History

Demars and Marx performed the first abdominoplasty to treat an obese abdomen in 1890 using an “orange wedge” transverse skin and fat resection below the umbilicus. The abdominal contouring procedures have a diversified history. Kelly reported the removal of an abdominal panniculus weighting 7500 g. Abdominoplasty kept evolving during the years with important new techniques. Vernon described umbilical transposition in 1957. In 1973 Grazer performed the plication of the medial borders of the rectus abdominus muscle. Toranto described the wide rectus abdominal plication (WRAP) in 1988 and Lockwood studied and delineated the superficial fascial system in 1991.

The first circumferential lower truncal surgery was performed by Somalo in 1940. Gonzales-Ulloa was the first to coin the term “belt lipectomy” where he removed excess circumferential lower truncal tissue using two horizontal incisions extending all around the body, both above and below the umbilicus. Circumferential dermatolipectomies however were fairly limited in use till the emergence of bariatric surgery as a major response to the obesity epidemic which still grips the world and the US in particular. Thus massive weight loss patients, with their circumferential lower truncal excess, began to challenge plastic surgeons to develop techniques that specifically addressed their body contour deformities. Aly and Cram in 2001 were of the first to publish a series of patients that had undergone circumferential belt lipectomy and specifically addressed the massive weight loss patient. Since then there has been a multitude of papers addressing the same subject as more and more plastic surgeons gained more experience.

Physical evaluation

Patients who present for circumferential body lifts are most commonly massive weight loss patients. However two other groups can benefit and they include women who are 20 to 30 pounds overweight and are unable to lose that weight (Fig. 68.1), and a group of normal weight women who desire a remarkable improvement in their overall lower truncal contour (Fig. 68.2). Most of our comments here address the massive weight loss patient, who makes up 90% of patients who undergo belt lipectomy in our practice.

Fig. 68.1 A 61-year-old white female who had been 30–40 pounds over weight for most of her adult life is shown before (above), and 8 months after (below), a belt lipectomy. Notice the dramatic improvement in her overall lower truncal contour that would not have been possible with less extensive surgery.

Fig. 68.2 A normal weight 33-year-old white female patient who desired an outstanding improvement in her lower truncal contour is shown before (above), and 2 years and 9 months after (below), a belt lipectomy. This type of improvement, especially of the buttocks and lateral thigh regions, would not be possible with less extensive surgery.

A complete history is taken and physical exam carried out, emphasizing:

Fig. 68.3 A patient demonstrating the “translation of pull” concept before surgery (left and middle) and how well that approximates the improvement in the distal thigh after belt lipectomy surgery (right).

Anatomy

To understand how tissues act under the burden of massive weight loss it is important to understand the “zones of adherence”. These zones act as hooks upon which tissues hang. They vary in strength with strong adherence located at the sternum, midline of the back, the femoral/inguinal region and a zone located between the hip and lateral thigh fat deposits. A variable amount of adherence is located in the suprapubic region.

The presentation of the massive weight loss patients is quite variable and it depends on the BMI, the fat deposition pattern, and quality of the skin–fat envelope. The abdomen or back may have multiple rolls, one roll, or no rolls and a redundant ptotic mons pubis, usually with both vertical and horizontal excess. The entire lower trunk has an inverted cone appearance in almost all massive weight loss patients (Fig. 68.4). Usually the buttocks are both ill-defined and ptotic; sometimes deflated and sometimes overprojected.

Fig. 68.4 The “inverted cone” appearance of the lower trunk.

Understanding of the vascular topography of the trunk is fundamental for belt lipectomy surgery. The superior and inferior epigastric vessels supply blood to the skin overlying the rectus abdominis muscle through perforators that traverse the overlying fat to reach the skin. These perforators are generally ligated during abdominal flap elevation. Lateral to the rectus abdominis muscle and superiorly to the anterior superior iliac spine (ASIS), skin is supplied by the intercostal, subcostal and lumbar vessels that run superficial to the Scarpa’s fascia. These perforators are the remaining blood supply to the skin overlying the rectus muscle after flap elevation during the anterior aspect of the belt lipectomy.

