Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

penetrate fascia at midaxillary line and travel in subcutaneous tissues
dermatome
ASIS, anterior superior iliac spine.
The umbilicus is located at or near the midline at the level of the iliac crests. The umbilicus is the central
focus of the abdomen. The ideal umbilicus has superior hooding, round or oval shape, is shallow, and has
inferior retraction. The blood supply is based on the subdermal plexus, the ligamentum teres remnant,
and perforators from the deep inferior epigastric system.
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Patient Selection and Evaluation
Pertinent history to obtain from patients seeking abdominoplasty include gravidity and parity history,
previous abdominal surgeries (including cesarean sections), history of weight loss/gain, gastrointestinal
or respiratory ailments, and tobacco abuse. Patients should be nicotine free for a minimum of 4 weeks
prior to and after an abdominoplasty to minimize postoperative complications. Compliance can be tested
with a urine cotinine test. 3,4
On examination, assess for the presence of hernias (order a CT if needed) and take note of the excess fat
and skin, skin tone and appearance, and the presence of scars. 29,30 Small hernias may be addressed at the
time of abdominoplasty depending on the surgeon’s comfort level. The amount and location of excess fat
and skin will aid in determining the best technique to address the abdomen. Patients with striae, which
represents a thinning or rupture of the dermal layer, must be counseled that an abdominoplasty will
remove stria located inferior to the umbilicus but those located supraumbilically may be made worse by
the procedure. Scars may limit the movement of the abdominal skin flap and a subcostal scar has
potential to compromise the vascular supply to the skin flap. Examination of the patient should also
include assessment of myofascial laxity via a diver’s test (worsening lower abdominal fullness with
flexion at the waist) and a pinch test (assessing abdominal fullness with the abdomen both relaxed and
tensed). When the patient is supine, tensing of the abdominal muscles with a small sit-up should reveal a
diastasis rectus if present.
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Marking, Positioning, and Safety
Patients should wear an undergarment or swim bottom of choice to their operation so that the incision
can be planned with minimal exposure. Anatomical points should be marked including the xiphoid,
midline, ASIS, and pubic bone. Previous scars should be marked. The lower excision should be at least 5
to 7 cm above the vulvar commissure and should be below any cesarean scar if possible. The upper
marking is made based on pinch test of the abdomen both centrally and laterally. This marking should
come down inferior to the ASIS to minimize visibility.
Prior to entering the operating room, the operative table should be checked that it is able to flex. The
patient should be padded appropriately, and previously described measures to minimize hypothermia
should be employed. Sequential compression stocking should be applied. Data accrued by the American
Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) from 2001 to 2006 indicate
abdominoplasty is the procedure with the highest frequency of death due to pulmonary embolism (PE).
All patients undergoing abdominoplasty should be carefully risk stratified and at minimal receive
sequential compression stockings. 9,31 Any excessive hair can be clipped and the patient is prepped with a
wide field ensuring that the umbilicus is free from debris.
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Operative Options and Techniques
There are a variety of abdominoplasty techniques that can be employed to improve the contour of the
abdomen. Selecting the correct procedure is based upon the examination of the amount and distribution
of excess fat and skin, assessment of skin tone and quality, and the presence of a diastasis (Table 64.2).
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Traditional Abdominoplasty
In a traditional abdominoplasty, the umbilicus is transposed and the rectus muscles are plicated. A
circumumbilical incision is made and dissection is carried down to the rectus sheath. An orientation
suture placed in the umbilicus will aid in prevention of twisting at inset. The lower incision is incised and
dissection is carried up to the xiphoid, minimizing extensive lateral dissection to preserve blood supply
and taking care to keep the disinserted umbilicus intact to the abdominal wall (Figure 64.2A). A marking
pen or methylene blue is used to outline the medial edge of the rectus bilaterally. The rectus sheath is
then plicated (Figure 64.2B). The bed is flexed at the waist, and the amount of abdominal wall skin that
can be safely excised while maintaining a tension-free closure is marked (this may be slightly different
than the preoperative estimation). The surgeon can determine where the area of greatest tension will be
on the closure based on the patient’s needs. The upper incision is made, the abdomen irrigated, and
meticulous hemostasis achieved. To minimize dead space and tension at the closure, a surgical assistant
can aid in advancing the abdominal skin flap and progressive tension sutures can be placed. 32 Drains can
then be placed; however, some studies have found foregoing drains with the use of progressive tension
sutures is safe and without increased risk of seroma formation. 33 The neoumbilicus spot is located on the
abdominal skin flap based on the umbilical location on the abdominal wall. A small circular or ovoid
opening is made and the umbilicus is reintroduced into the skin flap and secured with several suture
layers, keeping in mind ideal umbilical aesthetics and the patient’s body habitus and preference. The
closure of the abdomen is performed in multiple layers with sutures in the Scarpa layer, deep dermis, and
subcuticular space.
FIGURE 64.2 A. The abdominal flap is dissected up to the xiphoid, minimizing excessive lateral dissection. A stitch in the
umbilicus helps with orientation when it is delivered through the new opening in the abdominal flap. B. The edges of the rectus
are outlined and plication is performed to restore the muscles to their anatomic position abutting each other on the midline.
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Miniabdominoplasty
In the miniabdominoplasty, also referred to as a short-scar abdominoplasty, the surgical goal is to remove a
small amount of skin and subcutaneous tissue from the lower abdomen only. The scar is limited and the
position of the umbilicus remains unchanged. Usually no plication of the rectus muscles is performed.
The option of a short scar can be appealing to younger patients, but dog-ears can be problematic because
of the shorter incision. Careful patient selection is crucial for patient satisfaction.
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High Lateral Tension
Popularized by Lockwood, the high lateral tension abdominoplasty endorses an oblique vector of pull of
the abdominal skin flap. 34 The oblique vector aids in reducing the horizontal epigastric laxity. In this
technique, more skin is excised from the abdominal skin flap laterally than centrally. The tension at the
line of closure is borne by meticulous closure of the superficial fascial system (Scarpa fascia). 7
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Fleur-de-lis
With the fleur-de-lis technique, the standard low horizontal incision is combined with excision of a
vertical ellipse of abdominal tissue (Figure 64.3). This procedure is best for a patient who has both
horizontal and vertical skin and tissue excess that is commonly the case in a weight loss patient. 35 First
described by Dellon, the procedure seeks to restore a more aesthetic abdominal contour. 36 The major
disadvantage of this procedure is an additional scar that is on the vertical midline. Care must be taken to
only undermine to the degree necessary for skin resection. The addition of liposuction to the lateral
abdomen will result in a discontinuous undermining that will aid in increasing excursion of the
abdominal skin flap laterally without increasing the risk of vascular compromise to the skin flap.
FIGURE 64.3 In the fleur-de-lis abdominoplasty technique, a horizontal and vertical wedge of tissue is excised in order to
address excess tissue in both directions.
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Lipoabdominoplasty
Popularized by Saldanha, this abdominoplasty technique substitutes liposuction of the abdominal skin
flap in lieu of wide lateral undermining in an effort to preserve perforating vessels and thus the blood
supply to the skin. 37 Undermining of the skin flap is limited to the area that will be plicated, and the
liposuction with a superwet technique is performed in the areas lateral to the rectus. 38 Liposuctioning of
the undermined regions of the flap could result in skin flap necrosis and must be avoided or performed
with extreme caution.
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Postoperative Care
At the conclusion of the abdominoplasty procedure, the patient will be flexed at the waist. To minimize
tension at the closure, the patient should be transferred to a stretcher/bed that is likewise flexed at the
waist with the knees elevated (beach-chair position). Most would recommend that the patient maintain a
semiflexed position at the waist, even when ambulating, for several weeks duration to minimize tension
at the closure. If drains are utilized, the patient and/or a caregiver must be educated on proper drain care.
