by Kristen M. Rezak, MD; Michel C. Samson, MD, FRCS (C), FACS; and Martin I. Newman, MD, FACS
All from the Department of Plastic Surgery, Cleveland Clinic Florida
Body contouring procedures performed for the massive weight loss patient (MWL) have been shown to be safe and effective in treating the significant skin excess that results from the rapid and substantial weight loss following bariatric surgery. There are a host of procedures available today to manage the resultant skin redundancy, and aesthetic outcomes can be remarkable. Although techniques may differ among plastic surgeons, there seems to be a general agreement that the MWL patient benefits from a modification of the approach utilized for the traditional, non-MWL cosmetic surgery patient. Substantial progress has been made in treating the complex, multidimensional skin excess that occurs throughout the body in the MWL patient. One difference appreciated by many of those familiar with this patient population is that the skin redundancy on a MWL patient extends circumferentially in a majority of the cases. The traditional abdominoplasty was not originally designed treat this circumferential deformity sufficiently.1 In recent years, procedures were developed to manage the anterior and posterior skin excess concomitantly and effectively. There are many ways to describe these specialized techniques; however belt lipectomy and lower body lift are two of the more commonly used terms to date.2
The concept of circumferential skin removal was first described in 1940 by Somalo and modified into the belt lipectomy by Gonzalez-Ulloa in the 1960s.3 These techniques have been modified for application to the MWL patient. In practice, the terms lower body lift and belt lipectomy are used interchangeably. The lower body lift aims to treat the pannus, lateral thigh laxity, and buttock ptosis in one combined procedure. Pubic mons ptosis may also be corrected in the vertical dimension with this procedure, but the transverse skin excess of the pubis is often observed as well. Such a side-to-side deformity of the pubis may benefit from an additional procedure termed monsplasty.4 In essence, the lower body lift will lift the mons and remove the pannus with the frontal part of the procedure, raise the buttocks with the posterior portion of the procedure, and help restore an hourglass shape to the hip and flank regions.5-7
Preoperative Consultation and Patient Selection
At initial consultation with a plastic surgeon, many MWL patients often focus on their undesired pannus and request abdominoplasty. Many of these patients neglect to consider what is often observed at presentation—a skin excess that extends circumferentially around the lateral thighs to the buttock region. One option to be considered when presented with this scenario is the circumferential lower body lift. Based on the patient’s priorities, a surgical plan can then be designed with attention to the likelihood that abdominoplasty alone, a “front only” procedure, may not address the lateral and posterior defects.1, 4 Another option is to perform the anterior procedure at one stage and then perform the posterior procedure at a later stage. The two-stage approach also has the obvious disadvantage of putting the patient through two separate procedures when one would suffice. Often, the patient desires the lower body lift but cannot afford to pay for the procedure. In these cases, the patient may elect to proceed with one part, such as the abdominoplasty first, then come back at a later date and undergo the buttock lift with adequate results.6
Patient selection must be done carefully in order to reduce the risk of complications. The lower body lift is a combination of procedures and therefore a longer and more extensive procedure. A thorough medical history, including smoking status, should be obtained.4 Other factors to consider when evaluating the patient are the past surgical history and the location of existing abdominal surgical scars. It is also important to differentiate a laparoscopic gastric bypass versus a gastric banding, as the port placement in the gastric banding can often affect the surgical markings and technique of the lower body lift. A port placed in the midline can inhibit plication performed during the abdominoplasty portion and the patient must be informed that this may limit the results. Also, body mass index (BMI) is an important factor in calculating risk of morbidity in these patients and should be taken into account when planning for the lower body lift. Lower body lift should be performed with caution in patients with a BMI>32 as this places the patient at a higher risk for complications including deep vein thrombosis (DVT) and seroma.8,15-17 Aesthetic results are also inversely proportional to the BMI at the time of surgery. Patients with lower BMIs (23–27kg/m2 range) often predict a more pleasing aesthetic result.1,9
Operative Details and Postoperative Management
The lower body lift technique varies from surgeon to surgeon. The plastic surgeon relies on his or her preoperative markings to guide him or her through the most precise skin excision.5,10 The markings are performed in the standing position. Defining the final incision line is paramount in achieving an excellent result as well as obtaining high patient satisfaction. The final scar can be determined and adjusted based on the preoperative markings.