Lateral to the rectus muscle and inferior to the ASIS the skin receives blood supply from the superficial epigastric vessels and branches that come from the deep circumflex vessels. The skin of the posterior trunk is supplied by the lumbar perforators, and branches from the latissimus dorsi and gluteus maximus myocutaneous territories.

Technical steps

Markings

The anterior midline is marked first. With the mons pubis superiorly elevated to a pleasing appearance a horizontal pubic mark is made 1 to 2 cm above the level of the pubic bone and it ranges from one edge of the hair-bearing surface to the other. From this edge, another marking is made toward the anterior superior iliac spine with the abdominal tissues medially and superiorly elevated, to simulate the tension at closure, and thus help to accurately predict final scar position. Both sides are measured and then matched for symmetry. The pinch technique will determine the superior marking of the proposed excision. It is important to avoid acute angulation in the antero-lateral superior marking because the abdominal flap may be vascularly compromised. Overall the position of scar anteriorly is controlled by the position of the inferior marks.

Posteriorly the vertical midline is marked and the midline inferior limit of the resection is decided upon generally at the level of the top intergluteal crease, but this will vary depending on patient anatomy. The tissue is then pinched in the midline with the patient bent at the waist, to simulate the position the patient will be in after the anterior resection is performed, and the superior mark is made. Performing this mark with the patient bent is essential to prevent dehiscence. The inferior postero-lateral markings are made in a lazy “S” shape, at the junction of the smooth lower back skin and the dimpled buttocks skin. The superior postero-lateral marks are made by using the inferior marks to pinch up to a superior level and concomitantly evaluating the buttocks and lateral thigh contour. The superior marks in the midline are brought to a “V”-shaped dip. Overall final scar position in the postero-lateral aspect of a belt lipectomy will be controlled by the superior marks and will on the average be around 2.5 cm inferior to those marks. Figure 68.5 demonstrates a typical patient’s markings.

Fig. 68.5 A typical set of markings in a low BMI patient.

Surgical steps

Prior to surgery the patient has an epidural catheter placed to manage postoperative pain and potentially reduce venous thrombosis; a urinary bladder catheter is inserted; and sequential compression boots are placed and turned on prior to induction of general anesthesia. The surgery starts with the patient in the supine position. A circumbilical incision is made and blunt scissor dissection is used to dissect the stalk down to the level of the underlying muscle fascia. The inferior abdominal mark is incised first to Scarpa’s fascia level and abdominal flap is elevated superiorly to just above the level of the umbilicus (Fig. 68.6). The extent of dissection above the umbilicus is dependent on whether the panniculus is thick and will require liposuction, in which case it should be as narrow as possible, just enough to allow the appropriate abdominal wall plication. In patients with thin panniculi that do not require liposuction, the dissection can be more aggressive but it should always be just enough to allow for appropriate flap advancement. Abdominal wall plication is made in two vertical layers; the first is performed with an interrupted permanent 0 size braided suture and the second layer is a permanent monofilament #1 running suture. If the abdominal wall has persistent vertical laxity, horizontal rows of plication may be needed. Anterior thigh liposuction is performed in the supine position if needed. The patient is flexed at the waist and the abdominal flap is advanced inferiorly and tailored. Two drains are placed through separate stab incisions, usually lateral to the pubic region. The position of neo-umbilicus is determined by making a 1.5 to 2.0 cm vertical midline incision overlying the umbilicus and creating a path for the umbilicus to come through without resecting fat. The umbilicus is sutured at 3, 6 and 9 o’clock positions, with 3-point fixation sutures utilizing 3-0 monocryl from the surrounding abdominal fascia, to the umbilical subdermis to the abdominal flap subdermis. The reminder of the umbilicus is re-approximated with simple interrupted 3-0 monocryl inverted subcuticular sutures. Closure of the abdomen is performed in layers. The deep layer incorporates the superficial fascia system (Scarpa fascia anteriorly), up to and including the subdermis, with a long-lasting 0 sized monofilament suture, usually in an interrupted fashion. A second subcuticular layer is sutured with 2-0 or/and 3-0 monocryl in an inverted interrupted fashion. Skin glue is applied to all wounds including the umbilicus.

Fig. 68.6 The abdominal flap elevation from the inferior incision up to the level of the umbilicus (inferior to the black line) is performed at the level of Scarpa’s fascia.

