Chapter 38 Liposuction and circumferential lower truncal dermatolipectomy
The worldwide population of obese and morbidly obese individuals is growing faster than any other group. Consequently, we have a rapid increase in patients after weight loss, some of them through diet and exercise, and others who undergo a bariatric procedure with more or less irreversible gastrointestinal changes. Therefore, this new subfield of plastic surgery is gaining worldwide acceptance and there are many participating surgeons around the world. Following the establishment of modern body lift procedures by Ted Lockwood in the early 1990s1–5 and the progress in this surgical field, we nowadays benefit from different innovative approaches, which are all based on Lockwood’s philosophy. The main technical aspect, similar to modern face-lifting procedures, is the reconstruction of the superficial and deep connective tissue layers comparable to the superficial musculoaponeurotic system (SMAS) of the face. Nevertheless, it is essential to perform large-area tissue undermining and separation to allow a sufficient tissue mobilization and tightening of the affected areas with respect to an optimal result.
Since patients after bariatric weight loss can be more challenging candidates than nonbariatric patients, it should be mandatory for every post-obesity surgeon to have thorough knowledge of different post-bariatric procedures, including their side effects, and all available body contouring procedures, consequently being able to deal with their specific perils and pitfalls.
We carried out our first lower body lifts in 1999, consistently improving our standards and technique. During the following years we were able to detect and solve problems and complications, and consecutively implement refinements, which nowadays enable us to perform our circumferential lower truncal dermatolipectomy within 2.5 to 3.5 hours. Nevertheless, we should keep in mind that these surgical procedures are performed on formerly morbidly obese patients and particularly on postbariatric patients, who may present with malabsorption and nutritional deficiencies. Despite the fact that we deal with the largest body surface area, it is possible to perform these procedures with manageable risks when preoperative planning and operative performance are carried out meticulously and conscientiously. During our first years, we refused to carry out simultaneous liposuction in circumferential body contouring procedures, in order to avoid any risk of impaired tissue perfusion. Currently, adjuvant liposuction is widely accepted in tissue mobilizing procedures and can safely be included into lower circumferential contouring procedures; however, one must always be aware of its various limitations.
A precise physical examination and assessment of the medical history is mandatory in every patient. The examination of the lower body should include the upper and lower abdomen, the umbilical region, the midline region in standing and supine position, the flank and hip region with lateral thigh, the inner thigh, and additionally, the entire lower back region. For grading we recommend the Pittsburgh Rating Scale, published by Song et al.6
The first consultation should further include a thorough and detailed explanation of the entire procedure, preferably on PowerPoint® presentations. It is essential to demonstrate complications on images to visualize and emphasize possibilities such as wound separation and impaired scarring. The translation-test by Aly has proven to be worthwhile in clinical practice. The patient is instructed to grasp his tissue surplus at the height of his waist and pull the excess tissue firmly upwards. The visible skin lift and body contour improvement obtained in this way reliably forecasts the outcome of the thigh appearance after lower body lift operations. Optimal results can be achieved with a normal BMI < 25. With a higher preoperative BMI the patient must be informed about an exponentially limited postoperative result. The upper limit for massive weight loss surgery should not exceed a current BMI of 32.7
Further, we endeavor to enhance the patient’s understanding of impaired skin quality due to weight loss and bariatric surgery. In this context, we cite the latest article on this issue and inform every patient about secondary skin relaxation in this specific patient group. Therefore it is not uncommon to perform a secondary tightening procedure in particular cases.8
Initially, the boundaries of the patient’s preferred undergarment are marked in the standing position. The desired scar course is marked in red and double-checked by the patient. Dorsal markings are performed first. The posterior upper incision line runs about two to three finger breadths above the desired scar line and is marked in blue. The blue line, along its entire length, is then pulled caudally using the surgeon’s palm and is checked to make sure that it will reach the proposed red line of closure. In general, it should be at the lateral height of the umbilicus. The inferior proposed line of excision is estimated by strongly pinching the skin cranially, ensuring that approximately a quarter of the total resection height lies superior to the red scar line while the lower three quarters are inferior to it. The proposed inferior line of excision is an estimate that may need to be adjusted at the time of surgery. If avoidable, the anal cleft should not be elevated, since an elongation may result in patient dissatisfaction. It has been worthwhile to allow the upper incision line to run at a sharper angle into the anal cleft, in order to achieve an optical accentuation of the buttock form (Fig. 38.1).
