothermia and complications in postbariatric body contouring. Plast Reconstr Surg.
2012;130(2):443-448.
Modarressi, A, Balagué, N, Huber, O, et al. Plastic surgery after gastric bypass improves long-term quality of life. Obes Surg. 2013;23(1):24-30.
Vierhapper, MF, Pittermann, A, Hacker, S, Kitzinger, HB. Patient satisfaction, body image, and quality of life after lower body lift: a
prospective pre- and postoperative long-term survey. Surg Obes Relat Dis. 2017;13(5):882-887.
mebooksfree.net
C H A P T E R 6 4
mebooksfree.net
Liposuction, Abdominoplasty, and Belt Lipectomy
Terri A. Zomerlei and Jeffrey E. Janis
Key Points
Selection of the correct body contouring procedure—liposuction versus skin resection technique—is
essential to optimize outcomes.
Obtain a thorough personal and family medical history to appropriately calculate the patient’s
venous thromboembolism risk and plan mechanical and chemoprophylaxis for prevention of VTE.
Perform anatomic-based markings to keep incisions in cosmetically acceptable locations.
Be mindful of zones of adherence.
Decrease potential complications by proper positioning and padding and preventing hypothermia,
calculating local anesthetic dosing, and respecting blood supply and previous scars.
Selection of the appropriate body contouring procedure(s) is based on the presence and degree of skin
and adipose excess. Body contouring procedures are not strictly for weight reduction and patients should
be counseled in this regard.
mebooksfree.net
Liposuction
Liposuction, the surgical aspiration of fat from the subcutaneous plane, is one of the most popular
procedures performed by plastic surgeons. The first description of surgically removing fat for body
contouring is from the 1920s. Dr. Dujarrier, an obstetrician and surgeon, utilized a uterine curette to
remove fat from the knees of a ballerina resulting in catastrophic complications and eventual leg
amputation. Modern liposuction became popularized in the 1970s by Drs. Illouz, Fournier, and Otteni.
The key advancements and contributions by these surgeons were the use of a wetting solution, blunt
cannulas, and negative pressure evacuation. This greatly improved the safety of the procedure. 1
mebooksfree.net
Patient Selection and Evaluation
Suction-assisted lipectomy, or liposuction, is indicated for removal of localized excess adipose tissue or
lipodystrophy ideally in areas with good overlying skin quality and minimal excess skin. The patient’s
motivation and surgical expectations should be garnered early in the consultation process to sort out
those with unrealistic expectations or mental disorders such as body dysmorphic disorder.
A thorough medical history should be obtained on all patients. Nonessential supplements and vitamins
should be discontinued 3 weeks prior to surgery. Medications that could interfere with lidocaine
metabolism (such as psychotropics) should be noted. 2 Patients with a history of nicotine use or poorly
controlled diabetes should be counseled on the increased risk of wound healing complications, and
strong consideration should be given to deferring their procedures until they have had nicotine cessation
for 4 weeks prior to the proposed elective operation (compliance can be tested with a urine cotinine test)
and an A1C of less than 7.5. 3,4 In those patients who will be receiving large-volume liposuction (defined
as aspiration of greater than 5 L), a complete blood count should be performed preoperatively. In
addition, assessing personal and family history of bleeding problems, blood clots, and miscarriages is
important. The practitioner should obtain labs and/or hematology consultation as appropriate so that
venous thromboembolism (VTE) prevention is optimized.
Liposuction should not be offered as a treatment for global obesity or cellulite, and ideally patients
should be within 30% or their ideal body weight. 5 Women typically have a gynoid pattern of fat
distribution with accumulation in the lower trunk, hips, upper thighs, and buttocks. Men often exhibit an
android fat accumulation pattern with increased abdominal girth, thickened torso, and upper abdomen.
