Markings

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).

FIG. 38.1 Upper and lower incision line (blue) and resulting scar line (red) in the anterior (left) and dorsal view (right).

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).

FIG. 38.3 Anterior (left) and dorsal (right) vectors for medial tissue advancement.

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.

FIG. 38.4 Intraoperative marking of vectors and intraoperative positioning in prone position (with permission from Elsevier).⁹

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

General Considerations

We advise every patient to perform an extensive body scrub with antiseptic soap the night and morning before surgery.

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

Dorsal Preparation

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).

FIG. 38.5 Intraoperative view of the transposition-gluteoplasty procedure.

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).

FIG. 38.6 Intraoperative demonstration of flap dissection to ensure symmetrical resection (with permission from Elsevier).⁹

FIG. 38.7 Each flap should be measured in comparison to the contralateral side (with permission from Elsevier).⁹

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.

Before patients are turned into the supine position we perform a temporary closure of the lateral skin surplus utilizing a stapler and occlusive Opsite® foil.⁹

Anterior Preparation

Standard Technique

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.

With all techniques the dissection level is performed above Scarpa’s fascia (Figs 38.8–38.10), entailing a number of key advantages: long-lasting swellings can be prevented because the underlying lymphatic vessels are preserved, and the stretching of the SFS craniomedially provides an additional “inner traction” on the deep penetrating fascia system of the thigh. The SFS may then be fixated with 1/0 Ethibond sutures (Ethicon, USA) to the anterior rectus fascia (Fig. 38.11). Approximately three finger breadths below the umbilicus, Scarpa’s fascia is dissected and further mobilization of the abdominal flap is performed cranially on the anterior rectus fascia (Fig. 38.12). The central supraumbilical adhesion zone is sharply dissected between both rectus muscles, preserving the laterally incoming perforator vessels (Fig. 38.13).

FIG. 38.8 Intraoperative view of Scarpa fascia preparation and mobilization.

FIG. 38.9 Intraoperative view of Scarpa fascia preparation and mobilization.

FIG. 38.10 Intraoperative view of Scarpa fascia preparation and mobilization.

FIG. 38.11 Schematic demonstration of rectus diastasis and Scarpa fascia preservation (A) and fascial tightening and Scarpa-lift (B).

FIG. 38.12 Supraumbilical abdominal flap mobilization.

FIG. 38.13 Anterior rectus fascia tightening starting at the cranial midline.

Rectus diastasis and/or abdominal fascial laxity are corrected by vertical anterior rectus fascia plication (Figs 38.13 and 38.14). In simple cases, midline plication is sufficient; in more pronounced cases of fascial laxity additional oblique infraumbilical plications may be indicated. Lateral extended release of the abdominal flap may be necessary to prevent tissue bulging in the midline. Since the umbilicus is often prolonged in patients after massive weight loss, we shorten the entire umbilical stalk with a remaining 2–3 cm deep umbilical tunnel. The umbilicus base is now fixated at 3, 6, 9, and 12 o’clock to the anterior rectus fascia. The new position of the umbilicus is marked on the abdominal flap and a small distally based triangular or U-shaped pedicular flap is incised, followed by an extensive periumbilical fat removal, and continued cranially in the midline for accentuation of a “Champagne groove”. Temporary wound closure is performed with bullet forceps, followed by reconstruction of the SFS with PDS® 2×0 (Ethicon, USA). A multilayer wound closure with 2-0 and 3-0 Monocryl^® (Ethicon, USA) follows prior to intracuticular suturing. Because of the wound length, 2-0 Monocryl® (Ethicon, USA) is advisable (Fig. 38.15). Finally, Steri-strips are applied as described later. Alternatively, wound closure at the subdermal level may be performed with a single resorbable barbed suture (PDO 3-0, Quill®) in running manner. Skin closure may then be performed with an intracuticular monofil or barbed suture and alternatively with a two component skin closure system (refer to section Operation Time).

FIG. 38.14 Anterior rectus fascia tightening continued caudally to the symphysis.

FIG. 38.15 Skin closure in an everting manner with postoperative progression (upper) and schematic demonstration of the three-level suturing (lower).

(From DF Richter & A Stoff, Chapter 25, Abdominoplasty procedures. In Neligan, PC, Plastic Surgery, Third edition, Volume Two, Aesthetic, Copyright Elsevier 2013.)

Fleur-de-lis Technique

Initial preparation and dissection of a Fleur-de-lis lipectomy is equal to a standard abdominal lipectomy. On completion of the abdominal flap mobilization we check the horizontal resection utilizing bullet forceps, followed by an incision and resection of the midline tissue excess. After meticulous hemostasis the temporary vertical wound closure is performed, following any fascial tightening. Subsequently, the vertical tissue excess is checked in regard to the horizontal superior incision line prior to its resection. The umbilical insertion is performed after closure of the entire vertical wound. We routinely mark the midline of the future umbilical position and bilaterally excise a small triangle or semicircle, depending on the preferred incision pattern of the umbilical stalk. Umbilical reinsertion is then performed with 5-0 Prolene™ (Ethicon, USA), considering a small vertical umbilical diameter. We advise performing excisions at the umbilical level conservatively, since our first cases presented with postoperative increased umbilical diameters.