Next, the anterior markings are performed based on the frontal red line previously marked (Fig. 38.2). We routinely instruct the patient to firmly and symmetrically pull up the entire abdominal tissue, while we initially mark the midline, a minimal distance of 6 cm from the vulvar commissure (or base of the penis), and next the lower incision line from the midline point laterally, where they are connected to the lower dorsal line. Often the resulting scar line is placed too far cranially due to a lower incision line marked in the abdominal skinfold. Consequently, the mons pubis, which is often sagged and slackened, is not lifted. In more severe cases the lower incision line can be extended caudally in an elliptical or triangle shape into the mons pubis region for an effective local skin tightening. Nevertheless, it is essential to leave a distance of 6 cm to the upper vulvar commissure (or base of the penis) (Fig. 38.3). The upper incision line is then continued from the lateral aspect of the dorsal upper line medially to the height of the umbilicus. In cases of distinct tissue surplus in the upper abdomen we routinely inform the patient about the option of a fleur-de-lis incision pattern during the first consultation. If the patient agrees to this additional scar line, we draw the midline cranially to the xiphoid. The vertical incision line is then evaluated by pinching and marked in an elliptical shape, starting two finger breadths below the xiphoid. This is mandatory to avoid a further cranial scar ending. Also, it is advisable to mark the vertical incision lines in standing position, since the tissue tends to drop laterally and backwards in supine position. The upper horizontal incision line is then marked approximately one finger breadth below the height of the umbilicus.
FIG. 38.2 Anatomical landmarks.
Normal abdominal anatomic proportions. The approximate measurements for an average female abdomen are listed. These vary according to individual height and bone structure. The umbilicus is located in line with the most superior point of the iliac crest in 99% of patients. (A) Distance between top of mons and anterior vulvar commissure. Average height is 5–7 cm. (B) Distance between umbilicus and top of mons. Average height is 11–13 cm. (C) = (A + B) Distance between umbilicus and top of anterior and vulvar commissure (C = D)
(from Richter DF, Stoff A. Abdominoplasty procedures. In: Plastic Surgery 3rd edition (Neligan P ed.) Elsevier, Saunders, St. Louis, 2012, with permission from Elsevier).
Importantly, dorsal vector lines are marked to allow a mediocranial rotation of the gluteal and thigh region and a consequent sculpturing of the waist (Figs 38.3 and 38.4). A final check of the markings should be performed in the patient’s supine and prone positions.
For additional liposculpturing of the flank, back or lateral thigh regions, the markings are made in the typical manner. We advise refraining from excessive liposuction in the undermined gluteal area, since any additional impairment of microcirculation in this area may result in skin necrosis. Patients after massive weight loss frequently present with significant adipose tissue redundancy in the area of the circumferential thighs, we routinely perform widespread tissue reduction by vibration-assisted liposuction in this area during the initial circumferential lower truncal dermatolipectomy.9
Massive weight loss patients with bariatric therapy may have an increased risk of aspiration, so an experienced anesthesia team should be involved. Hypothermia may occur in these operations because of extended operation times and large wound areas, which may lead to shivering, crouching, and inappropriate cramping postoperatively causing increased wound tension. Preheated infusions, heated blankets and preheated beds can optimize patients’ comfort and safety.