39 A compression garment is worn by the patient for several weeks duration. The patient should avoid
heavy lifting and vigorous activity for up to 6 weeks postoperatively.
As described previously, abdominoplasty carries an increased risk of VTE, and thus patients should be
encouraged to ambulate early. Low molecular weight heparin or other anticoagulant should be given to
those patients deemed to be at higher risk when performing risk stratification. 31
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Scar Management
Scars, especially those that are widened or hypertrophic, can be troublesome to patients. Intraoperatively,
wound eversion and minimization of excess tension have been proven to improve scar appearance. In
addition, the use of dermal sutures with a self-adherent mesh and octyl-2-cyanoacrylate (PRINEO,
Ethicon, Raleigh, NC) has been shown to provide equivalent scar results as dermal sutures, and a
subcuticular stitch and is more than four times faster to perform. 40 In the presence of hypertrophic scars,
there is evidence that the use of pressure garments, scar massage, and pulsed-dye lasers can improve the
appearance. 41
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Complications
The surgeon’s efforts both preoperatively and intraoperatively should be focused on mitigating any
potential complications through careful preparation and technique.
Complications of abdominoplasty, however, do occur but are usually minor and may include small areas
of wound healing problems, poor scars, and lateral dog-ears. Small areas of wound dehiscence, suture
abscess, etc. can frequently be treated with local wound care. Those with widened scars or dog-ears can
be treated with minor revisional procedures, usually performed in an office setting several months later.
More significant complications can include persistent seroma, areas of flap ischemia, and larger areas of
wound dehiscence. Seroma is a common problem with abdominoplasty because of the larger area that is
usually undermined. As described previously, the use of progressive tension sutures or quilting sutures
has been shown to reduce dead space and in turn lessen the frequency of seroma formation. 32,33 The use of
drains and compression garments may also reduce the incidence of seroma. 42 Should the patient develop
a seroma, it can frequently be aspirated in an office setting using sterile technique so as not to introduce
an infectious nidus to the seroma. Larger areas of wound dehiscence can be allowed to heal via secondary
intention and be revised at a later date, or a delayed primary closure may be an option. Vascular
compromise of the abdominal skin flap can usually be avoided by minimizing large area of undermining.
If necrosis does occur, the wound is treated conservatively and allowed to heal by secondary intention
with revision at a later date.
The most worrisome complications are those that could prove life-threatening or severely compromise
the final aesthetic results. These include VTE and PE, large hematomas, infection, and large areas of flap
necrosis. As described previously, abdominoplasty carries with it a relatively high risk of VTE thought to
be attributable to the tightening of the abdominal wall, which may increase intra-abdominal pressure.
Therefore, all patients should undergo a thorough risk assessment, and mechanical and
chemoprophylaxis should be utilized. 31 Patients with any symptoms related VTE or PE such as extremity
pain and swelling or shortness of breath should be worked up immediately. Large hematomas should be
treated via surgical drainage and meticulous hemostasis. Infection is not a frequent abdominoplasty
complication. Areas of cellulitis can be treated expectantly with oral antibiotics. More concerning
infections may warrant surgical exploration. Larger areas of skin necrosis should be treated with local
wound care and subsequent debridements.
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Conclusion
Abdominoplasty is a powerful body contouring technique and requires understanding of the relevant
anatomy. A thorough physical examination helps the practitioner tailor the procedure to meet patient’s
specific needs. Complications can occur with any surgical procedure. Fortunately, with good patient and
procedure selection and meticulous planning and surgical technique many potential complications can be
avoided.
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Belt Lipectomy
Body contouring procedures address the soft tissue redundancy after weight loss. The popularity of these
procedures has increased in conjunction with the number of patients undergoing weight loss procedures.
In patients with generalized laxity of the truncal tissues, belt lipectomy is a high yield surgery because it
is a circumferential procedure that addressed multiple anatomic areas including the abdomen, back,
flanks, and thighs.
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Pertinent Anatomy
The surgeon should be familiar with the anatomy of the abdomen (see Abdominoplasty section) and
regional blood supply when performing body contouring of the trunk. Zones of fascial adherence are five
fixed points that serve as important anatomical landmarks (see T 1). Commonly, in the weight loss
patient, zones of adherence as well as a midabdominal fascial thickening are preserved.
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Patient Selection and Evaluation
A full history and physical should be performed on all body contouring patients. The medical interview
should include questions about the patient’s motivation for surgery and their expectations to identify
those who may have body dysmorphic disorder. Other questions include the method of weight loss (i.e.,
diet and exercise vs. a weight loss surgery). The specific type of weight loss surgery (restrictive vs.
malabsorptive) should also be obtained as those with malabsorptive surgeries have specific nutritional
needs (see Chapter 63). Weight loss before surgery should be stable for a minimum of 3 months prior to
surgical interventions. 43 The patient should be questioned about VTE risk factors so that they can be
properly risk stratified, and appropriate mechanical and chemoprophylaxis can be anticipated. 31 Many
times, weight loss or bariatric patients have a history of several medical comorbidities. All these should
be assessed and specialists should be engaged when appropriate to assess surgical risk and assist with
medical optimization.
On examination, the skin should be examined for rash, intertrigo, previous incisions, and striae. The
thickness and distribution of excess skin and subcutaneous tissue should be evaluated. The abdomen
should be examined for the presence of hernias. A CT scan can be ordered if needed. There are a variety
of names to describe body contouring procedures. As described by Aly, the belt lipectomy addresses the
lower truncal area by removing a wedge of tissue to improve the abdominal contour and create definition
between the lumbar area and the buttock. 44 However, with this procedure, the fascial zones of the trunk
and lower extremity are not markedly disrupted. This limits the ability of this procedure to substantially
address the thighs, and patients with concerns in this area may be better served with a lower body lift
(see Chapter 65). 45 The goals of the belt lipectomy are to eliminate the ptotic panniculus to define the
waist, eliminate lower back rolls, and elevate the lateral thighs and mons pubis. Proper patient selection
is the most important preventative measure available to the surgeon to mitigate the risk of postoperative
complications in the body contouring patient; thus a thorough preoperative assessment is crucial.
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Marking, Positioning, and Safety
The patient is marked in the standing position. Anatomic landmarks including the anterior and posterior
midlines, the suprapubic crease, and the iliac crests are marked. Based on pinch test and anatomic
landmarks, the upper and lower incisions are all marked with the anterior superior marking being similar
to that for an abdominoplasty and the midline posterior having the narrowest resection width. The
posterior markings should be based on pinch test both in the erect and flexed at the waist positions to
ensure the area is not overresected. The proposed line of closure is then marked by ensuring that it is at or
above the ASIS so the scar can be hidden with undergarments (Figure 64.4). Vertical hash marks through
the horizontal markings will assist with realigning the tissues after tissue excision. The markings will be
cursory as intraoperative adjustments may need to be made.
FIGURE 64.4 A. Anterior view of the markings for a belt lipectomy. The red line marks the inferior incision. The black mark
indicates the proposed superior incision. The green dashed line is a visual indicator of the eventual scar location. B. Lateral
view of the marking for a belt lipectomy. Black line marks the upper incision, red indicates the inferior incision, and the green is
to visually indicate the eventual scar location.