The locations of these markings differ with each surgeon but also depend on the trends in fashion as many patients are requesting that the scars be lower on the hips due to the popularity of low-cut jeans and pants. The final incision can be determined by using the standard pinch method—pinching the loose skin in between the thumb and fingers to determine the greatest amount of skin that can be resected.2 The posterior markings are made to place the final incision along the upper margin of the gluteal aesthetic unit. This is carried around to the front using the pinch method to determine the lateral skin markings. The abdominoplasty portion is marked by placing the lower marking along the top of the mons and extending the lines just below the superior iliac crests. The top lines are drawn using the pinch method and marked accordingly.1 The patient’s prior scars and port sites must be reexamined during this stage of the operation and the markings can be adjusted if needed.
The main components of the lower body lift include positioning the patient prone to perform the buttock lift and then supine to perform the abdominoplasty. Variations arise in positioning for the outer thigh lift. This is usually done in a prone/supine position or lateral-lateral-supine position depending on the preference of the surgeon. One of the key factors in positioning the patient is to achieve the most comfortable operative position for the surgeon while allowing the least amount of tension on the incision line. Flexing the operating room (OR) table during the abdominoplasty portion when the patient is supine or bending the legs when the patient is in the lateral decubitus position for the buttock lift can allow for the right amount of skin tension when closing the incisions.2 The degree of assistance and surgical experience determines how much can be done in one setting. With a two-teamed approach, large, combined cases can be done safely in one setting.4
Variations in the buttock lift portion of the lower body lift include the standard skin removal without undermining to the use of autologous flaps. Determining what is the best choice depends on the patient’s body habitus and the degree of weight loss. The standard skin removal without augmentation can be performed with excellent results in a great majority of patients. This involves removing only the previously marked-out skin paddle along the superior portion of the buttock and closing the incision, allowing for correction of the gluteal ptosis.12,13
However, a high proportion of MWL patients have not only gluteal ptosis, but also excessive flattening of the buttocks. Again, this is not something most patients appreciate preoperatively. The lower body lift tends to result in even more flattening of the gluteal areas. The use of autogenous tissue allows the surgeon to use otherwise discarded tissue and reposition it to correct areas of soft tissue deficiency.11-13 The augmentation is commonly performed during the buttock lift portion of the lower body lift, but it is important to note that this will lengthen the overall operative time. Alternatively, autologous fat grafting can be performed for gluteal augmentation at a later stage procedure, if the patient has sufficient fat depots for harvesting.12
The lateral thighs are also lifted during the lower body lift procedure. The lateral skin excess is removed as the incision is carried around to the front after the buttock lift has been performed. Use of liposuction in conjunction with the lower body lift has also been described.14 Liposuction is most commonly used in the “saddlebag” lateral thigh areas. The lateral thigh skin is loosened by the action of the thigh liposuction which also aids in skin closure. If there are significant fat deposits in these areas, the outer thigh lift can actually worsen the saddlebag appearance unless this area is sculpted with liposuction.2
The abdominoplasty portion of the procedure is then performed in the supine position. The abdominal flap is elevated and plication is performed to refine and tighten the abdominal wall. The umbilicus is repositioned and then the incision closed. Drains are left in place and some advocate the use of body garments for postoperative management. Some of the most common complications that arise after a lower body lift include seromas and wound healing problems such as infection or dehiscence. Flap necrosis, hematomas, and thrombotic events can occur but are not as common.15
Thromboembolic events have been shown to be higher in those circumferential lower body lift patients that have a BMI>30, or are on oral contraceptive pills or hormone replacement therapy. In these patients, the use of enoxaprin has been associated with a lower incidence of venous thromboembolism complications. There is a slightly increased risk for bleeding with its use, so the benefits and risks must be evaluated on an individual basis.17 Hospitalization after the lower body lift is recommended for adequate pain control and monitoring of any immediate complications. In healthy, low-risk patients, the lower body lift may be performed in an outpatient setting as long as careful follow-up is provided.
The lower body lift is a widely performed procedure that corrects circumferential skin excess in the MWL patient. Body contouring surgery is rapidly growing and techniques are evolving because of the high demand from the bariatric surgery. With proper patient selection and newer modifications of the lower body lift, the MWL patient should be able to achieve an excellent aesthetic result.
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Category: Body Contouring Perspective