Body contouring after massive weight loss*1

Dr. Matarasso: Obesity has reached epidemic proportions in this country. Fifty percent of adults are considered obese or overweight and 6% are considered morbidly obese. In 2003, between 100,000 and 130,000 bariatric operations were performed for obesity, increasing the demand for postoperative bariatric plastic surgery. The growing demand for body contouring after bariatric surgery makes it increasingly important to focus on some specialized techniques, which are generating a new subspecialty, “bariatric plastic surgery.” The first patient is a 52-year old woman who had a 200-lb weight loss after endoscopic gastric bypass (Figure 1). Her weight has been stable for 1 year. She has a history of open cholecystectomy. Dr. Hurwitz, can you describe your routine preparation for a patient such as this one? Do you consult with the general surgeon? What laboratory tests do you order, and what are your priorities for staging the procedures? This 52-year-old woman had a 200-lb weight loss after endoscopic gastric-bypass surgery. She had previously undergone open cholecystectomy. Dr. Hurwitz: I see patients after they have completed bariatric surgery and nutritional counseling and when their weight loss has stabilized. This is usually at least 1 year after the bariatric surgery. At this point, patients are considered nutritionally fit and unlikely to lose any more weight. Alan Matarasso, MD Dennis J. Hurwitz, MD Al Aly, MD Ted E. Lockwood, MD In obesity centers, nurse coordinators prepare patients for the broad range of procedures they will undergo and coordinate with their medical doctors to make sure that patients are medically fit. Internists check chemistries and albumin and prealbumin levels to ensure that they are optimal and that the patient's diet is appropriate. Dr. Matarasso: Dr. Aly, how do you prepare for these surgeries? Dr. Aly: A complete history and physical is performed to make sure that the patient is medically and psychologically fit to undergo such extensive procedures. As part of that workup, an extensive weight-loss history is obtained. After the initial visit, which includes the history and physical, my patients are required to come back for a second, extended visit. During the second visit, I familiarize the patient with the procedure he or she will undergo and discuss the risks and complications. If the patient is undergoing a circumferential truncal procedure, I stress that this will probably be the most extensive surgery he or she will ever have, making sure the patient understands that this is a major life event. Dr. Matarasso: Dr. Lockwood, looking at Figure 1, can you describe your approach to treating this patient and the impact of the subcostal scar on your planning? Dr. Lockwood: In addition to circumferential laxity of the trunk, abdomen, hips, and buttock area, she has cellulite and redundant fat all the way to the knees, so I would perform large-volume lipoplasty at the same time as the lower-body lift. The lower body lift is a combination of abdominoplasty and transverse thigh and buttock lifts. The subcostal or cholecsystectomy incision does not bother me much at all because I use a lateral tension abdominoplasty technique that basically requires no significant undermining other than tissue resected just centrally enough to close the diastasis. There is blood supply on either side of that scar. Whenever a patient has a scar like this one, I tell the patient that he or she may be at higher risk than other patients but that because we preserve the blood supply to those areas, this procedure will be less likely to cause tissue necrosis than a standard abdominoplasty technique. Dr. Matarasso: Dr. Hurwitz, would you handle this differently? Dr. Hurwitz: Because of the sheer magnitude of the patient's hip size, the weight on the closure is monumental. Of course, this weight will be somewhat decreased by the lipoplasty. I would feel more comfortable relying on a panniculectomy to avoid getting close to that scar. The other factor that bothers me with this patient is her epigastric fullness. I do not have a solution for that problem, except to advise the patient that with most abdominal and lower-body procedures, she will still retain quite a bit of epigastric fullness. Dr. Matarasso: With that concept in mind, Dr. Aly, do you think there is any advantage to closing the patient's diastasis at that level because the problem is probably a result of intraabdominal adiposity? Dr. Aly: One criterion for performing such extensive procedures on patients who have sustained massive weight loss is to bring them into a fairly normal range of body contour. If the patient