During examination of the abdomen, particular attention should be paid to any surgical scars that can
affect blood supply and also signal possible hernias. 4 A Valsalva maneuver or having the patient perform
a small sit-up should reveal the presence of any hernias. Obtain a computed tomography (CT) scan, if
needed. During the examination, the presence and extent of a diastasis recti should also be evaluated in
addition to assessing the degree of visceral versus external fat. Location of adipose deposits and
asymmetries should also be noted and discussed with the patient. Skin quality and quantity should also
be assessed noting that those with good skin quality will have more optimal results.
mebooksfree.net
Pertinent Anatomy
Thorough understanding of the pertinent anatomy is essential for effective liposuction treatment. The
subcutaneous adipose tissue is supported and separated into compartments and layers by a fibrous
network called the superficial fascial system. 6,7 The adipose tissue in a given region can roughly be
divided into two layers:
Superficial layer: Dense fat, contained within tight septae and adherent to the dermis. This layer is
most susceptible to contour irregularities.
Deep layer: Loose fat and less compact. This is the safest layer to suction.
Zones of adherence are recognized regions in which the subcutaneous tissues are securely adherent to the
deep fascia. Liposuction should be avoided or used with extreme caution in these areas as the risk of
contour irregularities is high 5 (Figure 64.1):
Gluteal crease
Lateral gluteal depression
Middle medial thigh
Distal iliotibial tract
Distal posterior thigh
FIGURE 64.1 In addition to surrounding the superficial fat layer, the superficial fascial system sends components through the
deep fat compartment attaching to the investing fascia of the underlying musculature. These extensions, where the superficial
subcutaneous plane is adherent to the underlying muscle fascia, are collectively called zones of adherence. These zones,
mebooksfree.net
which include the lateral gluteal depression, the gluteal crease, the distal posterior thigh, middle medial thigh, and inferolateral
iliotibial tract, are much more susceptible to contour irregularities.
mebooksfree.net
Marking, Positioning, and Safety
Patients should be marked in the standing position with an indelible marker. Areas to be suctioned are
marked with concentric circles in a topographical pattern, typically with an X at the most protuberant
point. Zones of adherence are noted and are marked with straight parallel lines or hash marks. Natural
creases should be noted, as these will be optimal areas to perform the incisions for liposuction to
minimize visibility 5 (see Figure 64.1).
Safety is of utmost importance in surgery, and several precautions should be taken with liposuction
procedures. 8 With large areas of the body usually exposed for the liposuction procedure, care should be
taken to avoid intraoperative hypothermia. Intravenous fluids (IVFs) and wetting solutions should be
warmed. Forced warm air blankets should be placed over areas not being suctioned, and the ambient
room temperature can be raised. Pressure points should be appropriately padded, as improper pressure
on the neurovascular structures in the body can lead to short- or long-term disability. Padding and
flexion of the arm and elbow less than 90 degrees and use of an axillary roll in the lateral decubitus
position reduces the risk of upper extremity nerve compression. The surgeon should work closely with
the anesthesia provider to ensure that the patient’s eyes are protected, the head is supported, and the
neck is in a neutral position. In the prone position, a soft hip roll placed beneath the iliac crests aids in
elevating treatment areas off the operative table. If the patient will be repositioned during the procedure,
close attention should be paid to careful choreography of all details.
Body contouring operations such as liposuction and abdominoplasty have a higher incidence of venous
thrombotic complications than other plastic surgery procedures. In 2011, the American Society of Plastic
Surgeons Venous Thromboembolism Task Force recommended a stepwise approach for plastic surgery
patients that includes: 9
Preoperative risk stratification
Prevention with mechanical and/or chemoprophylaxis
Patient education
At minimum, patients undergoing liposuction should have pneumatic compression stockings in place (if
the leg is not being treated). The use of chemoprophylaxis will depend on the preoperative risk
stratification.
