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