has not lost enough intraabdominal content to allow us to flatten the abdomen, that patient is not a good candidate for this procedure. You will not succeed in changing the overall truncal shape, especially on profile, if the patient has persistent intraabdominal excess. If you do not close her rectus diastasis, you will not be able to flatten out her abdomen, which is one of the major goals in the truncal region. I would like to address 2 other points. The first is the lower back rolls. Often that problem can be solved with a body lift; however, in many situations, the ordinary body lift will not eliminate the midback rolls, which will have to be addressed with an upper-body procedure. My particular approach to this patient would be to perform lipoplasty of her buttocks and thighs 6 months before the final procedure, in which I would perform a very aggressive belt lipectomy. Sometimes, if you carry the superior back incision at least 50% across that back roll, you may eliminate it. If you cross the back roll less than 50%, there is a significant chance that the roll will remain after surgery. I never promise that a back roll will be eliminated if I am not sure. My second point involves the subcostal incision from the recent cholecystectomy. In patients who have undergone this procedure, I use the cholecystectomy incision as the superior extent of my proposed excision and start the abdominoplasty by incising along that line, essentially performing a reverse abdominoplasty. Both superior and inferior flaps are elevated and then advanced against each other, and the excess is eliminated from the inferior flap. In a patient such as this one, the final position of the scar will be higher than in the average patient. Dr. Matarasso: Dr. Lockwood, what is your opinion? Dr. Lockwood: I always keep the incision in the bikini line or below, and I don't try to trace that subcostal incision or follow those rolls. It is amazing that with aggressive lipoplasty and a very strong lateral tension abdominoplasty, you get pull in an oblique and an anterior direction. In the posterior view, you would be amazed at how much of that is not a pull directly down. It is a pull that succeeds in bringing the back rolls around to the front and is very effective. You may still need a bra-line back lift superiorly for patients such as this one, but I would first perform an aggressive lateral tension abdominoplasty and lower-body lift with very aggressive suction in that area. Dr. Matarasso: The next patient is a 48-year-old woman who lost 160 lb after undergoing Roux-en-Y gastric bypass and presented with a body-mass index (BMI) of 28 (Figure 2). She is interested in improving her body contour, especially her arms. Dr. Hurwitz, would you comment on your approach to her dorsal back rolls and her arms? This 48-year-old woman lost 160 lb after undergoing a Roux-en-Y gastric bypass and presented with a BMI of 28. She is interested in improving her body contour, especially her upper arms. Dr. Hurwitz: I would recommend a brachioplasty, but in the context of her entire upper body. You can see in the anterior view the double roll of her abdomen and the midback roll. The upper roll of her abdomen will be minimally improved by a lower-body lift and circumferential abdominoplasty. In the first stage, particularly because of her preference, I would perform the upper-body lift, focusing on creating a new inframammary fold at the desired level. The inframammary fold is formed by suturing of the superior end of the reverse abdominoplasty flap to the sixth rib; direct skin closure is around the side and back as deemed necessary to remove back rolls. On the basis of the anticipated ultimate skin tensions, I position the back transverse skin excision so that the scar will lie along the bra line. In this patient, the bra line appears to be her back tan line. At the I would that superior to the roll, the bra line would come around and pull that roll, making it with the reverse abdominoplasty from the same You can with and if the patient The procedure be performed with a that the of her posterior Dr. Matarasso: there be with the Dr. Hurwitz: there is of the with the upper-body lift. As the inferior incision the posterior it an The of the the and the bra-line The then to the of the the scar from the and across the to the This the posterior the excess and the lateral of the and Dr. Matarasso: Dr. Aly, how would you approach Dr. Aly: In the upper patients with massive weight loss with excess skin and fat that involves the upper and the lateral the you cross the with the incision the lateral and a in the to how to in the to normal it is important to the and how it The upper