Based on surgeon preference, patients undergoing belt lipectomy will be repositioned a minimum of
twice. Because of intraoperative positioning changes, padding of extremities to prevent neurapraxias is of
utmost importance. The operative table should be tested to ensure it is in good working order and the
operative team should be well versed in optimizing patient safety through use of padding, positioning,
warming, and VTE prevention techniques. 46
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Technique
The surgeon should have well-laid plans for their operative approach to minimize operative time. The
patient position changes (supine to prone or lateral-lateral-supine) should be anticipated and
communicated with the operative team who should be sufficiently equipped to facilitate safe patient
turns. Starting in the supine position, the trunk is widely prepped and draped. The umbilicus is incised
and freed from the abdominal tissues and the lower abdominal incision is made. The dissection is carried
up to the xiphoid similar to that with abdominoplasty with the exception that the lateral area is
undermined to a greater degree. Any rectus diastasis is repaired and the abdominal flap is redraped.
Progressive tension sutures can be used if desired and/or closed suction drains are placed. The new
umbilical location is anatomically determined and the umbilicus is delivered and sutured into place. The
anterior abdomen is sutured closed in the standard fashion working some of the excess abdominal tissues
laterally. These lateral dog-ears are stapled closed provisionally and the patient is repositioned into the
prone or lateral position and appropriately positioned, padded, prepped, and redraped. The posterior
incisions are made based on tailor-tacking and a cut as you go technique, if that is the surgeon preference
to prevent overresection. The dissection is carried down to the musculofascia. Little to no undermining of
the superior or inferior skin flaps is performed. To optimize the superior excursion of the lateral thigh
and minimize contour irregularities, this area is liposuctioned in a discontinuous manner to partially
disrupt the pelvic rim zone of adherence. The lateral areas and the posterior resection areas are closed
over drains. The patient is then repositioned from the prone or lateral position back to the supine beach
chair position for extubation and application of compression garments.
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Complications
With a proper preoperative assessment and close attention to detail in the operative room, efforts can be
made to reduce complications by selecting appropriate patients, avoiding hypothermia, correct
positioning, and appropriate VTE prophylaxis. 47-49 In addition, controlling for overresection can
minimize tension and wound dehiscence. This is performed by committing to only one incision and the
undermining the skin resection estimated by pinch test. Prior to making the resection incision, the skin
flap is transposed under the first incision to estimate the safe amount of tissue resection.
Despite the surgeon’s best efforts, complications can occur. 49 The outcome can still be controlled with
early recognition and prompt steps to remedy concerns. Superficial wound healing problems and minor
wound dehiscence are the most common complications that occur with circumferential body contouring
procedures such as the belt lipectomy because of the competing tensions of the anterior and posterior
incisions. These can almost universally be treated with attentive local wound care. Seromas can also be a
troublesome postsurgical complication. Seroma formation can be minimized by only undermining the
tissues to the degree necessary for excision and closure. Other measures such as sharp dissection, closed
suction drains, and quilting or progressive tension sutures are also proven to reduce seroma rates. 42 If a
seroma does occur, it can commonly be treated with serial aspirations in the office of placement of a
seroma catheter. Untreated seromas can lead to infections, so these should be treated aggressively.
Because of the large tissue surface area, bleeding and hematomas can be a potential complication. Large
hematomas should be evacuated. Small hematomas that are not expanding and well drained can be
treated expectantly. Skin flap necrosis can also occur in the belt lipectomy patient and this is usually due
to excessive tension, previous incisions that compromise regional blood flow, and aggressive liposuction.
If this occurs, the area is treated with local wound care and allowed to heal secondarily. A revisional
procedure can be performed at a later date. The complication with the most potential for mortality is VTE.
Procedures that tighten the abdominal wall, such as recuts plication, are theorized to increase intra-
abdominal pressure, which affects the compression susceptible venous system. Risk stratification and
assertive use of mechanical and chemoprophylaxis is critical. 9,31 Patients should be counseled on the signs
and symptoms of VTE so that they can obtain prompt evaluation should they experience these.
Belt lipectomy is a circumferential procedure performed following massive weight loss that improves the
abdominal contour and laxity, back rolls and buttock, and lateral thigh ptosis. Proper patient selection
and optimization is essential to maximize outcomes and prevent complications.
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Questions
1. Several weeks following an abdominoplasty, your patient presents for follow-up and informs you
that she was recently evaluated by her primary care physician because of complaints of outer thigh
discomfort. She was diagnosed with meralgia paresthetica. Which structure was likely injured
during her procedure?
a. Iliohypogastric nerve
b. Ilioinguinal ligament
c. Genitofemoral nerve
d. Lateral femoral cutaneous nerve
e. Pectineus muscle
2. Following large-volume flank and abdominal liposuction, your patient is taken to the recovery
room. While the patient is being transferred to the overnight observation unit, they begin to
complain of perioral numbness, develop hypotension, and start seizing. What medication should be
administered?
a. Phenobarbital
b. Dantrolene
c. Lipid emulsion
d. Phentolamine
e. Epinephrine
3. You are performing large-volume liposuction at a local hospital. Which of the following is not an
endpoint for liposuction aspiration?
a. Pinch test
b. Skin laxity
c. Aspirate volume
d. Skin turgor
e. Length of operative time
4. When assessing a patient during consultation for an abdominoplasty, what is the clinical
significance of a positive diver’s test?
a. The patient has an incisional hernia.
b. The patient has excess lower abdominal fat.
c. The patient has excess lower abdominal skin.
d. The patient has myofascial laxity.
e. The patient has a diastasis rectus.
5. Which of the following is true regarding belt lipectomy?
a. The postoperative scar is at the same level as with a lower body lift.
b. All zones of adherence are left intact.
c. More than one patient position on the operative table is necessary.
d. The superficial fascial system is not approximated at closure.
e. Belt lipectomy has minimal effect on the waist contour.
1. Answer: d. The lateral femoral cutaneous nerve is the most frequently injured nerve during
abdominoplasty. Injury to this nerve causes meralgia paresthetica, which is characterized by
anterolateral thigh burning, tingling, and numbness. It emerges close to the ASIS, and keeping some
fat overlying the musculofascia in this area may prevent nerve injury. The iliohypogastric nerve
innervates the suprapubic region. The genitofemoral nerve courses deep into the abdominal wall and
originates from L1 to L2. The ilioinguinal ligament is a band that originates from the ASIS and inserts
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on the pubic tubercle. It is formed by the external oblique aponeurosis and is continuous with the
fascia lata of the thigh. The pectineus muscle is a flat, quadrangular muscle on the anteromedial
thigh.
2. Answer: c. This patient is suffering from lidocaine toxicity or LAST (local anesthetic systemic
toxicity). With large-volume aspirates, lidocaine dosage must be carefully calculated and kept below
35 mg/kg. Lidocaine toxicity is best treated with 20% lipid emulsion. The current agreed hypothesis
for intravenous lipid emulsion efficacy in treating cardiotoxicity and the effects of lidocaine toxicity
is the formation of a lipid sink, that is, an expanded intravascular lipid phase that acts to absorb the
offending circulating lipophilic lidocaine toxin, hence reducing the unbound free toxin available to
bind to the myocardium. LAST treatment consists of the following steps:
Infuse 20% lipid emulsion. (Upper limit is approximately 10–12 mL/kg over the first 30 minutes.)
Bolus at 1.5 mL/kg (lean body mass) intravenously over 1 minute.
Provide continuous infusion at 0.25 mL/kg per minute.
For persistent cardiovascular collapse, repeat bolus up to two times.
Double the infusion to 0.5 mL/kg per minute, if remains hypotensive.
Continue infusion for at least 10 minutes after circulatory stability is achieved.