The patient is turned to the lateral decubitus position keeping the waist flexed. Four to five pillows are placed between the knees to create lateral hip flexion, which allows an aggressive lateral resection. The patient is re-prepped and draped and the lateral thighs are infiltrated with modified Klein solution in preparation for liposuction. The superior back marking is incised from the lateral dog ear to the midline of the back and the dissection is taken down just above the level of the muscle fascia in patients who have excess buttocks projection. In patients who lack projection, the incision is taken down to the level of the superficial fascial system. The dissection is then carried inferiorly to the level of the inferior markings. Lateral thigh liposuction is performed and if necessary discontinuous undermining is performed with either a large liposuction cannula or a “Lockwood elevator”. The inferiorly based flap is then elevated superiorly and tailored to the level of the superior incision. Closure is performed, over a closed suction drain inserted through a separate stab incision, and performed in a similar manner to the anterior closure. The patient is then turned to the opposite lateral decubitus position and the same exact procedure is performed on the opposite side. The patient is transferred to a flexed hospital bed by the surgeons.

Fig. 68.7 A high BMI patient, above 35, is shown before (above) and after belt lipectomy (below). Patients in this range of weight will often attain less than optimal results overall. Note that other areas of the body such as the upper back, arms, and thighs are still not deflated and will reduce the overall impact of the surgery.

Fig. 68.8 An intermediate BMI patient, 30 to 35, is shown before (above) and after belt lipectomy (below). The patient had a large ventral hernia that involved the umbilicus, which was sacrificed. Patients in this range of weight will attain intermediate results between the high BMI patients (Fig. 68.7) and the low BMI patients (Fig. 68.9).

Fig. 68.9 A low BMI patient, 30 to 25, is shown before (above) and after belt lipectomy (below). Patients in this range of BMI are more likely to attain an excellent result when compared to higher BMI patients (Figs 68.7 and 68.8). Note this is the same patient shown in Fig. 68.5.

Postoperative care

The patient is required to stay in a hospital setting for a minimum of two days. The epidural infusion is managed by the anesthesia team to a level that controls pain but does not impede sensation or motor function. The patient is required to walk the same day as surgery, with assistance. The epidural infusion is kept running, along with routine pain control measures, for 36 hours after surgery. The infusion is then discontinued and the patient is managed on oral pain medications in anticipation of discharge. The urinary catheter is discontinued 4 to 6 hours after the epidural infusion is stopped because the infusion prevents most patients from urinating without the assistance of a catheter. Ambulation is difficult postoperatively and should be rehearsed prior to surgery. A straight sitting position, prior to standing, is not advised because it can cause dehiscence. Thus the patient is rolled out of bed with their own guidance once they are completely awake, alert, and can sense tension. The semi-flexed position that the patients are placed in immediately after surgery should be maintained for approximately one week. At the end of the week the patients are allowed to slowly straighten up over a few days. Compression garments are utilized after the drains are removed and are advised for as long as the patient is willing to wear them. Drain removal is based on a criterion of 30 to 40 mL/day. Four to 6 weeks are required to return to regular life for patients who do not experience complications. Patients are seen frequently in the clinic during the period of time their drains are still in place and then followed up every 6 months for a few years. The final results are not attained till a full year has gone by, and in some the results continue to improve for two years.

Complications

The complications related to the belt lipectomy surgery are quite common. In our first 70 consecutive patients, 56% had at least one complication, 7% had more than one complication, and 44% had no complication. Patients with BMI above 35 had a complication rate of 100%. In this series the incidence of each complication was: seroma (30%), wound separation (20%), psychiatric difficulties (8.6%), infections (4.3%), tissue necrosis (4.3%), pulmonary emboli (2.8%), deep venous thrombosis (1.4%). The pulmonary emboli and deep venous thromboses occurred before the use of epidural anesthesia, and only one pulmonary embolus was radiographically confirmed, but all were treated presumptively because of the nature of the complication. Since we have initiated the use of epidural infusions, we have not had a single pulmonary embolus or deep vein thrombosis. We also noted in this study that the complication rate increased as the BMI increased. Overall both the patient and the surgeon need to be aware that this type of surgery is fraught with complications and should not be contemplated without a great deal of care and thought.