In patients with extreme weight loss (>120 kg) and consecutive skin redundancy the abdominal tissue tightening mostly requires fleur-de-lis resections, which significantly reduce the lower abdominal circumference. In the thigh area these patients additionally present extensive circumferential tissue redundancies, which we prefer to remove by a medial scar approach, beginning from the lower abdominal scar at the mons pubis and descending caudally to the medial thigh region. In this regard, we recommend performing the closure of the abdominal region while shifting the lower lateral and anterior thigh tissue medially. This allows a circumferential tightening of the entire thigh circumference. Immediately and in the first weeks postoperatively, patients have to deal with a significant skin surplus at the lateral mons pubis region, which will be eliminated by the following inner thighplasty. Taking this maneuver into account, this modification allows an optimal tightening of the entire thigh simply by two procedures. Representative case studies are shown in Figs 38.16–38.27.

FIG. 38.16 Preoperative anterior view of a 34-year-old patient after 48 kg weight loss.

FIG. 38.17 Preoperative lateral view of a 34-year-old patient after 48 kg weight loss.

FIG. 38.18 Preoperative posterior view of a 34-year-old patient after 48 kg weight loss.

FIG. 38.19 Six-months postoperative anterior view after circumferential lower truncal dermatolipectomy.

FIG. 38.20 Six-months postoperative lateral view after circumferential lower truncal dermatolipectomy.

FIG. 38.21 Six-months postoperative posterior view after circumferential lower truncal dermatolipectomy.

FIG. 38.22 Preoperative anterior view of a 42-year-old patient after 81 kg weight loss.

FIG. 38.23 Preoperative lateral view of a 42-year-old patient after 81 kg weight loss.

FIG. 38.24 Preoperative posterior view of a 42-year-old patient after 81 kg weight loss.

FIG. 38.25 Three-months postoperative anterior view after circumferential lower truncal dermatolipectomy and breast reshaping.

FIG. 38.26 Three-months postoperative lateral view after circumferential lower truncal dermatolipectomy and breast reshaping.

FIG. 38.27 Three-months postoperative posterior view after circumferential lower truncal dermatolipectomy and breast reshaping.

Operation Time

Depending on the findings for each patient, the initial operations last from 6 to 9 hours. Since unpredictable risks can arise from extensive operation times (e.g., long periods of susceptibility to contamination, surgeons’ fatigue, long anesthesia, drying out of the wounds) it was our first intention to reduce this problem.

We perform the procedure with only two turns, starting in the prone position and completing in the supine position. This enables a considerable decrease in operation time and allows one team to operate simultaneously on each half of the patient’s body. However, one surgeon has to take the leading position, controlling for an equal resection and standard operative performance. Further, the application of running barbed sutures for subdermal closure and the two component wound closure systems, including an adhesive mesh tape and a next generation cyanoacrylate (PRINEO™ Skin Closure System), may decrease the operation time markedly.¹²

Symmetry

To achieve a symmetric result regarding scar course and umbilical position we endeavor to comply with the following instructions:

Wound Healing Disorders

Circumferential lower truncal dermatolipectomies include extended tissue mobilization with a corresponding impairment of tissue perfusion. Therefore, it is essential to have precise knowledge of the vascular anatomy and the restrictions implicated by this procedure.

For this reason we advise respecting the following instructions:

Wound healing problems represent the most frequent complication after circumferential operations. Erroneous postoperative repositioning or excessive mobilization may cause wound dehiscences. Procedure-related staff training is therefore mandatory for optimal perioperative patient care.

Suture granulomas due to the large number of resorbable sutures occur frequently and may cause local infections with wound openings. In patients with bariatric surgery we endeavor to monitor proteins, vitamin C, zinc, blood glucose, as well as hemoglobin levels.^10,16

Scarring

Patients who have had massive weight loss are less fastidious in terms of optimal scarring and scar sparing techniques. It is advisable to extend scars in advantage of an optimal tissue removal with corresponding tissue tension.

Publications on the superficial fascial system by Lockwood in the early 1990s have brought a new understanding, including with respect to scar formation.^1–3 Dissection on the level of the superficial fascia in the buttock area preserves a stable layer for reconstruction and tissue transposition of the gluteal fatty tissue. Further, the reconstruction of the SFS enables a tension free closure on skin level, in addition to an everting skin closure for optimal scar formation (Fig. 38.15).

Patients have to be informed in detail about the planned scar course, the consequences of the operation and any esthetic limitations and problems that might arise and finally about the preferred postoperative scar treatment.

