Chapter Body Contouring in Grab & Smith Book 2013

8/10/2019 Chapter Body Contouring in Grab & Smith Book 2013

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P RT VII

ODY CONTOURING

CH PTER 6

LIPOSUCTION

MARY K. GINGRASS

Liposuction is the surgical aspiration of fat from the subcu-

taneous plane leaving a more desirable body contour

and

a

smooth transition between the suctioned and

the

nonsuc-

tioned areas. Liposuction

is

one

of

the most popular cosmetic

procedures performed by board-certified plastic surgeons

in

the United States. Although liposuction is

not

a technically

difficult procedure

to

perform,

it

requires thoughtful planning

and

careful patient selection

to

achieve consistendy pleasing

results. Poor planning

or

poor executionu result in unc:or-

reaable deformities.

lnSTORY

The aspirationof fat using blunt cannulas and negative-pressure

suction was first popularized inEurope in he late 1970s.

1

Three

French surgeons, Drs. Yves-Gerard lliouz, Pierre Fournier,

and Francis Otteni, were the

.first

to present their lipoaspira-

tion experience at the 1982 American Society

of

Plastic and

Reconstructive Surgeons annual meeting in Honolulu, Hawaii.

The procedure was initially met with skepticism in the

United

States. In late 1982, a blue ribbon committee was coil1Il lis

sioned by the American Society of Plamc and Rec:onstructive

Surgeons

to

visit Dr. lliouz in Paris and the committee returned

with a cautiously optimistic report. American surgeons' inter-

est in liposuction and public demand for minimally invasive

body contouring have steadily risen since then.

PATIENT SELECTION

Patient selection is a critical determinant

of

a good surgical

result, especially

in

body contouring.

Not

all patients who

request liposuction are good candidates. The consultation

begins with an assessment

of

the patient's goals. What does

the patient wish to change about his or her body? What does

the patient expect

to

aa:omplish with liposuction? The surgeon

then provides the patient with a

.n:alistic

appraisal ofwhat

c n

and

cannot

be

acc:omplished. Some

patients may require alter

native procedures (such as an abdominoplasty)

or

liposuction

combined with an open surgical procedure.

n

astute surgeon

is wary of patients who are particularly poor candidates

or

liposuction such as

(a} pafec:tionistswith

imperceptible defor-

miries,

. b)

those

with

undalying mental illness

that prohibits

realistic expecwions (body dysmorphic disorder,

or

active

eat-

ing

disorders),

and (c)

signiicandy overweight patients who are

incapable

of

weight reduction and/or weight maintenance

after

liposuction.

If

a patient is steadily gaining weight before liposuc-

tion, he or she are likelyto continue

this

trend after liposuction.

A detailed weight history is an important part

of

any lipo-

suction consultation. Ideal candidates

are

at a stable weight

with a working diet

and

exercise regimen

in

place. Patients

who have a history of frequent

or

signilicant weight lluc-

tuations are

at

high

risk for weight gain alter liposuction.

Maintaining a stable weight and practicing a

diet

and exercise

regimen for at least 6 to 12 months indicates the necessary

commitment to lifestyle cltange.

Liposuction should

not be offered as

a treatment

or obe-

sity. In a perfect world, it is used to remove genetically dis-

tributed

or

diet-resistant fat.

In

practical terms, however, it

is

frequently used

to

remove fat that could be lessened with diet

and exercise. Ideal liposuction candidates are within 20

of

their ideal body weight

or

less than 5

lb

above chart weight.

Abnormally distributed bulgesof fat or fat that resides outside

the con.6nes

of

he ideal body shape are the target areas that

are

most commonly suctioned.

PATIENT EVALUATION

A thorough physical examination is always performed. Although

the

focus of

the examination should

be

on problem areas, it

is important to take the entire body shape into consideration.

n

overall harmonious body contour is the desirable outcome.

The patient is examined for areas of disproportionate fat, asym-

metry between the two sides, dimpling/cellulite, varicosities,

and

zones of

adherence.

Asymmetries are

noted and, if they are

significant, they

are

brought to the attention

of

the patient.

If

the abdomen

is

being considered as a potential surgical site, it

should be carefully examined for hernias,

signi.6cant

abdominal

wall laxity, abdominal scars, history

of

abdominal radiation,

and anything that might

affect

abdominal wall integrity.

One

o

the most important physiaalindings, whichwillhave

significant bearing on dle final outc:ome,

is

the patient's skin

tone, or

dermal

quality.

It is important

to

pinch and palpate

the

skin, assessing for the

degree

of

laxity and dermal

thickness.

A

thicker dennis

is

more likely to retract

after

liposuction and

give

a desirable result. Thin, stretched skin with striae (indicating

dermal

breakage)

is unlikely to retract and may look worse after

liposuction.

If t

is determined that the

skin

quality is unsuitable

for liposuction, alternative procedures are proposed, such as

skin

excision, i f ndicated. Liposuction does

not treat cellulite;

thus one should not

make

promises to this

ellec:t.

The quality of the fat should also be assessed because it

may affect the outcome. The anatomy

of

the subcutaneous

adipose tissue varies throughout the body. Some areas

of

the

body have both a deep adipose compartment and a superfi-

cial adipose compartment, which

are

separated by a discrete

subcutaneous fascia. The superficial fat

in

the

trunk

and thigh

consists

of

smaller lobules, tightly organized within vertically

oriented, thin, fibrous septa. The deep fat consists

of

larger

lobules arranged more loosely within widely spaced and more

irregularly arranged septa (Figure 65.1).

2

In these areas, the

deep layer

o

fat is the target for liposuction. The overlying

superficial fat

is

(usually) relatively thin and will act as a pro-

tective layer to hide small contour deformities, especially for

the inexperienced liposuction surgeon.

In

contrast, other areas

of

the body

that

are commonly suctioned (arms and lower

legs)

have only one layer

of

fat. Suctioning these areas with

smaller cannulas will help avoid contour irregularities.

79


2/42

680

PanVD:: Body Contouring

Abdomen Superficial

layer(DL)

Paralumbar

Muscle

layer

Gluteal Thigh

SL

DL

I

SQF

FIGURE 65.1.

Superfic.ial.

and deep

fat

layeri. Markman and

Ba.rron

studied

the

subcutaneous

t:is ue of the trunk and lower extremity,

finding

that the fat

lobules

in

the superficial layer (SL) are small and

tightly

paded

within

closely

spaced septa, whereas those

of

the deep

layer (DL)

are larger, more iaegular, and

len

organized. The arrange-

ment

becomes

less

obvious

in

the gluteal and

thigh

area, and disap-

pears as one proceeds from trochanter

to

knee. There

is

only one

fat

layer

in

the lower

leg.

(Adapted from Markman

B,

Barton F Jr.

Anatomy

of

he

subcutaneous tissue

of

he

truDk

and lower

extremity.

Pkut

R.econstr SUI g. 1987;80:252.)

Superficial

liposuction,

a

technique

popularized by

Marco

Gasparotti

and

others,

uses small

cannulas

to aspi-

rate fat

from

the superficial planes (1 to 2 mm). Proponents

of this technique contend that aspiration in

the

superficial

plane

leads to predictable

contraction

of the overlying skin.

Superficial

liposuction

leaves very

little margin

for error

and should not

be attempted

until

the

liposuction surgeon

has

gained oonsiderable experience

in

the

deep

and

interme-

diate planes.

INFORMED CONSENT

Informed consent should be regarded by the surgeon not

only

as a legal responsibility

but

also

as

a mutually ben

eficial transaction. The

patient

is informed of the risks,

benefits, and available alternatives

to the procedure

being

considered. A well-informed

patient knows what

to expect

in the postoperative period. In the event of a postoperative

complication,

there is less likelihood of compromise of the

doctor-patient relationship if the patient was well informed

initially.

ANESTHESIA

The

appropriate

type of anesthesia shou ld be chosen based

on surgeon preference,

patient

choice, estimated volume to

be removed, and whether other surgical procedures

are

being

combined with liposuction. Liposuction

can

be performed

safely

as an outpatient

procedure in

an

office setting or in

an

outpatient surgery facility as

long

as

strict

adherence to

patient safety is maintained. Local or regional anesthesia is

generally appropriate for aspiration

of

smaller volumes, and

general anesthesia is preferable

when larger

volumes

are

removed. When large-volume liposuction (>5,000 mL o tota l

aspirate) is performed, or when liposuction is combined with

a signifiamt open surgical proc:edure(s), hospital admission or

24-hour observation in a hospita l setting is rec:ommended.