mebooksfree.net
Wetting Solution and Fluid Management
First introduced by Illouz, the advent of the use of wetting solution has greatly improved the safety of
liposuction. 1 Wetting solutions can be a variable composition but usually include saline or lactated
Ringer’s, lidocaine, epinephrine, and sometimes sodium bicarbonate. The wetting solution has multiple
functions and aids with anesthesia, hemostasis, and emulsification of adipocytes. There has been an
evolution of wetting solution techniques that have helped decrease blood loss (Table 64.1). 10-12 The
desired wetting solution composition and amount is instilled into the treatment area via a fine infiltration
cannula through a small stab incision that will also function as the liposuction port. Ideally, the fluid
resides at least 7 to 10 minutes in the tissue for optimal vasoconstrictive effect. High lidocaine doses can
result in severe systemic complications. Traditionally, maximal lidocaine dosing is 7 mg/kg. In wetting
solution, however, much higher doses, up to 35 mg/kg, have been reported as safe. The maximal safe
dose of lidocaine should be calculated for each patient. 12-14
TABLE 64.1
Commonly Used Wetting Solution Techniques a
Technique
Infiltrate Volume
Estimated Blood Loss (as % of Aspirate Volume) (%)
Dry
No infiltrate
∼20–40
Wet
200–300 mL/area
∼25
Superwet
1 mL infiltrate: 1 mL aspirate
∼1–4
Tumescent
To skin turgor
2–3 mL infiltrate: 1 mL aspirate
∼1
aThe essential difference among these techniques centers on the amount of solution infused into the tissue and the resultant blood loss with
aspiration.
Intraoperatively, appropriate fluid administration and balance is critical. 15 This will include IVF
administration to replace preoperative deficit and to provide appropriate maintenance fluids, which can
vary depending on whether the patient is undergoing large-volume liposuction. Clear communication
with anesthesia staff is essential.
mebooksfree.net
Treatment Types
Once the patient has been deemed an appropriate candidate for adipose reduction, technique selection is
the next step. Current options for traditional liposuction include suction-assisted liposuction (SAL),
power-assisted liposuction (PAL), ultrasound-assisted liposuction (UAL), and laser-assisted liposuction
(LAL). SAL is the most frequently utilized modality among plastic surgeons.
mebooksfree.net
Traditional Liposuction
SAL is a two-stage technique that requires infiltration of wetting solution followed by suction evacuation.
This technique is popular because of its lower cost of equipment investment, ease of use, and reliability.
However, SAL is more labor-intensive and does not perform as well on areas with fibrous fat.
PAL is a technique that uses a variable- speed motor that provides oscillation in a reciprocating motion at
rates of 4000 to 6000 cycles per minute. Because PAL can break up fibrous fat more readily, this modality
can significantly cut down on physician fatigue due to shorter procedure times and employing less
physical labor to use.
UAL applies ultrasonic energy to break down fat and facilitate suction aspiration. UAL works to emulsify
the fat by three mechanisms: 16,17
Mechanical: direct tissue effects by the ultrasound wave; this is the primary mechanism
Cavitation: tissue fragments based on the formation and collapse of intracellular microbubbles
Thermal: absorption of the ultrasound waves produces heat
Treatment with UAL involves three stages:
1. Infiltration of wetting solution
2. Emulsification with ultrasound treatment
3. Evacuation of emulsified fat and final contouring
With the use of smaller cannulas and conservative ultrasound application times, the frequently cited
complications of UAL (contour deformities and thermal injury) can be avoided.
LAL uses a small laser fiber to emulsify fat and tighten skin. A four-step technique is used:
1. Infiltration
2. Application of energy to the tissue
3. Evacuation
4. Subdermal skin stimulation
This treatment modality is purported to have the benefit of skin tightening. However, several well-
designed studies have failed to show a significant benefit over SAL. 18
Peer-reviewed studies failed to show consistent evidence-based benefits for the use of UAL and LAL over
SAL. The aesthetic outcomes, patient satisfaction, and incidences of long-term complications appear to be
more related to technique and not technology. As a result, SAL/PAL remains the leading techniques
employed. 18
Surgical endpoints for liposuction can be divided into primary and secondary endpoints and depend on
the treatment modality used:
Primary endpoints
SAL/PAL: contour, symmetrical pinch test, and presence of bloody aspirate
UAL: loss of tissue resistance, contour, and presence of bloody aspirate
Secondary endpoints
SAL/PAL/UAL: treatment time and volume
mebooksfree.net
Cryolipolysis
In select patients who prefer to avoid surgery for adipose reduction, treatment with cryolipolysis may be
employed. Cryolipolysis is a noninvasive technique to destroy adipose cells through administration of
controlled thermal reduction via a specialized machine. 19,20 Because of their susceptibility, exposure of
adipose cells to below normal temperatures (+5° to −5°C) results in apoptosis-mediated cell death with
preservation of overlying skin integrity. The subsequent inflammatory cascade results in removal of the
damaged cells over the course of 3 months. The most common complication following cryolipolysis is
hypoesthesia of the treatment area that usually resolves over several months. Other less common
complications include surface contour irregularities, chronic pain, and rarely, paradoxical adipose
hyperplasia. 21
mebooksfree.net
Technique
Once the wetting solution has been instilled and allowed sufficient time for effect, the liposuction cannula
is introduced. The cannula is inserted into the access incision(s) and using even strokes, the cannula is
moved in a fanlike pattern. The deep plane is suctioned first, with the dominant hand guiding the
liposuction cannula and the nondominant hand overlying the treatment area, providing stereotactic
feedback on the cannula location and depth.