Phenobarbital is a barbiturate that acts as a nonselective central nervous system depressant and that
is used primarily as a sedative hypnotic and also as an anticonvulsant in certain populations. It is not
used for adult status epilepticus. Dantrolene is a postsynaptic muscle relaxant that lessens excitation-
contraction coupling in muscle cells. It acts by inhibiting Ca2+ ions release from sarcoplasmic
reticulum stores by antagonizing ryanodine receptors. It is the primary drug used for the treatment
and prevention of malignant hyperthermia, a rare, life-threatening disorder triggered by general
anesthesia. Phentolamine is an alpha-1 agonist and results in vasodilation. It can be used to reverse
the effects of local anesthetics containing epinephrine. Epinephrine is a direct-acting
sympathomimetic drug that acts as an agonist at alpha- and beta-adrenergic receptors. It produces
vasoconstriction to counteract the vasodilation and resulting hypotension associated with
anaphylaxis and other conditions.
3. Answer: a. When performing liposuction, endpoints include contour, pinch test (pinching the
operative area between the thumb and index finger to assure evenness of liposuction), and bloody
aspirate. The tone of the skin does not dictate an endpoint for liposuction. Skin turgor and the
fountain sign (escape of wetting solution when the infiltration cannula is withdrawn) are endpoints
for infiltration of wetting solution. The practice advisory on liposuction released by the ASPS
acknowledges that there are no scientific data available to support a specific volume maximum at
which point liposuction is no longer safe; with that said, it is important for the surgeon and patient to
know that the risk of complications is unavoidably higher as the volume of aspirate and the number
of anatomic sites treated increase. Assuming that the patient is tolerating anesthesia and the
procedure well, operative length is not an endpoint for liposuction, but should be kept to a
reasonable minimum. Close attention to prevent hypothermia, to position and pad the patient
appropriately, and to use appropriate deep vein thrombosis prophylaxis will minimize adverse
outcomes from a prolonged procedure.
4. Answer: d. To perform a diver’s test, the patient flexes at the waist from a standing position.
Presence of a lower abdominal protuberance with flexion that is not present in the erect position
indicates laxity of the myofascial system that is most commonly a result of pregnancy. Myofascial
laxity can be improved with plication of the rectus muscles.
5. Answer: b. The resultant scar from a belt lipectomy is generally located more superior than that of
a lower body lift. With the wedge of tissue being removed located more superior encompassing the
abdomen, flanks, and lower back, there is a greater effect on the waist contour. Because of the
circumferential nature of the procedure, a minimum of two position changes is necessary during the
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surgery in order to adequately address the abdomen, back, and lateral flank/thigh area. To obtain
maximal lift from the belt lipectomy, the zones of adherence of the lateral thighs are discontinuously
disrupted with liposuction.
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References
Illouz, YG. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg. 1983;72:591.Illouz’s technique of using a
wetting solution, blunt cannulas, and negative pressure aspiration improved the safety of lipolysis and is the foundation of how liposuction is performed
today. Illouz also recognized over the course of his experience represented in this paper that deeper liposuction tunnels allowed for a smoother contour
and less skin excess.
Broughton, G, Crosby, MA, Coleman, J, Rohrich, RJ. Use of herbal supplements and vitamins in plastic surgery: a practical review. Plast
Reconstr Surg. 2007;119(3):48e.
Harrison, B, Khans, I, Janis, JE. Evidence-based strategies to reduce postoperative complications in plastic surgery. Plast Reconstr Surg.
2016;138:51S.
Rinker, B. The evils of nicotine: an evidence-based guide to smoking and plastic surgery. Ann Plast Surg. 2013;70:599.
Chia, CT, Neinstein, RM, Theodorou, SJ. Evidence-based medicine: liposuction. Plast Reconstr Surg. 2017;139(1):267e.
Markman, B, Barton, FE. Anatomy of the subcutaneous tissue of the trunk and lower extremity. Plast Reconstr Surg. 1987:80:248.
Lockwood, TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991;87:1009.
Haeck, PC, Swanson, JA, Gutowski, KA, et al. Evidence-based patient safety advisory: liposuction. Plast Reconstr Surg. 2009;124(suppl 4):28S.
Murphy, RX, Alderman, A, Gutowski, KA, et al. Evidence-based practices for thromboembolism prevention: summary of the ASPS Venous
Thromboembolism Task Force Report. Plast Reconstr Surg. 2012;130(1):168e-175e.
Klein, JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg. 1987;4:263.
Rohrich, RJ, Kenkel, JM, Janis, JE, et al. An update on the role of subcutaneous tissue infiltration in suction-assisted lipoplasty. Plast Reconstr
Surg. 2003;111:926.
Gutowski, KA. Tumescent analgesia in plastic surgery. Plast Reconstr Surg. 2014;134(4 suppl 2):50S-57S.
Klein, JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol.
1990;16:248.
Swanson, E. Prospective study of lidocaine, bupivacaine and epinephrine and blood loss in patients undergoing liposuction and
abdominoplasty. Plast Reconstr Surg. 2012;130:702.
Rohrich, RJ, Leedy, JE, Swamy, R, et al. Fluid resuscitation in liposuction: a retrospective review of 89 consecutive patients. Plast Reconstr
Surg. 2006;117:431.
Kenkel, JM, Robinson, J, Beran, SJ, et al. The tissue effects of ultrasound assisted lipoplasty. Plast Reconstr Surg. 1998;102:213.
Zocchi, ML. Ultrasonic assisted liposuction: technical refinements and clinical evaluations. Clin Plast Surg. 1996;23;575.
Prado, A, Andrades, P, Danilla, S, et al. A prospective, randomized, double-blinded, control clinical trila comparing laser-assisted lipoplasty
with suction assisted lipoplasty. Plast Reconstr Surg. 2006;118:1032.
Ingargiola, MJ, Motakef, S, Chung, MT, et al. Cryolipolysis for fat reduction and body contouring: safety and efficacy of current treatment
paradigms. Plast Reconstr Surg. 2015;136(6):1581.
Derrick, CO, Shridharani, SM, Broyles, JM. The safety and efficacy of cryolypolysis: a systematic review of available literature. Aesthet Surg J.
2015;35:83.
Stroumza, N, Gauhier, N, Senet, P, et al. Paradoxical adipose hyperplasia (PAH) after cryolipolysis. Aesthet Surg J. 2018;38(4):411.
Wall, SH Jr, Lee, MR. Separation, aspiration, and fat equalization: SAFE liposuction concepts for comprehensive body contouring. Plast
Reconstr Surg. 2016;138(6):1192.This article proposes a comprehensive multistep process toward body contouring aimed at reducing complications and
fulfilling aesthetic ideals. Wall and Lee describe detailed steps of the process and a retrospective 5-year review of their liposuction results on 129
patients.
Del Vecchio, D, Wall, S Jr. Expansion vibration lipofilling: a new technique in large-volume fat transplantation. Plast Reconstr Surg.
2018;141(5):639.
Horton, BJ, Reece, EM, Boughton, G, et al. Patient safety in the office based setting. Plast Reconst Surg. 2006;117(4):61e.
Appelt, EA, Janis, JE, Rohrich, RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006;118(1):237.
Steinbrech, DS, Sinno, S. Utilizing the power of fat grafting to obtain a naturally-appearing muscular “6-pack” abdomen. Aesthet Surg J.
2016;36(9):1085.
Weinberg, GL. Lipid emulsion infusion: resuscitation for local anesthetic and other drug overdose. Anesthesiology. 2012;117:180.
Huger, WE Jr. The anatomic rationale for abdominal lipectomy. Am Surg. 1979;45:612.This anatomic study introduced a simple and reliable
regional vascular map of the abdomen. The map is divided into three zones based on regional anatomy. Lipectomy or abdominoplasty alters the normal
anatomic blood supply to the superficial abdominal wall. These postsurgical anatomic changes explain tissue survival following the surgery.
Buck, DW II, Mustoe, TA. An evidence-based approach to abdominoplasties. Plast Reconstr Surg. 2010;126:2189.