Attention

to perioperat:i.ve uid management is imperative

when significant volumes

are

suctioned. Appro:Dmately 70

o the injec:ted subc:utaneous fluid will be absorbed and mast

therefore be taken

into

aa:.ount

when

calc:al.ating intraopera-

tive intravenous (IV) haid. Anesthesiologists unfamiliar with

liposuction may

not

be aware of this fact

and

excessive fluids

may be administered. When the superwet technique is used

(see Wetting Solution below), the following guidelines or fluid

resuscitation

are

recommended: (a) for volumes


3/42

where

it

causes micromechanical, thermal, and cavitational

effects on subcutaneous fat. The intervening fibroconnective

tissues remain relatively unharmed and available for postoper-

ative slcin retraction. The emulsified fat is suctioned away with

low-power suction. UAL requires much less physical effort on

the part

of the surgeon

than

does SAL because

much

of

the

work is done by

the

ultrasonic energy. UAL is

an

extremely

efficient tool for the removal of fat in fibrous areas such as the

upper back,

the

hypogastrium,

and

the breast. UAL has been

shown to cause less disruption of vasculature than SAL/ which

translates into less bruising in most cases. There is energy dis-

sipation in all directions at the

tip

of the UAL probe or can-

nula, which gives

it

a certain airbrush effa:t. Some surgeons

believe it is a superior tool for sculpting and find there is less

need for cross-tunneling compared with SAL.

There are

also disadvantages to UAL.

There

is potential

for frictional injury

at the

skin entry so cons tant irriga-

tion

at the incision or a skin protector must be used. Seroma

rates

can

be high with prolonged ultrasound treatment times.

There is some elevation

of

tissue temperature with UAL and,

i f mproper technique is used, thermal injury can occur. With

proper training, these problems rarely occur. UAL is safe

and

effective when the surgeon

is

properly trained and the proce-

dure

is performed properly.'

Power-assisted liposuction (PAL) was developed n the late

1990s

to

address some

of

the concerns

about

UAL. PAL

is

basically traditional SAL powered by a reciprocating cannula.

The

main advantages

of

PAL over SAL

are

its efficiency in

fibrous areas and its ease of operation for the surgeon. There

is no particular salvage of fibroconnective tissue or neurovas-

cular structures as there is with UAL. The main advantage of

PAL over UAL is

that

there is no heat generation. PAL is an

excellent

tool for the

surgeons who

remain

uncomfortable

with the

potential for

heat and

the power

of

UAL.

The use of laser assistance to improve liposuction results

has recently been proposed. Proponents advocate that the

application of laser energy, applied either externally or inter-

nally to

the

fatty layer, disrupts adipocyte cell membranes.

However, studies by Prado et aL failed to demonstrate clinical

advantages with internally applied laser-assisted liposuction

ova:

traditional SAL

in

a double-blind, randomized, controlled

Chapter 65: LipoNcUOD 681

tria1.

7

Studies by Brown

et

al. failed to show

any

adipocyte

disruption by histologic or scanning electron microscopy in

porcine and human fat treated with laser-assisted lipoplasty

versus traditional SAL.

1his

study also failed

to

show any clin

ically significant differences in patients treated with internal

or external laser-assisted lipoplasty.

8

MARKING AND POSIDONING

Preoperative markings provide an

important

topographic

map, enabling the surgeonto visualize the targeted convexities,

avoid concavities,

and

address asymmetries when the patient is

lying

on

the operating table. Markings should be made imme-

diately prior to surgery with the patient in a standing position.

A

permanent marking pen is imperative so

that the

markings

w ll not wash of

when

the patient is prepped. Asymmetries

are

carefully marked and brought to the attention of the patient.

Depressions and indentations can be marked with a different

color marker so that these areas can be avoided or treated to a

lesser degree than surrounding areas (Figure 65.2).

Patient positioning is

planned

before the

patient

enters

the

operating

room

and depends

on

which areas

are

being

suctioned. Although most body areas can be suctioned from

either the prone or supine positions, some surgeons prefer the

lateral decubitus position for the hip rolls and lateral thighs.

When several body areas

are

to

be suctioned,

an

intraopera-

tive position change is necessary. Some surgeons prefer to

prep

the patient

circumferentially while standing and

then

have

the patien t lie

down

on a sterile drape. A locally anesthetized

patient

can

rotate on the operating table as necessary through-

out the procedure. When the procedure is performed

under

general anesthesia a position change is usually required. The

patient is first prepped in

the prone

position, which allows

easy access

to

the back, flanks, buttocks, lateral

thighs,

and

the

posterior aspect of

the

entire lower extremity. The patient

is then

turned

to the supine

position

and reprepped and

draped. The abdomen, breasts, arms, and the anterior aspect

of the lower extremity

can

be addressed from this position.

Patients are prepped with a 3-minute Betadine scrub, fol-

lowed by Betadine paint. Warming blankets

are

recommended

on

unexposed body

parts

and

a Foley

catheter

should

be

FIGURE 65 2

Preoperative mark:ings

before

circumferential

thigh liporuction.

Markinga

are

similar

to a topographic

map.

Lines and

circle

represent surface features of the body showing the specific shape and size

relatioDShip between

the component pam. n this case, progressively

smaller circles

indicate

a higher point (or more

fat

in relation to the surrounding areas. Markinga are extremely important to assist

the rurgeon

in getting smooth,

e-n:n,

and predictable 'ults.


4/42


5/42


A B

FIGURE 6S.3. Crou-tunnellng. Cross-tunneling

is

a tllclmique use

to

enhance smoothness and to

deaeue

the

risk

of contour irregularity. The

patient

is

in the prone position with her head on the left side of the picture. A. The liposuction cannula is inserted into the gluteal crease incision

black arrow) to suction the left lateral thigh, and into the parasacral area

to

suction the left posterior

hip.

B. A second

incision is made

and the

same areas are auctioned

from

a incision in the midaxillary line (at a right angle from the first .. ine . of suction).

injection into

the

face instead of aspiration is increasingly pop -

ulat. The trunk, including the abdomen. back. breast. and pos-

terior

hips

(flanks),

as

well

as

the

lower extremity, including

the knees,

calves, and ankles, have all been successfully treated

with

liposuction.

In

the author,s experience, treatment

of

gyne-

comastia is particularly amenable to UAV

3

(Chapter S7 . The

upper

arm is also well suited for

UAL

or SAL

when

the skin

is not too loose. The buttocks

can

be successfully treated but

should be approached with

some

degree of caution. Creation

of flat or

ptotic

buttocks

is not

only unsighdy,

but c:an

require

acisional measures to repair.

POSTOPERATIVE COURSE

Incisions for cannulas larger

than 3.0

mm

are

generally closed

with a

5 0

nylon suture . Some surgeons recommend leaving

smaller incisions

open

to

allow wetting solution

to

drain.

The patient is dressed in a compression garment

that

covers

the areas that have been suctioned. The author believe

that

compression foam (e.g., Topi-Foam, Byron Medical, Tucson.

AZ

under

a

garment

decreases early bruising and edema,

which seems to speed recovery.

An

abdominal binder can be

used when only

the

hips and/or abdomen

are

treated.

I f thigh

suction is also done, a girdle is preferable. The

patient may

experience significant serosanguineous drainage from incision

sites

for

approximately

24 to

36 hours, which

can be

alarm-

ing

to family and friends

if

hey

are

not informed in advance.

Showering is permissible

on

postoperative day 1

or 2.

A vaso-

vagal response is not uncommon the first time the postopera-

tive garment is removed, so patients should be warned ahead

of time to have someone with them the first time they remove

their garment. The patien t is instructed

to

replace the compres-

sion foam over the suctioned areas until days 3 to

5

i f olerated.

Drains are

recommended

for

gynecomastia and

when

>

2,000 mL lipoaspirate is removed

from

the abdomen alone.

They

are

left in place until drainage is less

than

5 to 30

mL

in a 24-hour period. Ideally, foam padding is left in place for

3 to 5 days. Compression garments

are

generally encouraged

24

hours per day or 4 weeks (6 weeks

i f

circumferential thigh

suctioning is performed). Postoperative follow-up visits

are

scheduled

at S

to 7 days to remove sutures; at 2 weeks to make

sure

that

bruising

is

subsiding normally and

to

advance the

patient's activity; at 8 to

12

weeks to

make

sure

that

edema

is subsiding normally

and to assess the early result. The final

postoperative

contour

will not be evident for approximately 6

months. Maximal sm:lling can be expected

at

postoperative

days 3

to

5.