Accurate patient positioning is essential for avoidance of scar asymmetry and impairment of tissue perfusion in the areas of maximal pressure. The entire team, including anesthesiologists, surgical nurses and surgeons must constantly and conscientiously check the patient’s positioning. Pressure necrosis can arise around the periorbital regions and at the breasts, particularly in the prone position.10
We routinely install a urinary catheter and wrap the lower legs with compression bandages for deep vein thrombosis (DVT) prevention. Further, we administer a single-shot antibiotic to every patient. In specific cases the postoperative continuation of antibiotic prophylaxis may be considered.11
We routinely perform the operation with two teams of one surgeon and one medical assistant. The leading surgeon performs all the markings and is responsible for the entire performance. Preparation, dissection, and wound closure are performed simultaneously on each side of the patient’s body. After endotracheal intubation and the installation of a urinary catheter the patient is turned to the prone position on a padded operating table. Next, the patient is scrubbed and covered with sterile drapes, followed by a wide-area infiltration of tumescent solution (1 liter of Ringer solution including 1 ampule of Suprarenin) between the superior and inferior line, which is performed until a satisfactory tissue turgor is achieved. In cases of additional flank, back, or thigh contouring, additional tumescent infiltration is performed.
The initial skin incision (utilizing the cold blade or alternatively the Colorado® Microdissection needle) is made along the superior marking line and is carried out down to the level of the underlying superficial fascia, which is exposed using the Colorado® Microdissection needle or alternatively the Harmonic™ ultrasound scalpel, both of which easily separate the superficial lamellar from the subfascial lobular fat. Next, the dissection is continued inferiorly just above the robust white superficial fascia. The dissection level above the superficial fascia differs considerably from the original technique by Lockwood, who dissected subfascially. The preservation of fascia to the deep gluteal fat as the “gluteal SMAS” is conceptionally similar to the “facial SMAS” used in face-lifts. The superficial fascia is dissected at the height of the inferior resection line, before flap mobilization is continued caudally. Further, this allows a reconstruction of superficial fascia upon wound closure. Lateral gluteal adhesions are released caudally up to the gluteal fold height, before dissection is continued to the lateral thigh, where the preparation level is above the aponeurosis of the tensor fascia lata muscle. Further distal mobilization of the lateral thigh can be carried out bluntly using the Lockwood underminer. With completion of dissection, the waist and gluteal fatty tissue is widely mobilized and covered with robust superficial fascia. This is particularly suited for autologous gluteal augmentations, since patients after massive weight loss frequently suffer from flattened buttocks. For this purpose, two to three 1×0 Ethibond threads (Ethicon, USA) are sutured from lateral to medial, grasping the stable fascia and consequently displacing the gluteal fatty tissue to the middle of the buttock. For cranial repositioning, three to four 1×0 Ethibond threads (Ethicon, USA) are sutured from caudal to cranial at the medial aspect of the buttocks. By reconstruction and tightening of the gluteal adipose tissue, the gluteal flaps are lifted cranially with a consequent final skin closure under less tension. Further, this maneuver is able to improve the shape of the waist (Fig. 38.5).
The detachment in the zones of adherence combined with an extended mobilization allow an enormous tightening of the skin. The stage of resection should always be supervised by the “leading” surgeon in terms of symmetrical resection. We advise to utilize bullet forceps for determination of the amount of resection. The marked vector lines (Fig. 38.4) are incised from medial to lateral and adjusted for maximum tension. The redundant medial, central and lateral gluteal flaps arising in this way are measured precisely in tensed condition for symmetrical resection, which is subsequently carried out between the clamps (Figs 38.6 and 38.7).
Reconstruction of the superficial fascia system (SFS) is then performed with PDS 2×0 (Ethicon, USA). The SFS is extremely stable, allowing avoidance of any suturing of fat tissue in terms of consequent fat necrosis. After readapting the SFS, wound closure is performed in layers with resorbable suture material (see below). Two suction drains are placed in each gluteal/back and lateral thigh region and buried in the wound for sterile turning of the patient.
The inferior incision is checked and re-marked before the patient is scrubbed, adjusting the initial inferior line to the laterally ending gluteal incision line. Infiltration of tumescent solution is then performed in the marked areas. Vibration-assisted liposuction, however, is performed at the time of wound closure, again avoiding excessive liposuction in the areas to be undermined.