Gutowski, KA. Evidence-based medicine: abdominoplasty. Plast Reconstr Surg. 2018;141:286e.
Pannucci, CJ. Evidence-based recipes for venous thromboembolism: a practical safety guide. Plast Reconstr Surg. 2017;139:520e.
Pollock, H, Pollock, T. Progressive tension sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg.
2000;105:258.
Macias, LH, Kwon, E, Gould, DJ, et al. Decrease in seroma rate after adopting progressive tension sutures without drains: a single surgery
center experience of 451 abdominoplasties over 7 years. Aesthet Surg J. 2016;36:1029.
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Lockwood, T. High-lateral tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96:603.In this article,
Lockwood introduces his belief that the circumferential trunk is a subunit and provides evidence against two commonly held abdominoplasty principles
of that time. Firstly, he challenged the principle that wide undermining of the abdominal flap to the costal margin was necessary by achieving excellent
results with widespread liposuction and less flap undermining. Secondly, Lockwood drew attention to the previously neglected lateral abdominal wall
tissues and resected excess tissue in this area transferring the tension of closure to the superficial fascial system.
Friedman, T, O’Brien Coon, D, Michaels, J, et al. Fleur-de-lis abdominoplasty: a safe alternative to traditional abdominoplasty for the massive
weight loss patient. Plast Reconstr Surg. 2010;125:1535.
Dellon, AL. Fleur-de-lis abdominoplasty. Aesthet Plast Surg. 1985;9:27.This is the first description of this technique. The author emphasizes the
advantages of using both a horizontal and a vertical resection in order to restore a favorable contour to the abdomen.
Saldanha, OR, Federisco, R, Daher, PF, et al. Lipoabdominoplasty. Plast Reconstr Surg. 2009;124(3):934.
Matarasso, A. Liposuction as an adjunct to a full abdominoplasty. Plast Reconstr Surg. 1995;92:1112.
Khansa, I, Khansa, L, Meyerson, J, Janis, JE. Optimal use of surgical drains: evidence-based strategies. Plast Reconstr Surg. 2018;141(6):1542-
1549.
Richter, D, Stroff, A, Ramakrishnan, V, et al. A comparison of a new skin closure device and intradermal sutures in the closure of full-
thickness surgical incisions. Plast Reconstr Surg. 2012:130(4):843.
Khansa, I, Harrison, B, Janis, JE. Evidence-based scar management: how to improve results with technique and technology. Plast Reconstr
Surg. 2016;138(3):165S.
Janis, JE, Khansa, I, Khansa, L. Strategies for postoperative seroma prevention: a systematic review. Plast Reconst Surg. 2016;138(1):240.
Rubin, JP, Nguyen, V, Schwentker, A. Perioperative management of the post-gastric-bypass patient presenting for body contouring. Clin
Plast Surg. 2004;31:601.
Aly, AS, Cram, AE, Chao, M, et al. Belt lipectomy for circumferential truncal excess: the University of Iowa experience. Plast Reconstr Surg.
2003;111:398.
Lockwood, TE. Lower body lift. Aesthet Surg. 2001;21:355.
Colwell, AS, Borud, LJ. Optimization of patient safety in post-bariatric body contouring: a current review. Aesthet Surg J. 2008;28;437.
Almutairi, K, Gusenoff, JA, Rubin, JP. Body contouring. Plast Reconstr Surg. 2016;137:586e.
Hunstad, JP. Body contouring in the obese patient. Clin Plast Surg. 1996;23:647.
Fischer, JP, Wes, AM, Serletti, JM, Kovach, SJ. Complications in body contouring procedures: an analysis of 1797 patients from the 2005-2010
American College of Surgeons National Surgical Quality Improvement Program database. Plast Reconstr Surg. 2013;132(6):1411-1420.
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C H A P T E R 6 5
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Lower Body Lift and Thighplasty
Omar E. Beidas and J. Peter Rubin
Key Points
The lower body lift is a powerful procedure that reshapes the hips, buttocks, and lateral thighs.
Because the lower body lift does not address the medial thighs, a medial thighplasty is required to
treat the thigh deformity.
Together, these two operations contour the lower trunk and thigh in a single stage or in separate
stages.
The massive weight loss (MWL) patient is left with deformities of varying degrees, with somewhat
predictable patterns of excess skin and fat. The lower trunk and thighs can be dramatically improved by
combining a lower body lift (LBL) and thighplasty. Although many variations of each of these procedures
have been described in the literature, key principles are applied according to each patient’s anatomy and
preferences. Importantly, patients must be accepting of long scars in exchange for improved contour,
especially for the medial thighs where a vertical scar is necessary to correct the circumferential excess of
skin. 1,2
Not every patient presenting after MWL needs an excisional procedure; each patient is assessed
individually and an operative plan is created based on the nature of the deformity and the patient’s goals.
Moreover, patients who have plateaued at a high BMI or require optimization of medical comorbidities
may not be ready for major elective surgery. The Pittsburgh Rating Scale 3 is a useful tool to grade a
patient’s deformities and can assist the surgeon with operative planning. Patients with low-grade
deformities have excess adipose tissue with adequate skin tone and may be treated with liposuction
alone. Patients with high-grade deformities require skin and subcutaneous tissue resection with or
without liposuction.
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Approaches to Thigh and Buttock Contouring
The LBL was introduced over 25 years ago to treat the ptotic, wrinkled skin and subcutaneous tissue of
the abdomen, hips, back, and buttocks. 4 With the understanding of the relevant vectors, Lockwood
combined procedures that were typically carried out in multiple stages into a single stage. He introduced
the concept of suspending the superficial fascia system (SFS) 5 to anchor the incision and achieve a
circumferential correction of the lower trunk. Lockwood referred to this initial technique as the lower
body lift #1 (LBL #1)—a combination of abdominoplasty and medial thighplasty—and later developed
the lower body lift #2 (LBL #2)—a combination of high-lateral-
 tension abdominoplasty, lateral thigh lift,
and buttock lift. LBL #1 is best suited for patients with minimal abdominal laxity and is infrequently
applied to the MWL population as many require a significant abdominal resection. However, the LBL #1
may be useful for patients who had a prior abdominoplasty. The LBL #2 is applied for patients with
abdominal skin laxity, and this circumferential approach is the most common and familiar variant in
current practice. Both variants exert a significant upward lifting effect on the lateral thighs. The actual
vector, though primarily vertical, also causes a mild lateral and vertical rotation (outward spiral motion)
of the medial thigh tissues. The correction of medial thigh skin laxity from an LBL is small in magnitude,
and patients with significant laxity of the medial thigh skin will require a medial thighplasty procedure.
The medial thigh lift was introduced in 1957, 6 but not widely adopted; over 20 years elapsed before
another specific article about thigh lift was described. 7 Complications associated with the original
description included vulvar distortion due to scar migration and early recurrence of ptosis. It was not
until Lockwood wrote about anchoring the SFS of the thigh to Colles fascia that thighplasty gained
popularity. 8
Thighplasty requires resection of skin and subcutaneous tissue in a longitudinal, transverse, or combined
axis. Various incision patterns are described, including a longitudinal medial incision, a longitudinal
lateral incision, or a transverse incision in or near the groin crease. 9–11 The transverse thigh lift is also
known as a proximal thigh lift, generally reserved for patients with minor deformities. 12 The transverse
thigh lift is not the procedure of choice in MWL patients because it can only treat the proximal third of the
thigh deformity. It is important to recognize that transverse-only excisions have low power to correct
thigh deformities and the force of pull is not transmitted past the proximal third of the thigh. Overly
aggressive transverse resection in an attempt to obtain a greater correction of skin laxity can result in
labial spreading. The medial vertical thigh lift is better suited for the MWL patient whose excess tissue
can be treated along the entire length of the thigh. Lateral vertical thigh excisions are rarely used, but
have a role in cases of severe deformities in which both medial and lateral excisions may be of benefit.