In

the

author's

aperience, 60%

to

80%

of

the

swelling subsides by 6 weeks postprocedure, and it takes a full

4 to 6 months for 100% of the swelling to resolve, depending

on

the extent

of

he

procedure.

Patients begin ambulating

on the day

of surgery.

Oral

flu-

ids

are

encouraged. Physical activity should be

low

for the first

week

to

discourage excessive edema, followed by a

gradual

increase

in

activity during the second week, depending

on the

amount of suction that was done. At the end of the first wedt,

most patients can return

to work

and should be encouraged

to

begin light exercise, such as brisk walking

on

a treadmill

(with compression gannents ont). At

3

to 4

weds,

i f edema

and

bruising

are

resolving appropriately, the patient should

be advancing to .full activity and may wean him- or hersdf

out

of the compression garment over the course of a week.

These

are general guidelines for patien ts undergoing average

volume liposuction (lipoaspirate 2,000 to 5,000 mL and must

be tailored to the individual patient. Large-volume liposuction

and

circumferential

thigh

patients will need a more restrictive

postoperative regimen.

RISKS

AND POSSmLE

COMPLICATIONS

Any

surgical procedure ha s risks. Fortunately, serious com-

plications

are

rarely associated with liposuction procedures.

The most common undesirable sequelae after liposuction

are

contour irregularities, which are

related

to

inexperi-

ence and lack of attention to detaiL Contour irregularities

generally fall into four categories: (a) overcorrection, (b)

undercorrection, (c) failure of skin

retraction

or

abnormal

skin retraction,

and

(d)

complex

deformities consisting

of

combinations of

a, b, and c.

14

Revisionary procedures

should be performed only after

all

the

swelling

has

com-

pletely subsided. Generally, the treatment of undercorrec-

tion

is removal of

more

fat;

the treatment

of overcorrection

is fat injection (Chapter 44); the

treatment

of loose skin is

skin excision; and the treatment of complex deformities is

beyond

the

scope of this

chapter.

The best

way

to treat

contour

irregularities

is

to

avoid

them.

Other

risks, including unusual bleeding, which could result

in unusual ecchymosis or permanent skin discoloration, hema-

toma, seroma, infection, dysesthesia, fat embolism, thrombo-

embolism, Buid imbalance, lidocaine toxicity, skin necrosis,

perforation of viscera, and death, fortunately, are rare.

Lidocaine toxicity deserves special mention because

according

to

the

Physiaam Desk Reference,

the maximal


6/42

68 PanVD odyContouring

D

FIGURE 6S.4. Ultrasowtd-assisted liposuction of a woman shown

before A,.

C and 12 mondu after B, D UAL

of

the abdomen,

postx:rior hips, and circumferential thighs. A total of 4,700

mL

of wetting solution was .infiltrated and a total of 4 775mL of ipoaspirate {fluid and

was

removed: 575mL

from the abdomen,

475

mLfrom each

postx:rior

hip, and 1,625

mL

from each thighwhich

w

treated circumferentially.


7/42


B

c D

FIGUJlE 65.5.

Ulttasound-assisu:d liposuction

of

a

SO-year-old

woman.

She wu

treau:d

with UAL to the

abdomen, postuior

hips,

and

lawai

thigh . A

total of

1 250 mL, 600 ml., and 700 mL

of

wetting solution

wu

iDfiltrated into

the

abdomen, hips and

lawai

thighs,

retpec:tively.

A total

of

1,300 mL, mL, and

n5

mL

of lipoaspirate,. .re pectively, wu removed

from each area. The

total iDfiltrated

wat 3,850mL, and

the

total

aspirau:d

wu 4 950

mL Preoperative

Tiewo

A and C, Postoperative

Tiewo

Band

D.

recouunended dose of

subcutaneous

lidocaine

HCI when

used in combination with epinephrine is 7 mglkg

in an

adult,

yet numerous studies have documented the safety and effi-

cacy of larger doses (greater than 5 mglkg of lidocaine for

the

purposes

of

liposuction

11

(Chapter 12). Table

65.2

lists

the signs and symptoms of lidocaine toxicity.

If

lidocaine

toxicity is suspected,

the

injection

of

lidocaine is

stopped

immediately. Benzodiazepines

are the

drug

of

choice for

the

treatment

of

seizures.

ON LUSION

Liposuction is

an

extremely popular cosmetic procedure in

today s body-oonscious society. Technically, it is a relatively

easy procedure

to

perform

adequately

however,

it

requires

strict

attention

to detail and a keen aesthetic eye to perfect

the

rt of liposuction. Sucking fat is easy, whereas sculpting

the

body

by

removal

of

the right amount

of

fat,

and

leaving

behind a more optimal body contour, is

an

art.


8/42

686

PanVD:: Body

Contouring

C D

FIGURE 65.6. Ultrasound-assisted liposuction of the breast in a man with

gynecomastia.

The patient

is shown before

{A,

C) and

4 months ftu

B,

UAL o he breast. A total o 65

mL

o wettiD3 solution

was

infiltratedinto each breast and 575

mL

of lipoaspirate

{fluid

and fat) was

removed from

each brcut.

A

c

FIGURE6S.7. Suction-assisted lipoplasty of

he

neck in a 53-year-old woman shown before A, B) and

afte t C) SAL

of the neck. Superior results

can

generally

be obtained with liporuc:tion of he neck in the

younger

population;

however,

this woman had very good

skin

retraction for

her

age

Careful preoperative assessment of skin quality and thorough preoperative

collOlleling

with this

type

of patient

ill

imperative. In thU

cue, inc:Uions

were

made in the

submental area and

behind

each ear in order to allow contouring along the

jawline.


9/42

Chapter 65: LipoNcUOD

687

T BLE

65 2

LIDOCAINE

TOXICITY

EARLY SlGNS

LATER SlGNS

LATE SIGNS

Plasma

concentrations 3

to

6 pg/mL

Lightheadedness

Plasma

concentrations

5 to 9

pglmL

ShivexiDg

Plasma

concentration

>

10 pglmL

Convulsions

Restlesmess

Drowsmess

Til:witus

Slwxed speech

Metallic taste in mouth

Numbness of lips and tongue

CNS, amttal

uervo1111

system.

Muscle twitching

Tremors

1.

FoiU llier

P. Poplllarization of the tedu ique. In: Retter

GP,

ed. Lipopbuty:

Tht Of)

tWJ

o Bllmt Slldion Liptomy 2nd ed. Boston,MA:

Little Brown; 1990:35-38.

2.

Markman B, Barton FR. Allatomy

o

the tubcuwleoua

tiaue

of

the

trwlk

and lower exttemity. P Mt Ro111trSwrg. 1987;80:2.48.

3.

RohrichRJ, Ktnktl JM,Jtulis JE, eul.

AD

update

on the roleofNbcutmeous

infilttation

in

mctio H&Iisted lipopl.uty. PIAu R :Omw

4. Pitman GH, Teimourian B. Suttionlipectomy: complications and reslllt by

survey. Pl ut

R :OIUtf' S..rt.

1985;76:65.

S

Keabl

JM, Robinson

J

Beran SJ, et

al.

The tissue effects of

attisted lipoplatty.

Plast Reco1Uitr

SNrt 1998;102:213.

6. Ablaza

VJ GiDgrass MK,

Perry

I.e.

et

al.

Tissue temperauues

chuiug

llltta-

solmd attisted lipoplatty. Plast Reco1UitrSNrt 1998;102:534.

7. Prado A. Andrades P, DaniUa S,

Lelliz

P, Castillo P, Gaeto F. A pro-

spective, randomized, double-blind, controlled clinical

trial

comparing

CNS

depression

Coma

laser-assisted lipopbsty with suction assisted lipoplatty. Pltut Recomtr

Swg

2006;118:1032.

8.

Brawn S, R KeulW J, Yollllg V, Hoopman

J

Coimbra M

Effect

of

ow-level laser therapy

on

abdominal adipocyus before lipoplasty

p r

dures.

Pltut

kCO'IIIh'

S111g.

2004;113:1796.

9

The

wt t

tedu ique. In: nlouz YG, DeVillers

YT, edlJ Body by

Lipoputy New York, NY: Livingstone

10. Hetter

GP.

