Mid-body Excision

The mid-body is usually addressed with circumferential abdominoplasty. In contrast to the nonbariatric patient, these patients typically present with skin excess that extends onto the hips and lateral thighs and posteriorly to the back and buttocks. In patients with limited posterior excess, a near-circumferential abdominoplasty that extends to the posterior axillary lines may be indicated. In the era before laparoscopic bariatric surgery, up to 20% of patients presented with ventral hernias after open bypass surgery. These abdominal wall defects are frequently addressed at the time of body sculpting.¹

Surgery of the Breast

We have described a variety of deformities of the female breast as well as a classification of these deformities (Table 53.1).²

TABLE 53.1 Classification of the Deformities of the Female Breast

The anatomic innervation to the breast has been described in multiple articles, dating back to Sir Astley Cooper’s description in 1840.³ Craig and Sykes identified the role of the third, fourth, and fifth anterior cutaneous nerves, and the fourth and fifth lateral cutaneous nerves, in supplying sensation to the nipple–areola complex.⁴ The importance of the lateral cutaneous branch of the fourth intercostal nerve as innervation to the nipple–areola complex was documented by Courtiss and Goldwyn.⁵ In light of these anatomic considerations, we generally employ a superolateral dermoglandular pedicle in our reduction mammaplasty and mastopexy cases.

In the female patient, the skin envelope, degree of nipple ptosis, and deficiency in volume must all be considered in selecting the appropriate technique. In patients with excess residual volume as well as ptosis, a standard reduction mammaplasty may be effective. Many patients, however, have a deficiency in volume, particular in superior pole fullness, combined with excess ptotic skin. In these patients, mastopexy alone may be indicated, or mastopexy with “autologous augmentation” using a dermoglandular flap in continuity with a pedicle that is rotated into the superior pole of the breast, or a mastopexy combined with augmentation using a mammary prosthesis. The male breast generally requires a reduction of excess skin, typically with an inferior pedicle reduction.

Brachioplasty or Recontouring of the Arm and Axilla

Excess skin in the upper extremity can extend from the chest wall distally to the elbow. We have described anatomic zones that are useful in planning the surgical approach (Fig. 53.1):⁶

FIG. 53.1 Classification of deformities of the arm is useful for surgical planning.

Liposuction alone is rarely suitable in addressing the upper extremity deformity. Excision of the excess skin from the elbow to the axilla is generally the most effective approach. Authors have described a variety of incisions, including ones located posteromedially,⁶ inferiorly,⁷ and in the bicipital sulcus.⁸

Surgery of the Back

In the nonbariatric patient, back contouring is infrequently indicated or considered. In the weight loss patient, on the contrary, consistent deformities of the upper back are encountered. These deformities usually take the shape of four folds in distinct anatomic positions along the back. We have named the folds by region in order to standardize their nomenclature: breast fold, scapular fold, lower thoracic fold, and hip fold (Fig. 53.2).⁹ The lower two folds also are used to mark the superior line of excision during circumferential abdominoplasty surgery.

FIG. 53.2 We have named four anatomic folds along the back that are remarkably consistent in location in the weight loss patient: breast fold, scapular fold, lower thoracic fold, and hip fold.

Surgery of the Thighs

Patients often request contouring of both the medial and lateral thighs. Deformities take distinct shapes. Many patients present with thighs that are cone-shaped (Fig. 53.3), whereas others present with cylinder-shaped thighs (Fig. 53.4). Cone-shaped thighs present with greater vertical skin excess than horizontal and, thus, may require only a transverse excision; cylinder-shaped thighs, however, typically present with both vertical and horizontal excess that may require both vertical and transverse excisions.¹⁰

FIG. 53.3 The cone-shaped thigh presents predominantly with vertical excess and can be addressed with a transverse excision.

FIG. 53.4 The cylinder-shaped thigh presents with both vertical and horizontal excess and, thus, frequently requires both transverse and longitudinal excisions.

Surgery of the Face and Neck

The degree of skin excess and soft tissue ptosis observed varies with the patient’s age and amount of weight loss. Patients younger than 45 years often have enough skin elasticity to allow skin contraction after weight loss and avert noticeable deformity of the face and neck. Patients older than 45 years present with skin excess along the face and neck as well as variable degrees of soft tissue ptosis, including midfacial descent, that require surgical attention.¹¹

Mid-body Excision

In the majority of our patients, complete circumferential excision is accomplished. Generally, the procedure can be completed in 3 to 3.5 hours using our technique.¹² This necessitates rotating the completely prepped patient directly on the operating room table, maintaining sterility. The procedure commences along the anterior abdomen and is continued as far posteriorly as possible. The patient is then rotated into a prone position. All tissue between the lower thoracic fold and the hip fold is marked for excision. No undermining of the back flaps is performed, which has drastically reduced the rate of skin flap necrosis and seroma formation. Drains are removed when output is less than 30 ml per day per drain. Pain control is assisted through use of a pulsed electromagnetic frequency (PEMF) device applied over the dressings.¹³

Breast Reconstruction after Weight Loss

As described above, weight loss patients demonstrate an augmented blood supply to the soft tissues, allowing the use of long de-epithelialized dermoglandular flaps. Given this anatomic feature unique to this patient population, we typically rotate dermoglandular flaps in continuity with a superior or superolateral pedicle to provide an autologous augmentation of the superior pole of the breast.¹⁴ Placement of a breast prosthesis may further increase projection and fullness.

Brachioplasty

As described in the “Anatomic Considerations” section, excess skin is observed from the elbow through the posteromedial arm and across the axilla onto the lateral chest wall. Our approach involves excising the excess tissue with a posteromedial incision in an S-shaped pattern. This accomplishes two goals: the posteromedial scar is more concealed with the arms adducted and the S shape redistributes the tissue over a longer length and decreases the potential for linear scar contracture. A Z plasty across the axilla reconstitutes the natural domed shape to the axilla.⁶

Surgery of the Back

The posterior portion of the breast fold and the scapular fold can be flattened by removing an ellipse encompassing the breast fold and one-half of the scapular fold, elevating the residual scapular fold to close the defect. The lower thoracic and the hip folds are eliminated with the posterior portion of the circumferential abdominoplasty, as described above.

Thigh Surgery

Depending on the extent of the excess skin, namely whether or not the excess extends inferior to reach the knee, this area may be addressed with only a superior transverse excision. Otherwise, in thighs that are more cylinder-shaped with excess extending inferiorly, a medial vertical scar to the knee generally is needed.

Face and Neck

Patients younger than 45 years tend to demonstrate enough skin contracture that surgical correction is not indicated. Over age 45 years, both skin excess of the face and neck as well as soft tissue descent require surgical attention.