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Lower Body Lift
Multiple variations of the LBL exist based on the patient’s deformity and desired outcome. An LBL
generally needs a more inferior resection, and a belt lipectomy resection is located more superiorly, at the
level of the waistline. A belt lipectomy (Chapter 63) tends to emphasize waist shape, directly excising
central adiposity of the flanks, and is therefore well suited for the typical android body fat distribution.
The more inferior resection pattern of an LBL enables more control of lateral thigh and buttock shape and
is better for patients with a gynecoid body type whose excess adiposity is in the hips and thighs.
Although the higher incisions of a belt lipectomy give the surgeon better control over the contour of the
waist and flank, the lower incisions of the LBL exert a more powerful and direct lifting effect of the lateral
thighs for gluteal autoaugmentation with autologous flaps. The more caudal the incision, the more
buttock autoaugmentation tissue can be incorporated into the dermoglandular flap. Matching the variant
of the procedure to individual body types is the key to optimizing outcomes.
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Patient Evaluation
Patients almost never present requesting an LBL. Generally, they highlight their dissatisfaction with the
appearance of their abdomen, lateral thighs, and/or buttocks. Many do not realize the LBL is an option
until brought up by the surgeon. The first determination that must be made is the lower truncal
procedure that will best address the patient’s deformities and meet their goals; both anterior and
posterior deformities must be considered. Candidates for LBL are those with circumferential skin laxity
when an anterior approach alone will not treat the 360° nature of the deformity.
The anterior assessment requires a thorough physical examination of the abdomen. The surgeon must
evaluate the patient’s skin quality, excess skin, subcutaneous versus intraabdominal fat distribution,
rectus diastasis, hernias, and existing scars. It is vital to pay attention to the location of previous scars
when deciding on any areas that may need liposuction or undermining. Patients who have undergone
adjustable gastric banding surgery will have a subcutaneous port along the abdominal wall; it is
important to note its location as it may be encountered intraoperatively. Posteriorly, the physical
examination focuses on the lower back and buttocks. MWL patients have a characteristic appearance of
the buttocks, with loss of adiposity, decreased projection, and ptosis, in addition to lengthening of the
infragluteal fold.
Depending on patient and surgical factors, patients may need clearance from other medical specialists.
Although these issues are covered in both Chapters 16 and 63, they are worth repeating as MWL patients
and body contouring procedures are independent risk factors for complications. 13–15 Please refer to the
two chapters referenced above for appropriate venous thromboembolism prophylaxis, pre- and
postoperative antibiotic dosing, intraoperative positioning, maintenance of body temperature, and fluid
balance. Figures 65.1 and 65.2 depict a patient of each gender who underwent LBL.
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FIGURE 65.1 A–C. This 35-year-old woman lost 150 lb after gastric bypass surgery and desired body contouring of multiple
areas. She underwent a staged approach with lower body lift and brachioplasty followed 3 months later by dermal suspension
parenchymal reshaping mastopexy and thighplasty. D–F. Three months postoperative photographs show the first stage of her
lower body lift.
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FIGURE 65.2 A–C. A 48-year-old male fitness trainer who lost 100 lb through diet and exercise and desired abdominal
contouring. D–F. One year after lower body lift.
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Surgical Technique
Markings
Markings begin posteriorly by identifying the midline. The patient and surgeon together decide on the
optimal scar placement that is in an acceptable location to the patient to address their chief complaint.
The superior line—the stable anchor posteriorly—is marked. Vertical lines are drawn at consistent
intervals to align the superior and inferior lines. Next, the width of resection is estimated by means of
pulling the caudal tissue in a cephalad direction until the skin is taut in appearance. This marks the
inferior line of resection. The posterior resection has the appearance of a bow tie, tapered centrally given
the strong zone of adherence and flaring laterally where tissue is more lax. To preserve the sacral dimple,
the scar should come together in a “V” at the midline. Maximum buttock projection is most aesthetic
when located at the transposed horizontal level of the pubic symphysis; therefore, surgical planning
should take this into account. If gluteal autoaugmentation is planned, the resection width is adjusted to
accommodate the anticipated additional volume. Male and female markings sometimes differ based on
the area to be resected, as shown in Figure 65.3.
FIGURE 65.3 Side-by-side pictures to demonstrate the sometimes necessary difference in marking a female versus male for
lower body lift (LBL) procedure. A. The woman in Figure 65.1 marked for her LBL. B. The man in Figure 65.2 marked for his
LBL with a more cephelad pattern of resection best suited for his specific body type.
Once the posterior markings are complete, they are extended anteriorly, where the inferior line is now the
stable anchor. At the midline, the marking is made 7 cm superior to the labial commissure. The marking
is carried laterally over the thigh superior to the inguinal ligament to avoid disrupting lymphatic
drainage. The superior line anteriorly need not be drawn as it is determined intraoperatively. Areas of
liposuction are marked using different color ink.
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Intraoperative Steps
Several different techniques have been described for the LBL. At a minimum, 1 intraoperative patient
position change is required to access the torso circumferentially, whereas some prefer 2 position changes.
If the procedure is to begin in the lateral or prone position, the patient is intubated and a Foley catheter
placed while on the stretcher, then the patient is flipped onto the operating room table. The patient is
positioned appropriately, all bony prominences are padded, and the head and neck are placed in neutral
alignment. All visible lower truncal surfaces are prepped and draped in typical sterile fashion.
Alternatively, some surgeons prefer to prep the patient while standing before moving onto a sterile drape
on the operating room table.
The patient’s trunk is prepped down to the operating room table along with the thighs circumferentially.
As previously described, an additional arm board can be placed adjacent to each thigh to be able to
abduct them and decrease tension during the posterior closure. 16 A solution of 1:100,000 of epinephrine
in normal saline is injected subcutaneously along the markings. The width of resection is verified with a
single towel clamp placed across both incisions, as the LBL is one of the few procedures where the
surgeon commits to the entire width simultaneously. After waiting approximately 10 minutes, the
incision through the dermis is made. The resection is tailored to the patient, and as is often said in a
breast reduction, the tissue left behind is more important than the tissue removed. Preservation of gluteal
fat pads to ensure adequate gluteal projection is vital to avoid flattening of the buttock shape.
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Thighplasty
Both short and long scar versions of this operation exist, and the incision length is determined according
to the patient’s preference and soft tissue deformity. In the long scar version, the incision stays medial to
the patella before curving inferiorly in a lateral direction. Combined with LBL, thighplasty completely
reshapes the lower trunk and thigh circumferentially.
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Patient Evaluation
Most patients present in consultation requesting a solution to excess skin in the medial upper thigh that
causes chaffing, moisture buildup, and difficulty fitting into clothes. The thigh is assessed in a
circumferential fashion to decide on the optimal approach that will address the patient’s excess tissue and
meet their expectations. Often, vertical thigh lift is combined with liposuction of the lateral thigh and
medial knee to debulk tissue that is not treated by the excision. This is discussed with the patient at the
preoperative visit. Before and after pictures are shown in Figure 65.4.
FIGURE 65.4 Preoperative (A,B) and postoperative (C,D) thighplasty.
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Surgical Technique
Markings
The patient is marked with the patient on a bed, in the supine position, with thighs abducted in frog leg
position. The first mark is made 4 cm away from the midline at the level of the mons pubis. In the area of
the mons, the incision should stay in or near the proximal thigh crease to avoid scar migration and labial
widening. This is then extended within the groin crease to mark the natural line that exists in this region.