The

efiKt of aw

dose epinephrine

on

the hematocrit

drop

fol-

lowing lipolysis. Aesthl tic Pltut S111g. 1984;8(1):19.

11. Klein

JA

The tedmique for liposuction surgery.

Am

JCormetic

Swg 1987;4:2.63.

12. Klein

JA.

Tumescent tedmique for regional anesthesia permits lidocaine

doses of 35 mglkg for liposuction.J

S rg

Oneol 1990;16:248.

13. Gingrass

MK.

Shermak,

MA.

The treatment

of

gynecomastiawith llltrasound-

assisted lipoplasty. PertptP Mt S111g 1999;12:101-112.

14. GiDgnus MK, HenselJM Secondary In: Mathes SJ, Hentz VR,

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Speeifi


10/42

CH PTER 66

BDOMINOPL STY ND

BELT

LIPECTOMY

AL S. ALY

AND

EMIL

J.

KOHAN

INTRODUCTION

Body conrouring of

the

lower

trunk

region

is an

integral

part of

the

plastic

lll'gCOll's

armamentarium.

The

lower

trunk

is a cir-

cumferential st.rllct:l:lre

that

begins at

the

inferior border of

the

breasts and ends

at the

pelvic rim. Although this is a convenient

unit, it is difficult to separate from surrounding structures wch

as

the

thighs

and the

thorax. Deformities

in the

lower truncal

.region

are

variable

in

nature

and

require different approaches

for their treatment. advances

in

bariatric surgery have

resulted

in

a

large

population

of

weight loss patients, which has

led

to an

emphasis

on

the

evaluation

and

treatment

of

lower

truncal

contour

deformities. This chapter will focus

on

exci-

sional procedures,

with

or without liposuction, in the treatment

of lower truncal deformities. Problems

that can

be ameliorated

by liposuction techniques alone

are

covered

in

Chapter65

PATIENT

PRESENTATION

Patients with lower truncal complaints demonstrate a variety

of deformities

on

a continuum from minimal excess

fat

to cir

cumferential

fat and

skin excess accompanied

by

abdominal

laxity

of

the

fascia

1

(Table 66.1).

Weight

is the

first important

factor that

affects

the

pre-

sentation

of

patients

with

lower truncal deformities.

k use

absolute weights

can be

misleading,

body

mass index (BMI),

which

relates weight to height, is

the most

commonly

used

parameter.

It

is calculab:d

in the

following manner:

Body mass index =weight in kilogramsl height in mettM)

2

Body

mass

index =weight in pounds/ height in inches

x7 3

Patients

who

present

for

lower truncal contouring span

the

range

of

BMI from normal

to

obese.

The

upper limit

of normal BMI

is 25;

26 to 30

is

consid-

ered overweight;

and 30 and

above is considered obese. A

variety of surgical approaches

are

required

to treat

patients in

different BMI ranges.

A second factor

that

affects

the

presentation of patients

is

the fat

deposition

pattern

which is genetically controlled.

Women

typically deposit

fat in

the

infraumbilical abdomen,

lateral

thighs,

hips, and medial

thighs.

Men

tend

to deposit

fat

in the

flanks,

the

infraumbilical abdomen,

and

intra-abdomi-

nally.1 Although these patterns

are

common, dramatically dif-

krent

patterns of

fat

deposition

are

often present even within

the

same gender.

The

quality

of the skin-fat

envelope

is

a

third factor

to

evaluate. Some women

who

have

had one or

more pregnancies

T ILE

66 1

FACTORS THAT

AFFECT THE

PRESENTATION OF

THE PATIENT REQUESTING LOWER

TRUNCAL

CONTOURING

Body mass index

at

presentation

Fat deposition pattern

Quality of

the skin-fat envelope

88

may

present

with

abdominal skin laxity and stretch

marks.

The

skin

in

those patients

is

stretched beyond its ability

to

rebound back

to

its original elasticity. A

similar

process occurs

with

massive weight gain

and

subsequent weight loss

in

which

the

skin

is

overexpanded, leading

to

a sk in-fat envelope

that

is loose

and

indastic.

HBTORYOFBODYCONTOuruNG

Body

contouring

procedures

early

in

the

twentieth century

consisted

of

dermatolipectomies

of

hanging abdominal

pan-

niculi.

In

these procedures, excess skin

and

underlying

fat

were

removed

to rid the

patient

of

hanging tissues

with

minimal

attention

to

aesthetic principles.

In

the

second

half

of

the

cen-

tury, advances in abdominoplasty techniques

led to

improved

scar placement, abdominal wall plication,

and

umbilical trans-

position. In

the

1980s liposuction was introduced, and it

became a tremendous tool

in the

armamentarium of

the

plas-

tic surgeon for affecting body contour , replacing a

number of

excisional procedures. Currently, plastic surgeons routinely

use

both

excisional

and

liposuction techniques, a lone

and in

combination,

to

improve abdominal contour.

RELEVANT ANATOMY

Fat

in

the

lower

trunk

is organized into superficial and deep

layers separated by

the

superficial fascial system,

which

per-

vades

the

entire body. Anteriorly

the

superficial fascial system

is

rekrred to

as Scarpa s fascia {Figure 66.1) .

The blood supply

of

the

abdominal skin

and

fat

is impor-

tant

to

understand.

The

skin overlying

the

rectus muscles is

primarily supplied

by

arteries

that

originate from

the

superior

and

inkrior

epigastric vessels

that

run within

the

rectus mus-

cles. Branches from these vessels perforate

the

overlying rectus

fascia

and

traverse through

the two

layers

of

abdominal fat,

finally reaching

the

skin. This direct blood supply of abdomi-

nal

skin

is

interrupted during

the

elevation

of the

abdominal

flap

in

a traditional abdominoplasty. A secondary blood sup-

ply is derived from lateral intercostal, subcostal,

and lumbar

vessels

that

course anteriorly

in the fat

superficial

to

Scarpa s

fascia (Figure 66.2). These vessels

are the

only remaining

blood supply

of

central abdominal

skin

after traditional flap

elevation. Intem:1ption

of

these vessds

by

scars, such as cho-

lecystectomy, or

chevron scars,

can

lead

to

necrosis

of

tissues

inferomedial

to the

scar.

The

superficial epigastric vessels

supply

blood

to

the

skin

of

the

lower abdomen

but

are

also

divided during abdominoplasty procedures.

The lower

trunk has

fascial attachments between

the

skin

and the

underlying muscle fascia

that act

as anchoring points

or

zones

of

adherence (Figure 66.3). These zones

of

adher-

ence restrict

the

overlying skin from moving during

the pro-

cesses of aging

and/or weight

fluctuations. Posteriorly,

the

midline

has

a

zone

of adherence

that

overlies

the

spine.

The

anterior midline of

the

abdomen

has

a less well-defined zone

of

adherence. Three horizontal zones of adherence

are

located

in the inkrior

aspects

of the

lower

trunk;

one

is located

at

the

inguinal region bilaterally

and

extends toward

the

anterior

superior iliac spine (ASIS). Another is located just above

the

mons

pubis and is variable

in

its adherence properties. The

third

is located bilaterally between

the hip

and lateral thigh

fat


11/42

Chapter 66: .Abdominoplasty and Belt Lipectomy 689

Skin

Superficial fat layer

fascial system

Scarpa fascia anteriorly)

Deep muscular fascia

FIGURE

66.1. Organization

of fat

and

fu


12/42

690 PanVD:: BodyContouring

These patients

are

usually young women who have had

one or two pregnancies, have good sldn elasticity, and are not

They

may

or

may not

have localized

fat

depos-

Its m

other

areas

of the trunk

and lower extremity such

as

the hips and lateral thighs. The goal of surgery in this patient

population is to eliminate the infraumbilical abdominal waD

laxity

and the

minimal skin

and

fat excess.

Technique (Mini-Abdominoplasty)

n incision is marked in

the patient's

natural suprapubic

crease

and

angled

toward

the ASIS.

Often

the incision

can

be

limited to the width of

the

pubic hair or just beyond its lateral

edges. Intraoperatively, the proposed incision is made

and the

dissection extended to the muscle fascia.

An

abdominal.Bap is

elevated superiorly to

the

level

of the

umbilicus.

The

infraum

bilical rectus muscle diastasis is identified, and rectus fascia

plication is performed. Some surgeons prefer a single layer,

whereas others favor a two-layer plication (Figure 66.5). The

abdominal

.Bap

is advanced inferiorly

and

tailored to remove

the

excess skin and underlying fat. This advancement will usu-

ally pull

the

umbilicus

down

1 to 3 em.