trunk, or with weight and then with weight The with this but are at 2 One is in the of the and the other is in the of the anterior from these 2 points. The from these are in the the more they you usually see the in the lateral or in the lateral inframammary region. a normal contour, you need to that lateral inframammary back to position to a I do not make an incision in the inframammary I am performing or surgery. I lift the lateral with a lateral roll and that line will with the incision that from the these are I that patients who have sustained massive weight loss are less and more with their Dr. Matarasso: Dr. Lockwood, can you comment on Dr. Lockwood: I am not a of in the do not perform lipoplasty in the but it is very important to remove this excess somewhat into the I use a technique with a fairly aggressive to with the and the upper region. I get quite a bit of with that and the incision is in and I do not the incision with a transverse back lift or but I will use that of incision if I need to at a Dr. Matarasso: describe procedures that they use for gastric the the which can be the gastric bypass Roux-en-Y and with or a of these procedures result in a weight-loss before patients lose all of the weight they will so the of surgery on which procedure has been the procedures such as the gastric bypass Roux-en-Y and the can to and as as of the and some of the such as and are What and do you make for these patients in of and Dr. Lockwood: I on all these patients in the and when I perform major and thigh patients in the for 6 I each patient before surgery for and all The of me and my Dr. Aly: In the truncal procedures, I use an for postoperative In the my and a plastic on all of these a the patient. with the patient in a position and to lateral The us with lateral After we position the patient on the to make sure no tension is on either the anterior or posterior This is important because is one of the of circumferential procedures. a on the that the patient not be at all he or she is and the patient can or her tension and can the my patients undergoing these procedures are I a the average is between 2 and I patients from out of to in the for Dr. Hurwitz: I that these patients be I to with patients in the The of patients requires The and me to perform surgery in body a significant of body at I to use because of nutritional these patients are so we on much blood from in my area, blood is Dr. Matarasso: The patient is a old who lost lb after undergoing a Roux-en-Y gastric bypass (Figure presented with a BMI of 28. is interested in improving overall contour, especially area. Dr. Hurwitz, what is your approach to the in a patient who has sustained massive weight This lost lb after undergoing a Roux-en-Y gastric bypass and presented with a BMI of 28. is interested in improving overall body contour, especially in the area. Dr. Hurwitz: It is that will focus on just that area. This patient an of As in the other patients we have of skin and is can perform such as and lipoplasty. these patients demand a good and are This patient does not so in these but I that less than an will of I have been with a technique that will be this that I a I 2 of skin the superior of the This a broad inferior skin One the and the other into the roll of skin you can see this patient's as around the back as I to use lipoplasty of the inferior to remove tissue and the inframammary A broad undermining of the area, is I do not like or circumferential surgery in I think the is never the have been and are on Dr. Matarasso: Dr. Aly, what would be your Dr. Aly: This patient is a of in the patient who has sustained massive weight You can see the of anterior and posterior with excess skin In the lateral view, you can see how the lateral inframammary and the of the lateral roll are the because they are the from the 2 of My approach is to that have and them Both the and of the need to be I would the lateral inframammary to the in a I this by a roll that out as the lateral of the and the the is in the I make an incision along and it to the level of I lift the tissue the and it creating a flap. The inferior of the incision is then to the inferior of the creating the new inframammary I remove the as a skin and the then the What I just excess. one address excess. The technique I which with a excision of the lateral the excess at the same these more than are to in for contour. Dr. Matarasso: Dr. Lockwood, what is your technique for contouring a with skin Dr. Lockwood: This is a Because do not we I to these patients for a time the and of these There is a of in these the like a the and much of the is out to the side of the I would perform an lift, a very with to the and