Next, the adductor longus is marked along its course from groin to knee. A pinch or distraction test is
used to determine the estimated width of tissue that will be removed. If significant vertical excess is
present, a horizontal incision may have to be incorporated; this is done by means of sliding tissue along
the adductor longus superiorly and marking the estimated height of resection. Hatch marks are made for
easy reapproximation, and symmetry is verified. Representative markings are shown in Figure 65.5.
FIGURE 65.5 The same patient at her second stage, with markings performed prior to vertical medial thighplasty. A. Anterior
and (B, C) oblique views of markings.
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Intraoperative Steps
The thigh is prepped circumferentially for access to all areas. This permits liposuction of the excision site
as well as other regions, if needed (see Alternate Approach: Excision-Site Liposuction section). The
procedure begins with subdermal injection of a 1:100,000 epinephrine solution. Alternatively, the
epinephrine can be injected after the patient is intubated to allow for maximum effect and minimize
wasted time once the procedure has started. After waiting an appropriate amount of time for the
epinephrine to take effect, the anterior incision is made along its length. Dissection proceeds in a plan
immediately superficial to the muscular fascia toward the posterior marking. Care must be taken during
this step to avoid injury to the saphenous vein, which courses superficially, or lymphatic structures of the
groin. The dissection must not proceed past the maximum width of resection or risk raising a flap of
tissue that will have to be sewed back down. The preoperative markings are guides and therefore the
width of resection may differ from the anticipated width. As the surgeon approaches the posterior
margin, the ability to close the elevated tissue is intermittently verified.
Once the limit of dissection is reached, the margin of resection is verified by pulling the edges together
with a pair of forceps or towel clamp. Perpendicular hash marks are then made to simplify closure, and
the posterior incision is infiltrated with epinephrine prior to completing the resection. The wound is
irrigated and hemostasis is assured. The SFS of the thigh flap is secured to the Colles fascia using 2-0
absorbable suture to prevent labial distortion. A drain is placed at the base of the wound, exiting lateral to
the mons area, and the incision is temporarily closed with staples to mitigate edema. The deep SFS layer
is closed with 2-0 absorbable suture and the deep dermis is closed with 3-0 absorbable suture. The skin is
closed with 3-0 absorbable suture in the subcuticular layer, and cyanoacrylate glue is used to seal the
incision. Lower extremities are wrapped from foot to thigh with a compression bandage.
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Alternate Approach: Excision-Site Liposuction
Resection site liposuction as described by Drs. Pascal and Louarn 17 can be applied to thighplasty with
comparable results. However, new adopters of this technique should be careful as it requires a
commitment to the estimated width of resection and therefore can lead to over-resection. Tumescent
solution is infiltrated into the excision site and this area is aggressively lipoaspirated. Alternatively,
conservative tumescent followed by liposuction can be performed in an anterior to posterior direction to
ensure that the margins of resection can be closed. As much as is feasible, liposuction access sites should
be within the safe margin of resection to avoid additional small scars.
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Postoperative Care
Patients generally spend one to two nights in the hospital, depending on the concurrent procedure
performed. All patients are encouraged to ambulate with assistance on the evening of surgery. While
hospitalized, venous thromboembolism prophylaxis is based on a patient’s 2005 Caprini score, a
validated tool for use in plastic and reconstructive surgery. 18 A Foley catheter is left in place for one
evening until the patient can ambulate and use the bathroom. Showering may begin 24 to 48 hours
postoperatively. The morning after surgery, dressings are unwrapped and surgical sites examined for
signs of bleeding before discharge from the facility. Perioperative antibiotic use and drain placement is
left to the discretion of the surgeon.
The patient is seen in clinic within 1 week of surgery for a first postoperative visit. The postoperative
dressing is removed to examine the surgical sites. If drains were placed, they are discontinued based on
output. Patients are seen weekly until all drains are removed. Compression is maintained for 6 weeks.
Patients may use the postoperative medical wrapping or transition to a store-bought compression
garment of choice. Lifting is restricted to 5 kg during this same period.
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Complications
Common complications with truncal or extremity contouring procedures are usually minor and easily
managed on an outpatient basis. Those seen most often are delayed wound healing or wound dehiscence.
Another commonly seen complication is a seroma. More serious complications that could require a return
to the operating room are hematoma, surgical site infection, and nerve injuries during extremity surgery.
Some complications may necessitate revisions, such as scar widening or hypertrophy and chronic
wounds or sinus tracts. Recurrent skin laxity is a source of dissatisfaction for the patient and is an
unpredictable complication. Systemic complications are generally more worrisome, including but not
limited to deep venous thrombosis and pulmonary embolism, which could be fatal. For management of
these postoperative problems, refer to Chapter 63.
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Summary
Careful planning is the key to successful outcomes in LBL and thigh lift in the MWL population. The
surgeon must choose the optimal procedure for the patient’s unique deformity rather than stick to one
technique and apply it to all comers. Understanding and being able to manage complications is
paramount in the care of these patients.
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Questions
1. A 56-year-old woman presents to clinic after being referred by her bariatric surgeon. She
underwent laparoscopic Roux-en-Y 2 years ago. What is the procedure that will best address the
deformity shown in Figure 65.6?
a. Abdominoplasty
b. Lateral thighplasty
c. Liposuction
d. LBL
e. Panniculectomy
2. A 28-year-old man comes to your office after 60-kg weight loss secondary to gastric bypass
surgery. He has no major comorbidities and is otherwise healthy. He has an incisional hernia from
previous abdominal surgery and is interested in panniculectomy and simultaneous hernia repair. He
asks your opinion about a concurrent hernia repair and panniculectomy. What is the appropriate
response?
a. Both procedures can be safely performed in one operative setting.
b. It is best to fix the hernia at a first stage then perform the panniculectomy at a second stage.
c. The risk of complications is less when performed together than individually.
d. The risk of complications is too high to perform both procedures simultaneously.
3. What is the best treatment option for the patient in Figure 65.7 who has lost 100 lb and presents
desiring correction of excess thigh laxity?
a. Lateral thighplasty
b. Liposuction
c. Short scar vertical thighplasty
d. Transverse thighplasty
e. Vertical thighplasty
4. Which procedure has the highest risk of recurrent skin laxity?
a. Abdominoplasty
b. Brachioplasty
c. Dermal suspension, parenchymal reshaping mastopexy
d. LBL
e. Thighplasty
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FIGURE 65.6 A. Anterior and (B) posterior view of patient in question 1.
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FIGURE 65.7 Anterior view of patient in question 3.
1. Answer: d. LBL is the only procedure among the choices that will address the lateral thigh laxity
present in the patient depicted. None of the other choices alone would address the circumferential
deformity present, which is only treated by means of an LBL.
2. Answer: a. Multiple studies have shown the safety of simultaneous panniculectomy or
abdominoplasty combined with ventral hernia repair in all patient types (including MWL patients).
19-21 As with all procedures, patient selection and optimization is key, and these operations should not
be performed on smokers or poorly controlled diabetics.
3. Answer: e. The best treatment for MWL patients for treatment of excess skin and fat of the thigh is
a medial vertical thighplasty. Contouring surgery requires a shaping of the thigh in a cylindrical
fashion, which can only be obtained via a longitudinal incision on the extremity. Lateral thighplasty
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may be performed but would place a more visible scar on the outside aspect of the thigh. Liposuction
alone would not treat the excess skin present in this patient. A short scar vertical thighplasty would
not address the full-length deformity that is present at the knee region. Finally, transverse
thighplasty is incorrect as it is a transverse incision that will inadequately treat the distal thigh and is
prone to recurrence of laxity.
4. Answer: e. Of all the procedures for massive weight loss patients, thighplasty is the one that is
most likely to result in recurrent skin laxity. Unfortunately, this is neither avoidable nor predictable
by the surgeon preoperatively.