The closure of his incision, as in aU subsequent incisions dis-

cussed in this chapter, is performed in multiple layers, with the

most important layer being the reapproximation of the superfi-

cial fascial system, or Scarpa's fascia. Permanentor long-lasting

sutures

are

used in

this

layer in

an

attempt

to

limit widening

of

the scar in the long run. The authors prefer to use interrupted

monofilament absorbable sutures in the subcuticular layer

to

perkc tly approximate the skin with an overlying layer of medi-

cal-grade skin glue. Drains are inserted and a compression gar-

ment is used in the period by most surgeons.

A variation

of

this technique

can

be used in patients who

have minimal lower abdominal skin excess, no upper abdomi-

nal skin

excess,

and

both infra-

and

supraumbilical

reaus

diastasis. To aUow access to

the

supraumbilical rectus diasta

sis, the base of the umbilicus can be amputa ted. The abdomi-

nal flap is then elevated on either side of the midline in the

supraumbilical region, and a supraumbilical rectus plication

and

an

infraumbilical plication

are

performed. The umbilical

stalk is

then

resutured

to the

plication

at

the appropria te level,

and the

lower aspect

of

the

abdominal

.Bap

is tailored appro-

priately.

It

is also possible to use a minimal-incision approach

to the supraumbilical plication by making an incision in the

superior aspect of

the

umbilicus and using

an

endoscope to

perform a dissection superior to the umbilicus

that

is

wide

FIGURE 66 5 The

abdominal flap elevation and rectus

fascia

placa-

tion in a

miDi abdominoplasty.

enough to allow for

the

desired supraumbilical plication. In

any of he mini-abdominoplasty techniques discussed, liposuc-

tion can be used to decrease the thickness of any

part

of

the

abdominal

.Bap that

has not been elevated.

One

of the mostdifficult aspects

of

mini-abdominoplasty is

avoiding dog-ears because of

the

short incision.

ABDOMINOPLASTY

Generally, abdominoplasty is indicated in patients whose lax-

ity

involves

the

supra

and

infraumbilical regions, limited

to

the

anterior aspects

of

the lower trunk.

The

goals

of

abdomi-

noplasty depend on the presenting deformities. They include

creating a

.Bat

abdominal contour, eliminating abdominal

wall

laxity, enhancing

waist

definition in some patients,

and

eradi-

cating mons pubis ptosis if present.

Stretch marks

are

common

and

may be limited to the infra-

umbilical region or

may

include

both

the infra and supraum

bilical skin. Rectus diastasis of the entire vertical extent of the

abdomen is present in these patients, with the infraumbilical

diastasis usually more extensive because of the position of the

uterus during pregnancy. Preoperatively abdominal waD laxity

can

again be detected by the diver's test

and

physical

exami

nation. Massive-weight-loss patients

who

reach a near-normal

BMI may

also present with lower truncal excess limited to

the

anterior abdomen. However, most often they present

with

c:ir

c:umferential deformities

that

require more extensive c:irc:um.

ferential excisions.

Patients

who

present with excess intra-abdominal fat

that

would prevent .Battening of

the

abdominal wall by plication

are not

good candidates

for

abdominoplasty.

The

outer

skin/

fat envelope of the belly always conforms to the shape of an

inner balloon whose anterior wall is

made up

of

the

abdomi-

nal muscle wall. I f

that

wall is rendered convex in profile by

virtue of overly abundant intra-abdominal contents,

then

the

final profile of the belly will also

be

convex. Because abdomi-

nal contour

.Battening is one of

the major

goals of surgery,

these patients

are

better served

by

weight loss

prior

to contem-

plating abdominoplastytype procedures.

By the nature of an abdominoplasty, where an ellipse of

tissue is removed from

the

lower abdomen, dog-ears

can

be

created at the edges of the ellipse, especially in patients who

already have la teral excess. Patients

who

present

with

defor

mities

that

extend beyond

the

anterior

aspeas of the lower

trunk

may

require 1) mending the abdominoplasty exc:ision

laterally, 2) liposuction o the lateral

and

posterior trunk

and

or 3) circumferential dermatolipectomy to attain the best

pos-

sible c.ontour.

Some authors advocate the use of .Beur-de-lis or

"T"

type

excisions in which

an

anterior vertical wedge of tissue is

resected, as discussed later in this chapter. Generally,

as

cir-

cumferential lower truncal dermatolipectomy has become

more mainstream in plastic surgery because of the massive-

weight-loss population,

the indications for isolated abdomino-

plasty have narrowed.

Technique (Abdominoplasty)

The markings for

an

abdominoplasty

are

performed p rior to

surgery.

The

proposed excision is marked in the lower abdo-

men. Centrally,

the

inferior incision line is often marked in

the

natura l suprapubic crease

and then

carr ied laterally. Some

surgeons utilize a French bikini/thong pattem" in which the

lateral

aspects of the proposed inferior incision

are

angled

toward the ASIS, while others prefer a flatter

pattern,

with

many

variations described in the literature.

5

An

attempt is

made

to avoid

the

incision beyond the ASIS,

but it

is more

important to avoid dog-ears. With the inferior mark in place

the patient is slightly flexed

at the

waist,.

and

the pinch tech-

nique

is

used

to

approximate the superior extent

of

the exci-

sion. IdeaUy, the patient should have enough excess abdominal


13/42

skin to allow excision of the skin from just above the umbili-

cus

to

the suprapubic crease centtally.

In the operating room. a circumumbHical incision is made

and

the umbilical stalk is dissectl:d

to

the deep fascia. The

infe..

rior mark

of

the proposed abdominal

skin

excision

is

incised.

n abdominal flap is elevated superiorly, around the umbilicus,

and

up

to the xiphoid and costal margins (Figure 66.6). The

flap is classically elevated

at

the

level of

the underlying muscle

fascia but many plastic surgeons pre :r to elevate the flap

at

Scarpa's fascia

level.

lt

is

felt that this may reduce the rate

of

seroma formation. Two theories have been invoked as

to

the

etiology of

this

reduction. The most popular is that the remain-

ing

subscarpal fat contains intact lymphatic

vessels,

which help

absorb fluid in the wound. The other possibility is that the fat-

to-fat

intl:.r:face

leads

to

better adhesion between the abdominal

flap and the underlying tissues. Neither theory has been tested

experimentally; thus,

it is

not currently known why this type of

elevation

seems

to reduce seroma formation. Wide undermin-

ing

allows the greatest amount

of

abdominal flap advancement

at

the time

of

flap tailoring, but

it

also leads to the division

of

the greatest number

of

superior epigasttic muscle perfora-

tor vessels, leaving only the lateral intercostal, subcostal, and

lumbar vessels as the only viable blood supply

of

the flap.

Some

surgeons

pre :r

a more limited dissection above the

umbilicu.s,

just

to

the medial

edges

of the rectll9 muscle

fascia

to allow for

supraumbilical rectus fascia plication up

to

the xiphoid. The

benefit

of

the limited dissection

is

the increased number

of

the

perforator

vessels

left intact

to

support the blood supply

of

the

tailored abdominal.Bap.

ln

some patients, however, the limited

dissection will

not

allow the appropriate advancement

of

the

abdominal flap and may reduce the amount

of

tissue that may

need

to

be

resected to

create the best contour.

As

a general rule,

flap elevation should be restricted

to

just what will allow appro

priate rectus fascia plication and appropriate flap advancement.

Often it

is

best to limit the initi l elevation and then release the

tissues incrementally

to

allow for appropriate contour.

After flap elevation, rectus fascia plication is performed.

Many patterns have been proposed for plication, but a vertical

FIGURE 66.6. The extent of abdominal flap ele'f'lltion and fascial

plication in a traditional abdominoplasty.

Chapter

66:

.Abdominoplasty and Belt

Lipectomy

691

plication, in one

or

two layers, is most common. The patient

is

then flexed

at

the

waist,.

and the abdominal flap

is

advanced

inferiorly

to

facilitate the process

of

flap tailoring.