To mitigate the most frequently cited liposuction complication, contour irregularities, careful attention to
technique is important. Cross-hatching or cross-tunneling is the method of using the liposuction cannula via
multiple access sites to create intersecting sets of parallel lines over the treated area. This helps to ensure
the tissue is suctioned more symmetrically and evenly.
In 2016, Wall proposed a multistep process for nonthermal comprehensive fat management that focuses
on minimizing tissue injury and prevention of contour irregularities. 22 The SAFE (separation-aspiration-
fat equalization) liposuction technique is based on the following principles:
Optimize fat removal
Provide comprehensive means of body contouring
Preserve vascular integrity
Maximize skin retraction
Minimize potential for complications/revisions
Briefly, the separation step uses an exploded-tip (basket-tip) cannula with no suction to separate and
mechanically emulsify the fat. This step comprises 40% of the operating time and addresses both the
superficial and deep fat compartments. Aspiration is then performed with less aggressive cannulas. This
step should take approximately another 40% of the procedural time. The last step, fat equalization, again
uses an exploded tip without suction. During this step, the fat layer evens out the thicker and thinner
areas that may exist.
An extension of the SAFE liposuction technique utilizes the aspirated fat to perform expansion vibration
liposuction of the gluteal area. 23 This technique utilizes exploded liposuction tip and other nondisposable
existing instrumentation. Close attention is given to patient safety and avoiding critical structures when
lipofilling.
mebooksfree.net
Large-Volume Liposuction
The ASPS Patient Safety Committee has recommended, when the anticipated lipoaspirate amount is
expected to be greater than 5 L, several precautions should be taken. For safety reasons, the procedure
should be performed in a hospital setting as opposed to an ambulatory surgical center. In addition, fluid
shifts with large-volume liposuction can be significant, and thus specific fluid replacements should be
performed.
Maintenance IVF should be administered up to 5 L. Every 1 mL of aspirate beyond 5 L should be replaced
with 0.25 mL of IVF. Overnight monitoring of fluid balance (based on vital signs and urinary output)
should be considered. 24
mebooksfree.net
Treatment Areas
Many areas of the body can be treated with liposuction. The practitioner should keep in mind ideal
aesthetic contours based on gender.
mebooksfree.net
Arms
The upper arm can be contoured with liposuction alone or with concomitant brachioplasty to resect
excess skin (see Chapter 65). 25 Liposuction of the tissues that will be excised can facilitate dissection of the
tissues. Adiposity is usually focused at the posterior third of the arm and can be addressed through
access points on the distal radial side of the arm. The ulnar nerve can be superficial near the elbow and
could be inadvertently injured during the procedure. In addition, the medial antebrachial nerve pierces
the fascia of the arm approximately 14 cm proximal to the medial epicondyle and is susceptible to injury
in this area. The ideal aesthetic arm is lean with merging deltoid and biceps convexities.
mebooksfree.net
Back
The back anatomy is characterized by a thick dermis and fibrous, dense fat. Lipodystrophy of the back
tends to result in folds, especially inferior to the bra line. Improved contour can be obtained when the
fibrous attachments creating the folds are disrupted. The buffalo hump is an enlargement of the
dorsocervical fat pad and can be present because of genetics, certain medical conditions, or medication
use. In appropriate candidates, this area can be successfully liposuctioned. Because of the dense nature of
this fat, UAL is a commonly employed technique for this area.
mebooksfree.net
Abdomen
Lipodystrophy in the abdomen is predominantly in the infraumbilical region. Care must be taken to
ensure no hernias are present. In cases of significant excess skin or poor overlying skin quality with poor
elasticity, skin resection techniques are indicated. Ideal abdominal contour is gender-dependent, with the
female aesthetic having an hourglass figure defined by the flanks and a slight supraumbilical concavity
and infraumbilical convexity. Men should have no flare at the iliac crest and the infraumbilical area
should be flat.