very aggressive lipoplasty. I the and perform a the at that point than performing a or an incision There is no good solution to this You need to make sure that the patient can those Dr. Matarasso: you perform lipoplasty on these what do you Dr. Lockwood: I use Dr. Aly: I use a to Dr. Hurwitz: I like lipoplasty. The less I follow this with routine lipoplasty. Dr. Matarasso: all of the many procedures do you perform in 1 Dr. Hurwitz: A body lift, performed in 1 stage, is a circumferential abdominoplasty with a circumferential lower body lift. upper body lift includes a reverse abdominoplasty, of back rolls, and a operations can as as with the the lift less than other I perform a circumferential abdominoplasty with as the first Dr. Aly: I start out with a circumferential truncal or what I to a belt lipectomy. I will that with a procedure. I never it with an procedure, and I on the thighs in a procedure. The upper body lift is a combination of procedures a a brachioplasty, and of procedures can be performed or in 1 procedure. Dr. Lockwood: My routine is to the surgery to the from the bra line to the in one I perform a significant lipoplasty of the entire circumferential and thighs to the This is the first The second in to would an extended thigh lift in which I into the abdominoplasty can to this procedure. Dr. Matarasso: What is your between Dr. Aly: The is 6 I to see a in of and a to Dr. Hurwitz: If the first is the major lower body lift, I a of to be sure the patient is the stress and of major surgery. Dr. Matarasso: The next patient is a woman who lost lb after undergoing an open Roux-en-Y bypass surgery procedure (Figure after she She has a epigastric scar. I would like to focus your on her This woman lost lb after undergoing open Roux-en-Y bypass surgery. She lb 2 after surgery. She has a epigastric scar and is by The patient of the skin of the abdomen, hips, and Dr. Aly, can you describe how you would address her Dr. Aly: you at patients with massive weight you can see a of fat this is a of very you at her upper especially in the it as if she never obese. the that she is it appears as if she has a of persistent fat in her If that is the my initial approach would be to do a belt with a very aggressive lipoplasty of the thighs and months I would perform an extended which is a excision Dr. Matarasso: you would a scar on the Dr. Aly: a as as a scar. Dr. Matarasso: Dr. Lockwood, how would you approach this patient's thigh Dr. Lockwood: are do not the thigh The thigh is on as a procedure. The for the thigh from The procedure will a for a thigh lift. I would approach this patient with a circumferential abdominal lift. The then and and into the area. you that with the lower body lift, you need to in to months and perform an extended thigh lift, which does not an incision the part of the This patient can be with a aggressive thigh first the with the lateral tension abdominoplasty, and then the extended lift that the incision in the and on either side of the it the abdominoplasty lipoplasty in those Dr. Matarasso: Dr. Hurwitz, we have 2 what would be your Dr. Hurwitz: This me of an that is There is not a of fat If she be as you see in the the I am with the lower body lift, to much for the lower of the particularly the lower and anterior I have a problem like which is so as as I am to performing a thigh lift so that the which is in will not be It may out or it may but at least it is I have been very comfortable performing the abdominoplasty, lower body lift, and all at for the knees, I I try to the lateral lift. The approach is but these procedures can be performed in 1 stage, and then you can Dr. Matarasso: The next patient is a woman who lost 160 lb after an open Roux-en-Y procedure. She is and we see her after her gastric bypass (Figure This woman lost 160 lb after open Roux-en-Y bypass surgery. She is and lb after surgery. She has a epigastric scar that is to a incision The patient of the skin of her abdomen, hips, and as as procedures be performed in 2 Dr. Aly, you comment on your technique for her and her abdomen, especially the epigastric Dr. Aly: I would like to what she to for her If she them I would perform a her truncal I would be that she may have persistent excess of her intraabdominal that would me from out the abdominal I that when she is her abdomen is probably which is my way of her intraabdominal are She does have a and we address My a general for before a plastic and is very comfortable treating If I by I would have a general do that for I first make the inferior the abdominal flap to the the and with the if that requires the we do usually don't have to use because these patients have decreased intraabdominal us