As

the

abdominal flap is advanced, the surgeon can conttol where

the greatest tension will

be

at

closure-


14/42


15/42

Chapter66: .Abdominoplasty and Belt Lipectomy 69

FIGURE 66.9. Truncal deformity in

weight loss

patients. n the massive-weight-loss patient, the ptetenting lower truncal deformity

is

in the

shape ofan inverted cone. n a citcumlerentiallipectomya wedge of tissue ill removed. The diameter

of

the

wedge

at its superior edge is smaller

than

its diameter at

he inferior

edge.

rim (see Figure 66.9). s previously noted. the wedge to be

excised is generally located in a more superior position in belt

lipectomy when compared with the wedge to

be

excised in a

lower body lift. n either method. the anterior aspect

of

the

wedge is wider (in vertical distance) than the latl ral or postl -

rior aspects. The latl ral resection is

the

ne:xt

widest aspect so

as

to

reverse the lateral truncal descent (Figure

66.10).

FIGURE 66.10. A 31-year-old woman presented alter

an

80-lb

weight loss

to

reach a

body mass

index of 27.31. (Above)

Shown

with

preoperative markings fur a ciraunfe.rential belt lipectomy. Note that

the excision laterally ill generally

aggressive to

counteract the lateral

descent that occurs with maS&ive weight loss and/or aging. Vertical

marb

are placed along the ciraunfereDCe of the proposed resection

to help alignment at closure. Surrounding areas of the thigh are also

marked

for liposuction. (Below) he patient 6 months fter surgery,

demonstrating dramatic

waist

narrowing, elimination of the pannicu-

lus and lower

bad

rolls, and improved

buttoclcs

definition.

Because

of

the circumferential nature

of

the procedure,

more than one position is necessary

to

accomplish the resec

tion in the operating room. No matter what sequence is pre-

ferred by a particular surgeon, the abdominal part

of

the

procedure is performed in the supine position. Surgeonswho

advocate prone/supine r supine/prone positioning cite the

single

tum

required

in

the operating room

and

the ability

to

control buttock symmetry as their reasons for choosing the

"two-position" sequences. The supine/lateralllateral

or

lat-

eral/lateral/supine proponents prefer these "three-position"

sequences because they allow for easier lateral thigh liposuc-

tion and hip abduction in the lateral decubitus position, which

facilitates maximal lateral resections.

All

body positions have

potential complications associated with them, especially if the

patient is

to

be maintained in those positions for extended

periods

of

time.

The

surgeon should

be

familiar with those

complications andhow

to

prevent them.

The extent of anterior flap elevation in the abdominoplasty

portion

of

the circumferential procedure is based on surgeon

preference. The lateral elevation is usually more extensive

than in

an abdominoplasty, which compromises the remaining

blood supply

to

the abdominal flap

to

a greater

e:xb nt.

Thus,

it

is important that an effort is made to preserve as many lat

eral feeding vessels as possible. The plication of the rectus fas-

cia

is

similar

to

abdominoplasty plication except

that it

may

sometimes require plication distances that far exceed the usual

to

7

em encountl red with routine abdominoplasty. Closure

of the circumferential wound should include reapproximation

of

the superficial fascial system with permanent and/or long-

lasting suture.

During the lateral and posterior resection, some surgeons

prefer to incise the superior marks first and dissect

an

inferior

skin-fat flap, whereas others prefer the opposite. Some sur-

geons incise both the superior and inferior extents and excise

a predetermined marked amount. The authors prefer

to

incise

the superior side first and tailor the inferior-based flap based

on tension and creation

of

the appropriate contour.


16/42

69

PanVD:: odyContouring

Some surgeons choose to combine extensive liposuction

of

the surrounding regions, such as the lower back, the upper

back. and thighs, whe.n:as others limit their liposuction

to

the

lateral thighs. A major diffi:rence between belt lipeaomy and

a lower body lift is in the treatment

of

he pelvic rim s zones

of

adherence.

n

belt lipectomy, these attachments are disrupted

by liposuction of he lateral thighs, but they are

not

completely

eliminated. n

a lower body lift, discontinuous undermining

of

the anterior and lateral thighs, down to knee level, intention-

ally destroys the pelvic rim zones

of

adherence. lhis allows

significant thigh elevation.

11

The results attained from circumferential lipectomies

depend, to a great extent, on the presentation of the patient

and the type

of

procedure chosen (see Figure

66.10). As a

gen-

eral rule, the lower B.Mis at presentation lead to better aes

thetic results and lower rates

of

c::omplic:ations.

10

11

COMPLICATIONS

Table 66.21istsc::omplications that can occur with lower trun

cal c::ontouring procedures.

14

Circumferential procedures are

associated with more complications, but they are often per

formed on patients with higher BMis. When complications

are stratified by BMI, noncircumferential and cirCUIIlkrential

procedures have

similar rates.

Superficial

wound

healing problems

are the

most

com

mon complication

that

occurs with any body contouring

excisional procedure because of the high tension created

at the wound edges. Conservative wound care will usually

allow healing

to

occur, with the possible need

for

subse

quent scar revisions. Wound dehiscences, defined as sepa-

ration

of

the wound at the level of the superficial fascial

system, are possible with any

of the

procedures discussed

in

this chapter but tend to occur more frequently with cir

cumferential procedures. In procedures limited

to

anterior

resections, mini-abdominoplasty, and abdominoplasty

dehiscences can be prevented by keeping patients flexed

at the waist for 5 to 7 days after surgery and educating

patients

on

a slow return to

the

full upright position over

the second week after surgery. Circumferential procedures

create competing anterior

and

posterior tensions, making

it

difficult to place patients

in

positions that do not stress

at least one aspect

of

the closure. Avoidance

of

dehiscences

in

this patient population entails adjustments

of

the c::om-

peting resections to account for opposing tensions, care-

ful

ambulation

of

the

patients

in the

early postoperative

period,

and

education of patients on

how

to help prevent

dehiscences.u

Seromas are common complications with lower truncal

c::ontouring procedures. They are due

to

large dissection sur

face areas and can develop anywhere in the surgical field but

tend to be located posteriorly in circumferential procedures.

T BLE

66 2

COMPLICATIONS

ASSOCIATED WITH

LOWER

TRUNCAL BODY

CONTOURING PROCEDURES

Seroma

Wound-healing

Infections

Tissue necrosis

Bleedinglhematoma

Thrombotic events deep venous thrombosis pulmouary emboli)

Psychiatric difficulties

Scar and contour asymmetry

Patients who present in the high BMI ranges are more likely

to develop seromas. Measures that are used to reduce their

occurrence include the use of suction drains, compression

gar

ments. reduction

of

activity, and use

of

quilting sutures. When

they do occur, they can most often be trea ted with serial aspi-

rations. For

seromas, sclerosing agents and seroma

catheter insertions may

be

utilized.

Seromas

are

the most

common source of infection after

lower truncal procedures. Simple cellulitis is fairly uncommon

and is usually treated by appropriate antibiotic coverage and

dose follow-up. Seroma pockets that become infected usually

present with overlying cellulitis, fluid collections that may or

may not spontaneously drain, fever, and generalized malaise.

A diligent effort should be made to find seromas

and

treat

them whenever suspected. Once seromas become infected,

aggressive intravenous therapy

and

appropriate surgical

drainage should be instituted.

Toxic shock syndrome can occur with any body contour-

ing procedure. Postoperatively, patients who appear toxic

with fever, chills, generalized malaise,

and

elevated white

blood cell counts should be investigated. Although there is

often

no

evidence of

frank

pus

or

large fluid collection in the

wounds, aggressive surgical drainage is urgently required in

this group

of

patients.

Vascular compromise can

occur

with lower truncal body

c::ontouring procedures, leading

to

tissue necrosis.

Most

com-

monly the necrosis occurs in the inferomedial aspect

of

the

abdominal flap. A number of factors can contribute

to

this

problem, which include excessive tension on the abdominal

closure, aggressive thinning of

the

abdominal flap, overly

aggressive liposuction,

and

anything that may lead to com-

promising the lateral feeding vessels

of

the abdominal flap

such as open cholecystectomy incisions. f necrosis occurs,

the wound is treated conservatively and eventually allowed

to

heal by secondary intention. Eventually, a scar revision may

be required.

Bleeding after lower truncal contouring procedures can be

extensive because of the surface area within which blood can

accumulate prior to detection. Although drains do not prevent

hematomas, they can often warn the surgeon

of

a develop-

ing hematoma. Small hematomas

that

are well evacuated

by

drains

in

place can

be

managed expectantly. Large hematomas

should be treau:d by surgical drainage.

Procedures that tighten the abdominal wall are theorized

to increase intra-abdominal pressure, leading to a decrease

in

venous

return

from the lower extremities. The possible

resultant stasis

of

blood in the deep venous system may

cause deep venous thrombosis and/or pulmonary emboli.