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References
Lockwood, T. High-lateral-tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(3):603-615.
Cormenzana, P, Samprón, NM. Circumferential approach to contouring of the trunk. Aesthet Surg J. 2004;24(1):13-23.
Song, AY, Jean, RD, Hurwitz, DJ, et al. A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast
Reconstr Surg. 2005;116(5):1535-1544.A classification system designed to grade the deformities of 10 anatomical areas after massive weight loss. The
Pittsburgh Rating Scale is a validated measure of contour deformities in MWL patients.
Lockwood, T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6):1112-1122.
Lockwood, TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991;87(6):1009-1018.
Lewis, JR. The thigh lift. J Int Coll Surg. 1957;27:330-334.
Schultz, RC, Feinberg, LA. Medial thigh lift. Ann Plast Surg. 1979;2(5):404-410.
Lockwood, TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg. 1988;82(2):299-304.An important article by Ted Lockwood
describing the high-lateral tension abdominoplasty with SFS suspension. Fifty patients underwent this technique with excellent lifting of the inguinal
and anterior thigh areas.
Spirito, D. Medial thigh lift and DE.C.LI.VE. Aesthetic Plast Surg. 1998;22(4):298-300.
Le Louarn, C, Pascal, JF. The concentric medial thigh lift. Aesthetic Plast Surg. 2004;28(1):20-23.
Sozer, SO, Agullo, FJ, Palladino, H. Spiral lift: medial and lateral thigh lift with buttock lift and augmentation. Aesthetic Plast Surg.
2008;32(1):120-125.
Shermak, MA, Mallalieu, J, Chang, D. Does thighplasty for upper thigh laxity after massive weight loss require a vertical incision? Aesthet
Surg J. 2009;29(6):513-522.
Shermak, MA, Chang, DC, Heller, J. Factors impacting thromboembolism after bariatric body contouring surgery. Plast Reconstr Surg.
2007;119(5):1590-1596.
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.
Coon, D, Michaels, JV, Gusenoff, JA, et al. Hypothermia and complications in postbariatric body contouring. Plast Reconstr Surg.
2012;130(2):443-448.An article examining effects of intraoperative hypothermia in patients undergoing plastic surgery after bariatric surgery. Results
demonstrated that hypothermia is associated with an increased risk of seroma formation and bleeding requiring transfusion.
Hurwitz, DJ, Rubin, JP, Risin, M, et al. Correcting the saddlebag deformity in the massive weight loss patient. Plast Reconstr Surg.
2004;114(5):1313-1325.
Pascal, JF, Le Louarn, C. Brachioplasty. Aesthetic Plast Surg. 2005;29:423-429.
Caprini, JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon. 2005;51(2–3):70-78.A landmark article by Caprini wherein
the first VTE risk-assessment tool was introduced. This study was later validated in the plastic surgery literature by Panucci et al. and is currently the
basis for stratifying outpatient plastic surgery procedures.
Shermak, MA. Hernia repair and abdominoplasty in gastric bypass patients. Plast Reconstr Surg. 2006;117(4):1145-1150.
Moreno-Egea, A, Campillo-Soto, Á, Morales-Cuenca, G. Does abdominoplasty add morbidity to incisional hernia repair? A randomized
controlled trial. Surg Innov. 2016;23(5):474-480.
Hughes, KC, Weider, L, Fischer, J, et al. Ventral hernia repair with simultaneous panniculectomy. Am Surg. 1996;62(8):678-681.
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C H A P T E R 6 6
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Brachioplasty and Upper Trunk Contouring
Amy S. Colwell and Nicole A. Phillips
Key Points
Brachioplasty and upper trunk contouring are increasingly performed for patients with redundant
skin following massive weight loss.
The goals of surgery are to remove redundant skin and restore more normal or enhanced contour.
Patient selection centers on optimizing medical conditions and nutrition while accepting realistic
expectations of outcomes.
Brachioplasty procedures successfully remove redundant skin and fatty tissue from the upper arm.
The most common technique leaves a visible scar along the inner aspect of the arm. The patient
needs to decide if the benefits of improved contour outweigh the presence of scar.
The breast deformity is typically characterized by deflated, ptotic breasts. The surgical procedure of
choice is related to the current and desired volume of the breasts and includes breast reduction,
mastopexy, augmentation-mastopexy, and less commonly autologous augmentation using
intercostal artery perforator (ICAP) flaps.
Upper body contouring includes removal of an axillary roll and back skin to tighten the entire upper
torso. This is commonly known as a bra-line lift and may be combined with breast and arm
contouring.
Management of excess skin and fat following massive weight loss (MWL) is an area of growing interest
and consumer demand. Given the steady rise in popularity of bariatric procedures, it is not surprising
that patients are seeking out body contouring procedures at increasing rates. The American Society for
Metabolic and Bariatric Surgery reported 216,000 bariatric procedures in 2016, compared with 158,000
procedures just 5 years earlier. 1
Today’s plastic surgeon should be comfortable with the surgical approaches and perioperative care
requirements for patients requesting body contouring procedures. The focus of this chapter,
brachioplasty and upper body contouring, highlights the upward trend of patient interest in these
procedures. According to data from the American Society for Aesthetic Plastic Surgery, breast lift and
brachioplasty have shown the most dramatic increase in cosmetic procedures performed since the society
began collecting data nearly 20 years ago. More than 24,000 brachioplasty procedures were reported in
2016, representing an 879% increase since 1997. Breast lift was the fourth most commonly performed
procedure in 2016 with over 161,000 procedures performed. The popularity of this surgery has increased
712% compared with 1997 rates. 2
For patients who have successfully lost weight following bariatric surgery or through diet and exercise
routines, satisfaction with results can be severely limited by the excess skin and deflated tissue that
remains. Although the health benefits of weight loss are undisputed, the psychosocial benefits may lag
behind as patients struggle with intertriginous rashes, skin breakdown, difficulty with clothing fit, poor
self-image, and functional impairment. The goals of surgery are to restore a more normal contour,
achieving improved appearance and function; however, expectations must be frankly discussed with
patients prior to surgery, as soft tissues that have been subject to significant weight gain/loss will never
recover their pre–weight-gain elasticity and appearance. Patients must fully understand that lengthy
scars are the trade-off for improved contour, and that minor complications such as wound dehiscence
and seromas are not uncommon. Patients with unreasonable expectations or who are unwilling to accept
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these risks are not good candidates for body contouring procedures. 3
At the initial evaluation, special attention should be paid to certain elements of the patient history. The
maximum body mass index (BMI) prior to weight loss should be recorded along with the current BMI.
Higher BMI at both time points has been associated with higher complication rates after surgery. 4,5
Timing of body contouring procedures should allow at least 12 months after bariatric surgery and
6 months at a stable weight for patients to achieve metabolic and nutritional homeostasis. If patients have
experienced a plateau of weight loss at higher-than-expected BMI, or are suffering from significant
nausea, vomiting, or nutritional derangement, referral back to the bariatric surgeon for reevaluation is
recommended. 4
Patients with a history of obesity also demonstrate high rates of significant medical comorbidities
including cardiac disease, insulin resistance, and obstructive sleep apnea. Risk factors for the
aforementioned should be carefully examined, and medical management optimized prior to any planned
surgical intervention. Furthermore, if a patient is on chronic anticoagulation, a decision must be made on
the safety of being off the medication for the perioperative time period. Finally, the patient’s
psychological status and social support network should be ascertained. MWL and outcomes after body
contouring procedures can precipitate tremendous changes in self-esteem, image perception, and
interpersonal relationships. Ensuring the safety and stability of the patient from a psychological and
social perspective should not be overlooked. 4
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