to bring the of good The epigastric scar is resected if the scar is and the of the elevated abdominal flap to an of redundant abdominal will out the scar in a we do not all the way we remove the skin around the scar to the and the fat we do not like to the if because we it can the blood supply of the of the abdominal flap on either Dr. Lockwood, I perform a complete of the abdominal flap because I at least in my as good a lateral be the are elevated and Dr. Matarasso: you an and a skin Dr. Aly: The is but with a we do not in the As I the for us to a incision is to the we do not in a around the scar. patients do not have excess in the upper flap. are like an at the and at the It is not to the upper part of the that we bring down. will perform truncal procedures in which they an and a around the scar in an to the patient's This to persistent lateral of the lower abdomen, and a It is on an of the of the patient who has sustained massive weight Dr. Matarasso: Dr. Hurwitz, what is your for the and how would the scar the abdominal Dr. Hurwitz: is performed in the context of an upper-body lift. I would perform a There will be an inframammary scar at the superior end of the upper-body lift, and the it. of a epigastric is an for a skin with transverse excision of skin between the and a I follow the of Dr. I avoid a The excision of skin the of the I the and for me that is a procedure. Because of the for I keep the of the as as The does remove excess upper abdominal The excision of the lower around the Dr. Matarasso: Dr. Lockwood, how would you with Dr. Lockwood: I would have a general the the and I would the at a second the has been I can approach this with a standard extended lateral tension abdominoplasty with undermining and extensive suction of the entire The problem with patients such as this one is of the inframammary it the or is performed with the use of an technique. Dr. Matarasso: Because bariatric plastic surgery is I would like to some general for any one of these what is the average of Dr. Lockwood: or 6 for a Dr. Aly: 2 or for a belt lipectomy. other procedures, it is usually 1 or 2 Dr. Hurwitz: for Dr. Matarasso: What of patients blood Dr. Hurwitz: percent of my patients who undergo surgery for more than Dr. Lockwood: Fifty percent to of my patients Dr. Aly: I would The I do not patients as much is because I do not perform as much lipoplasty as Dr. and Dr. Hurwitz, and overall I to perform less surgery in any Dr. Matarasso: What are your most with these are they and what is the of their Dr. Aly: My most for belt is to patients with a BMI of or this is all of these are by of and do not a to the The second most I is or a most of these are and do not a to the The most is an that to be and with of Dr. Matarasso: Dr. Lockwood, what your Dr. Lockwood: My second, and most for these patients is to I have very The problem can come from a or a are that do not but in of these Dr. Matarasso: Dr. Dr. Hurwitz: My is more than patients in the is fairly but of for 1 postoperative there have been no to the and no It me that with is I am sure we are all or The I have I have had a of but I have to the for in of my Dr. Matarasso: all of the What of your for any of these procedures, for of Dr. Lockwood: I do not use any or I do use and before the of I use in and patients and so that patients are are all the we can to the who with the of lipoplasty and the of circumferential from the bra to the that I do not In or hip there are to in A in which you reverse be a I do not these Dr. Aly: Because I use it would be to use You if you use with an in do so would be to risk a significant an Dr. Hurwitz: In the patients I have who have had and a history of had than what I would so I with the other the risks of Dr. Matarasso: use Dr. Aly: Dr. Lockwood: Dr. Aly: I would like to a general with massive weight loss have usually been a and before they get to a plastic What we do for them can the between their and the and bariatric are of what plastic surgery can for these It is important for plastic to obesity and body contouring after massive weight It is important for us to that these especially those with are to have and can be to overall they are an of patients to I would like to that this in plastic surgery new and that will on good plastic surgery Dr. Lockwood: have been treating weight loss patients for a The belt in have lipoplasty and it has a to In the we need to these patients in the than of focus be on how we can these patients to optimal Dr. Hurwitz: I have not had in my than in treating these patients the are this surgery is we their and they it. It is plastic surgery in of the magnitude of the the and the it has the of in plastic surgery.