Seroma

Because of the large area of the wounds, accumulations of wound fluid (seromas) may cause postoperative problems. Particularly at the lateral thigh, seroma may occur down to the knee region due to gravity. Seroma formation cannot be prevented with any degree of certainty.^17–19 Suction-assisted drains in the area of the lateral outer thigh are left until drainage is less than 30 ml within 24 hours. Progressive tension sutures are helpful tools for the reduction of dead space and may limit accumulation of fluids.²⁰ The potential of the ultrasonically activated Harmonic™ scalpel for reducing seroma formation in circumferential body lift procedures has been demonstrated in studies.²¹

Buttock and Waist Formation

After massive weight loss patients often present with a flattened buttock. Circumferential lower body contouring procedures remove redundant skin and adipose tissue, which may prohibit any contour improvement in the gluteal region. For this reason, it is of huge importance in certain cases to restore gluteal adipose tissue for gluteal enhancement with autologous tissue transpositioning (transposition-gluteoplasty) during circumferential lower truncal dermatolipectomy. This maneuver enables an enhancement of gluteal projection, gluteal shape and waist formation²² (Figs 38.28–38.36).

FIG. 38.28 Schematic demonstration of gluteal adipose tissue preservation during dorsal preparation (with permission from Elsevier).⁹

FIG. 38.29 Schematic demonstration of gluteal adipose tissue preservation followed by suture placement in vertical and horizontal directions (with permission from Elsevier).⁹

FIG. 38.30 Vertical and horizontal suturing for maximal tissue accumulation in the medial and cranial direction (with permission from Elsevier).⁹

FIG. 38.31 Preoperative anterior view of a 49-year-old patient after 55 kg weight loss.

FIG. 38.32 Preoperative lateral view of a 49-year-old patient after 55 kg weight loss.

FIG. 38.33 Preoperative posterior view of a 49-year-old patient after 55 kg weight loss.

FIG. 38.34 Twelve-months postoperative anterior view after circumferential lower truncal dermatolipectomy, breast reshaping, inner thigh lift and brachioplasty.

FIG. 38.35 Twelve-months postoperative lateral view after circumferential lower truncal dermatolipectomy, breast reshaping, inner thigh lift and brachioplasty.

FIG. 38.36 Twelve-months postoperative posterior view after circumferential lower truncal dermatolipectomy, breast reshaping, inner thigh lift and brachioplasty.

Infection

The risk of widespread infections in lower body contouring procedures is fortunately extremely low. The huge wound cavities and the disconnected adhesion zones that prevent any transgression to neighboring sections, allow microorganisms to spread unimpeded in a large operative wound. Therefore we advise the following principles: swift operating, careful operating, avoidance of tissue drenching, single-shot antibiotic therapy, preoperative antiseptic scrubbing of patients, antiseptic intraoperative lavage before wound closure, preoperative thorough umbilical scrubbing.

With these principles we are able to keep the risk of serious infections lower than 0.1%. The immediate surgical wound revision as well as the installation of a suction and irrigation system generally preserve from further aggravation.

Blood Loss

Patients with bariatric weight loss may suffer from malabsorption and nutritional deficiencies. We advise every patient to have their blood clotting status examined and to preclude any postbariatric anemia. Patients with greater BMI-drop regularly present a higher number and diameter of blood vessels, which may cause increased intraoperative bleeding. Further, particularly at the level of the anterior rectus fascia, we recommend ligating vessels with a diameter larger than 3 mm, since insufficient coagulation may lead to a postoperative clot removal with consequent bleeding, induced by hypertension or muscular contraction. Dissection of the wide and well-perfused wound areas as well as any indirect undermining, for example using the Lockwood underminer, can already cause greater blood loss. Any postoperative bleeding should be revised at the very earliest opportunity. Any unresolved venous hemorrhage will prolong drainage time and volume and consequently increase the risk of seroma formation. All along, patients have to be informed preoperatively about the possibility of blood transfusions. Autohemotherapy may be considered, but is usually refused by most experienced clinicians. For legal reasons, however, the patients must be informed about this option. Patients who will not consent for any possible blood transfusion must be refused from treatment.

Thrombosis

The patient’s medical history has to be checked in terms of former thrombosis, family history, and personal habits such as smoking or oral contraceptive pill. In all cases appropriate prophylaxis should definitively be considered. Prior to body contouring procedures, patients with any degree of varicosis are encouraged to have duplex sonography and, if necessary, any kind of variceal stripping.

Our standard thrombosis prophylaxis is performed with preoperative beginning low molecular weight heparin, intraoperative compression treatment of the lower legs and a postoperative beach chair position as well as early patient mobilization. In the United States intermittent compression stockings are considered a standard of care and can be considered as an alternative to compression stockings.

To date, we have observed three DVTs with a single pulmonary embolism event in our patient collective, without any fatality.