In a leaner patient, improved body contour can be achieved with high definition liposuction or etching.
With this method, the fat in the superficial plane is liposuctioned to improve or provide the appearance of
muscular definition. This technique can be used in conjunction with focused fat transfer. This technique
should be used only by the trained practitioner as there is a high risk for contour irregularities. 26
mebooksfree.net
Hips/Flanks
These areas are treated most often in the prone or lateral decubitus positions. There are gender aesthetic
differences and fat distribution tendencies that must be taken into consideration when treating this area.
In women, the adipose deposits are commonly in the hip overlying the iliac crest and extending down to
the lateral thigh zone of adherence. In contrast, the men tend to have adiposity in the flank or lateral
lumbar area.
mebooksfree.net
Buttocks/Thigh
There are also gender differences in the ideal gluteal region aesthetic. Women desire a rounded more
protuberant buttock without ptosis that merges with lateral thigh. Male gluteal area aesthetic is flatter
and angular with a squared off lateral contour. The fat in the gluteal area is denser and fibrous. The thigh
is a difficult area for liposuction because of the circumferential approach that is usually required. In
addition, zones of adherence and natural creases (gluteal crease) need to be recognized and appreciated.
Overzealous suctioning in the buttock can result in ptosis and in the thigh can lead to unflattering skin
redundancy. For this reason, liposuction in these areas should be approached with caution.
mebooksfree.net
Postoperative Care
Following a liposuction procedure, massage excess wetting solution out of access incisions and either
close primarily with suture or leave open, if small enough. Absorbent dressings are applied along with a
compression garment. The dressing can be changed as needed for drainage and the compression garment
should be worn at all times except during showering. Various lengths of time have been proposed for
length of time to wear compression garments but most advocate a duration of 2 to 4 weeks.
mebooksfree.net
Complications
Postoperative complications following liposuction can roughly be divided into early and late
complications. Patients should be aware that postoperative edema and ecchymosis are an expected side
effect of the procedure and occur to varying degrees in all patients.
mebooksfree.net
Early Complications
Inadequate fluid resuscitation: communication with anesthesia team is vital
Sinus tachycardia: can develop after administration of wetting solution because of the epinephrine
effect
Injury to solid organs, bowel, or blood vessels: always be aware of the plane the cannula is in
Hypothermia: use warming techniques
Skin slough: local wound care
VTE: the most common cause of death following liposuction. Risk for this complication increases
with large-volume aspirate (>5 L), increased wetting solution infiltration
LAST (local anesthetic system toxicity): begins with symptoms of central nervous system excitation
such as perioral numbness, lightheaded, and dizziness. Can progress with seizures and cardiac
arrest. Calculate safe lidocaine dosing prior to procedure. Treat with ABCs of resuscitation and lipid
emulsion infusion. 27
mebooksfree.net
Late Complications
Neurapraxia: motor weakness or sensory disturbance (numbness/pain) after liposuction. Should
observe and reassure the patient. Should resolve within 3 to 4 months.
Contour irregularities: this is the most common postoperative complication and can occur in up to
20% of patients. Techniques to help prevent include use of small cannulas, multiple access incisions,
and cross-tunneling. Treatment of irregularities requires secondary fat equalization and fat grafting
to oversuctioned regions, if needed.
mebooksfree.net
Conclusion
Liposuction is artistry as well as surgery. It entails a practical application of anatomic knowledge with
precision and craftsmanship and is a skill that can be attained and refined with clinical experience.
mebooksfree.net
Abdominoplasty
Abdominoplasty is a procedure that removes excess skin and fat and, in most cases, restores the rectus
muscle to a more anatomical position, creating an abdominal profile that is smoother and firmer.
Abdominoplasty outcomes can be optimized and complication reduced with a strong understanding of
the anatomy.
mebooksfree.net