Measures that are commonly used

in

the prevention of

thrombotic events include early ambulation

and

sequential

compression garments. Some surgeons feel that chemopro

phylaxis,

low

molecular weight heparin (enoxaparin pro-

phylaxis), is indicated in the perioperative period. At the

time of the writing of this chapter it is not dear

what

the

proper course of action should be

in

this arena. The authors

prefer

to

utilize epidural

catheter

infusions, which help

reduce pain, but have been found to reduce the risk of deep

vein thrombosis/pulmonary embolism as well, and avoid the

use

of

chemoprophylaxisY;

Patients who undergo large excisional procedures

of

the

lower trunk especially massive-weight-loss patients,

can

have psychiatric difficulties

in

the postoperative period that

may interfere with their recovery. Although this can occur

with any surgery, the long recovery period that is required

after circumferential procedures makes i t wise for the plastic

surgeon to activdy investigate a patient s psychiatric reserves

and

consider obtaining psychiatric clearance prior to sur

gery. The tendency

of

massive-weight-loss patients

to

have

lifelong psychiatric problems

that

are not solved by weight

loss alone also contributes to the relatively high incidence of

these problems.


17/42

Although careful marking techniques can help reduce scar

and

contour asymmetry, it is not possible

to

eliminate these

problems in many patients because

of

intrinsic skeletal and

soft tissue asymmetry.

It

is best for the surgeon

to

recognize

these natural asymmetries and point them out to patients

prior to surgery.

FLEUR DE LIS OR T TYPE

PROCEDURES

A fleur-de-lis

or

T-shaped excision, whether used

as an

abdominoplasty pattem

or

in combination with a circum-

ferential lipectomy, is advocated by some authors. The

advantage

of

the vertical wedge is

to

eliminate horizontal

excess, create more waist definition,

and

decrease lateral

fullness. Traditionally, this pattem has not been frequendy

used because it is difficult

to

justify a vertical midline inci-

sion without a preexisting vertical scar. Recendy, however,

it has found more use because many massive-weight-loss

patients have midline incisions and/or deformities that super-

sede the created vertical scar in unattractiveness. Even with

a preexisting scar, however, there are major disadvantages

to

the vertical aspect of the T pattem. There is an increased

chance

of

flap necrosis at the T intersection. When used

to

treat circumferential excess, a leur-de-lis resection pattern

does

not

eliminate all lateral excess

and

does

not

affect

lateral

thigh descent or buttocks ptosis. When the pattern is used

in conjunction with a circu.rnfi rentiallipectomy,

it

can create

a greater mismatch between the upper and lower circumfer-

ences

of

he inverted cone-shaped edges

to

be reapproximated

(see Figure 66.9). Finally, the vertical wedge excised can often

lead

to

epigastric fullness secondary

to

the dog-ear effect cre-

ated by the excision. Due

to

these disadvantages the authors

do not utilize this pattern

of

excision.

14

Chapter 66:

.Abdominoplasty

and

Belt

Lipectomy

695

eferences

1. Aly AS.

Approa.ch

to lhe massie we4\ht loss patient.

Ill:

Aly

AS,

ed.. Body

ContoNriflg Afuw

M.wiue

Wtlight

Lou. St.

Louis, MO: Quality

Medial

Publishing; 2006:49.

2.

La

Trenta GS. Suction...assisted lipectomy. Ill:

Rees

TD, La. Trenta GS,

eds.

All hnie Pl.utie SNrgery. 2nd ed. PhiLLdelphia, PA: WB SaWlders;

1994:1180.

3. Aly

AS.

Optioll8 in lower trunl::al surgery. fn: Aly

AS,

ed..

Afuw

M.wiv1t

Wllight

Lou. St. Louis, MO: Quality Medical Publishing;

2006:59.

4. Loc:kwood T. Superficial fascial system {SFS) of he trwlk and extremities: a

leW

c:oncept. PI.ut Recomw Sftrg. 1991;87:1009.

5.

La

Trenta

GS.

Abdomilloplasty.

Ill Rees

TD,

La

Trema

GS

eds. Aesthnie

Pkutie

S..rgM)'. 2nd ed.. Philadelphia,

PA:

WB

Saunders; 19. 14: 126.

6.

Lockwood

T. High-lateral-telllion abdominoplasty with superficial

fascial

system suspension. Pl4 R tWrS:t.lrg. 1995;. 16:603.

7.

Pollock

TA,

Pollock

H. No-drain abdominoplasty with progressie tension

sutures.C& PltutSNrg. July 2010;37{3) 515-524. [Epub 2010 May 23).

8.

Matarii IO

A.

Abdominopluty: a

system

of classification and treatment for

combined abdominoplasty and suc:tion...allisted lipectomy. Aathnie PList

Slwg. 1991;15:111.

9. Najera RM Asheld W, Sayeed SM, Glickman

LT.

Comparison of suoma

formation following abdominoplasty with or without liposuction. PIAu

Rt'eoft tr

Slwg.

January 2011;127{1):417-422.

10. Aly

AS,

Cram

AF.

Body

lilt:

belt lipectomy. 111: Nahal

F,

ed. The An

of

Aathlltie SNf'ler)l. PrinciplitS 4tUI Tctt:hnil:Jws. St. Louis, MO: Quality

Medial

Publishing;

2005:2302.

11. Aly A,

Cram

A, Chao M, et al. Belt lipectomy for circumferential t tWl

cal exc:ess: the Uninrsity ol Iowa experience.

PLut

RtitOIJ W

SNrg.

2003;111:398.

12. Loc:kwood TE. Thigh and buttock lilt.ln: Nah.ai F, ed.. Thti An of

&uhlltie

S..rgery. Principle 4IUI Techniqws. St. Louis, MO: Quality Medical

Publishing; 2005:2424.

13.

Loc:kwood

T. body

lilt.Oper

Tub

Pltutkeon r

S111g. 1996;3:132.

14. Grazer FM, Goldwyn RM. Abdominoplasty by survey, with

emphasison

c:omplli:ation. Pltut

Sll'fl{. 1977;59 513.

15. Aly AS. Belt lipectomy. In: Aly AS. ed.

Body

COIIJOMring After Mtulive

Wllight Lou. St. Louis, MO: Quality Publishiug; 2006.

16.

Rimier

JC

Scholz

T,

Shbeeb A,

Chua

W,

Wirth GA, Paydar

K

The inci.-

den< e of TeDOUll thromboembolism in postoperatin plastic and rec:ollllttllc:-

tive surgery patienl l with chronic spiD.al oord

iDjury.

Pltm RIIW'flltr

Sll'fl{.

2010;126:40.


18/42

CH PTER 67 LOWER

BODY LIFT ND DIIGHPL STY

JOSEPH P. HUNSTAD AND

REMUS

REPTA

LOWER BODY LIFTS

Key Points

The

lower body lift is reoommended for patients wi th circum-

ferential body laxity who have achieved significant weight

loss through surgical bariatric intervention or diet and exer-

cise regimens (see Chapter 66). The procedure is performed

in both

prone

and supine positions requiring patient reposi-

tioning intraoperatively. The circumferential component of

the procedure allows for the treatment of buttocks ptosis, lat-

eral and anterior thigh laxity, abdominal tissue redundancy,

as well as mons ptosis. The lower body

lift procedure can be

combined with various ancillary procedures such as autolo-

gous buttocks augmentation, fleur-de-lis abdominal contour-

ing, thigh lift. and mons reduction. There is overlap between

this chapter and Chapter 66 on abdominoplasty. We encour-

age

the

reader to study

both

chapters.

INTRODUCTION

The lower body lift serves as the "keystone" procedure upon

which

all

subsequent body contouring procedures are based.

1

3

t s important for patients

to wderstand

that there is

no

a:er-

dse

or skinr This is frustrating for patients

who

exercise regu

larly

but

have skin laxity

of he trunk

secondary to genetics.

The

10 \ I A:r body

lift

procedure is

far

more than a "belt lipectomy"

where circumferential excess skin is removed

from

the mid-

waist area of the

trunk

(Chapter 66). By placing the

rese


19/42

Chapter 67: Lower

Body Lift and

Thighplasty

697

FIGUJlE 67.1. Patient s cona:ms lower body A and

B.

Patients

oft:m

demonsttatetheir

wire

outcome

by

strongly lifting

the abdominal skin, thigh skin, and the buttocks areas.

in

the midline because of the strong zone of adherence

and reduced laxity. When autologous buttocks augmenta-

tion is planned, the amount of resection of the posterior

segment is reduced to accommodate the volume that will

be

added.

From the

upper marking

in the

midaxillary line

a dotted line is continued anteriorly across the abdomen,

representing

the estim ted

amount of resection. The exact

amount of the resection will be determined intraoperatively

(Figure

67.3A).

Areas

for

concurrent liposuction are then

marked as well.

A V-Y mark is made within the planned resection amount

at the

midaxillary line which will allow temporary closure

of this area when the patient is repositioned from prone to

supine (Figure 67.4B). For patients with significant transverse

as well as vertical tissue laxity, a concurrent vertical resection,

commonly referred to as a fleur-de-lis resection can be utilized

(Figure

67.5).

Most

massive weight loss patients are willing

to accept a vertical midline scar

in

return for correction of

laxity.

1

The final shape of the fleur-de-lis resection should be

closer to

an

ellipse than a triangle, to prevent excessive ten-

sion at the junction of the vertical and horizontal closure

FIGUJlE

67

1 he

lower abdominal

incision.

The first transverse line

is

placed

at

the level

of

the pubic symphysis with the patient suongly

elevating

the

abdominal skin. This is the ideal final location for the

incision which

is

placed in a

pleasiD3fy

low location. Notice that the

upper third

of he hair-'bearini

mons is routinely rcsec:ud.

(Figure 67.S). All markings are rechecked to ensure symmetry

and to avoid over-resection.

General anesthesia is initiated, antibiotics and steroids are

given (Ancef 1 g and Decadron 4 mg), and a Foley catheter is

inserted. When concurrent liposuction is planned, thorough

tumescent infiltration

of

all areas to be suctioned is perfonned.

The patient is carefully rolled

in

the prone position on

the

operating room table that has been arranged with padded

chest rolls, kneepads, and a roll

or

pillow beneath the ankles.

The patient is surgically prepped and draped taking care to

include the most anterior point

of

the planned V-Y closure

in

the midaxillary

line bilaterally.

Once prepped and draped, the markings are checked for

tension and symmetry. The posterior resection is performed

without undermining, forming a V -shaped resection. This

inward beveling allows closure to occur without dead space.

When autologous buttocks augmentation is performed,

the

intervening tissue between the upper and lower incisions is de-

epithelialized. This flap of tissue can be molded with suture

in a purse-string method or partially elevated and rotated as

a

flap.

,s

Laterally, the resection continues to the midaxillary line

where the temporary

V-

Y resection and closure is performed

(Figure

67.6).

Undermining is suggested

at

this point over the

trochanter to release

the

retaining elements

in

this

area

of

adherence. The posterior drain is placed and the end is coiled

and inserted beneath the skin

of

he V-Y closure to

be

brought

out anteriorly when

the

patient is turned supine. Hemostasis

is obtained and a three-layer closure is performed. The most

important layer

of

the closure, the superficial fascia, is closed

with either a number 1

r

0 Vicryl

r

equivalent suture.

Repair

of

the superficial fascial layer is performed under ten-

sion. Doing so allows

the

dermis to be approximated under

minimal tension which increases the chance of obtaining a

thin, inconspicuous scar. Size 2-0 or 3-0 Vicryl

r

equivalent

suture is used in

an

interrupted buried fashion to approximate

the dermis

at

each vertical oriented/tattoo mark and then at

approximately 1 em intervals. Finally. a running intradermal

number

40

Monocryl or equivalent suture is used to approxi-

mate the skin edges. The patient is carefully repositioned into

the

supine position. Foam rolls are placed beneath the knees

and the heels are padded. The arms are abducted and placed

on padded arm boards.Warm

air

blankets are placed over the

lower extremities. A standard surgical prep and drape

of

the

anterior body surface is performed. When indicated, liposuc-

tion is performed throughout

the

areas

that

were previously

infiltrated.


20/42

698 PanVD:: Body Contouring

FIGURE 67 3. ower body lift markings (A aDd B). Preoperative markings are demonsttawl with the patient .n:.laxed.

A

Note how low the

anterior

inc:.i ion is

in the midline,. removing a signifiamt pol lion of the hypertrophied mons. B. Realigmnent marks are added. In this

c:ase .

a

buttoc:ks augmentation using a gluteoplasty

will

be pc:rlonned and the markings for this are evident.

The temporary sutures placed

at

the midaxillary V Y clo-

sure are removed

and

the end

of

the

V

Y incision is contin-

ued anteriorly connecting

to

the lower abdominal incision.

The superficial inferior epigastric vessels are identified

and

controlled. Dissection continues in the cephalic direction to

the

level of

the umbilicus where perforating

vessels

are identi-

fied and controlled. Massive weight loss patients often have

perforators

of

significant caliber requiring suture ligature

or

vascular clipping. The umbilical skin is circumferentially

incised

at

its junction with the abdominal skin, and scissor

dissection is performed

to

the abdominal wall. Frequently,

this dissection naturally finds the natural plane between the

umbilical stalk and the subcutaneous tissue. The abdominal

flap that has been elevated up

to

the umbilicus is then usu-

ally split vertically

in

the midline which facilitates further

cephalic dissection (Figure 67.7A). Dissection is continued

in

the cephalic direction

to

the level

of

the costal margins

and xiphoid. Myofascial plication is performed with the help

of

muscle relaxation provided by the anesthesiologist. The

medial borders

of the

rectus diastasis

and

the anticipated

borders

of

the plication are marked with methylene blue.

The width

of

the plication can be modified as needed during

the plication process (Figure 67.7B). We utilize a number

0

looped nylon suture with a large tapered needle to perform a

running single layer myofascial plication, bringing together

the lateral borders of the marked plication boundary. This

double-stranded suture has proven

to

be highly effective

and

durable

and

has replaced

our

previous use

of

interrupted

sutures and a two-layer closure.

We

have

not

identified a

single instance

of

suture failure and premature release

of

the

myofascial plication utilizing the looped nylon method over

the last 10 years. At the level

of

the umbilicus the suture is

placed only

on

one side

of

the plication, allowing an appro

priate amount of fascial laxity around the umbilical stalk.

The looped nylon is tied

at

the level

of

the pubic symphysis

and the knot is buried. The use

of

the looped nylon allows

complete myofascial plication in a continuous fashion with

the creation

of

only one knot. A second layer

of

suture can

be placed

to

reinforce the first but we have rarely found this

to

be necessary.

Marcaine

0.5

is injected throughout the entire

area

of

undermining

and into

the

rectus

sheath

to

decrease

FIGURE

67.4. Lateral markmp in

lowc.r

body lift (A and

B).

The most important ma.rltini is in the

mida:xillary

line where the risk of over-

.resection is

the greatest.

A The final desired

incision line

is

marked and then sttong bimanual palpation is used

to

identify the redundancy. The

patient leans away from the surgeon to avoid over-resec:tion. B An anteriorly pointing V Y marking is made, which

signifies

the transition from

the

proDe to the supine portions of the operation.

B

B


21/42

c

FIGURE 67 5 FJeur de lis

markings.

The TC ttical resection

is

in the

shape of an ellipse.

It

is not a triangle because a triangle .n:seaion will

result in

e:xa:.ssive

tension at the final c:losure point.

With

an existiiJ3

Nlx:ostal scar, die

vertical ellipse

is shifted

to

the right which allows

for the inclusion of

his

scar

and

its removal in the leur de lis resection

hapter

67:

LowerBody Lift and

Thighplasty

99

FIGURE 67.6. Closure of the

supc:.rficial fascia.

The superficial

fascia

is marked

in

methylene blue and this is the line at which

the

high

tension closure

is

performed. Strong tension on the superficial

fas-

cia

decreases the tension across the final incision line which lessons

scar

widening.

FIGURE 67.7. Supine portion of lower body lift A-D).

A

The flap

is

divided at the umbilicus and

some

subcutaneous

tisNes

are left sur-

rounding the umbilicus

to

preserve its vascularity. B. Dissection

is

continued to the level of the xiphoid and markings are

made

for rectull

plication. The medial borders of the rectus are

first

marked and then an estimated line of plication is marked lateral

to

this in methylene blue.

C. ftu

the

plication has been completed, a final drain and the pain pump catheter are placed.

D.

Tissue to be resected

is

determined with the

Pitanguy demarcator.


22/42

700

PanVD:: ody

Contouring

postoperative pain. We place a lidocaine pain pump

Documents

Chapter Body Contouring in Grab & Smith Book 2013