Body contouring

Circumferential approaches to body contouring are a cornerstone for reshaping of the trunk after pregnancy, weight loss, or aging.

Procedures for trunk contour reshaping differ in design and execution, and body contouring surgeons should understand the fundamental principles of each procedure and be able to apply these in an individualized approach to meet each patient's unique anatomical features and aesthetic goals.

• In broad strokes, the belt lipectomy is a powerful tool for refining the waistline, while the lower bodylift generally has a more inferior zone of resection and effectively enhances lateral thigh and buttock shape.

Innovations in tissue repositioning during circumferential bodylifting have enabled significant advances in buttock shaping with local flaps.

Body contour deformities of the lower trunk can range from “anterior only” to “circumferential” deformities.

• If problems are restricted to isolated moderate lipodystrophy deposits, then liposuction may be the only treatment modality needed.

• Anteriorly, if skin laxity and/or abdominal wall weakness are encountered, then abdominoplasty techniques are needed to create the best contour.

• If the deformities involve skin and subcutaneous laxity circumferentially, then bodylift/belt lipectomy procedures are usually required to adequately address the issues.

Although it is true that tension is bad for scarring and blood supply, tension is essential for improving body contour in excisional procedures.

• In abdominoplasty, the elliptical excision creates the greatest amount of tension in the central zone of the abdomen. Thus, the areas above and below this region, superiorly the epigastric region and inferiorly the mons pubis, demonstrate the greatest amount of improvement.

• As the elliptical excision is followed laterally, the amount of tension decreases, reaching zero at its lateral edges ( Fig. 7.1 ) . Thus, the improvements above and below the excision, the anterior thighs, and the lateral abdomen also decrease in magnitude as the elliptical excision is traversed from medial to lateral.

  

• In an ordinary low BMI patient with “anterior only” deformities, there is little need for improvement above and below the excision, outside of the anterior abdomen.

• However, in most massive-weight patients, many 20–30 pounds overweight patients, and some normal-weight patients, there is a need for significant improvements above and below the level of excision circumferentially around the entire lower trunk ( Fig. 7.2 ) . Thus, with the tension maintained circumferentially, the improvement is also maintained circumferentially above and below the excision.

  

• If the concept of maintaining tension around the trunk is ignored in patients who need improvements circumferentially, either by doing an abdominoplasty or a T-type (fleur-de-lis) resection, the results are less than ideal, with the lateral and posterior aspects of the lower trunk remaining unchanged after surgery ( Fig. 7.3 ) .

  

There are three groups that can potentially benefit from bodylift/belt lipectomy procedures: massive weight loss (MWL) patients, the 20–30 pounds overweight group, and the normal-weight patients group.

MWL patients:

• Make up the majority of patients who undergo bodylift/belt lipectomy.

• The lower trunk of MWL patients can be thought of as a balloon. As patients gain weight and then lose it, the balloon is initially stretched by the weight gain, then deflated as weight loss ensues. The intrinsic elasticity of the skin is often irreversibly altered, leading to redundant lax skin, which is almost always circumferential in nature. The usual pattern is of an inverted cone ( Fig. 7.4 ) .

  

The 20–30 pound overweight group (BMI range of 26–28):

• Women who have never lost any significant weight despite reasonable exercise and nutritional habits.

• Often present with lipodystrophy of the lower trunk that is circumferential in nature, which leads to generalized lack of definition of the lower trunk ( Fig. 7.5 ) .

  

Normal-weight patients group:

• Ordinarily would be considered candidates for an abdominoplasty but desire more dramatic improvements in lower truncal contour.

• These patients often desire a remarkable improvement in their anterior thighs, lateral thighs, buttocks, and lower back.

• In many similar patients, liposuction can improve all of these areas when combined with an abdominoplasty; however, if patients desire significant lifting and contour delineation, then a circumferential excisional procedure is required ( Fig. 7.6 ) .

  

• A subgroup of normal-weight patients who can benefit from a bodylift/belt lipectomy is the older patient whose skin will not contract with liposuction due to skin laxity and will require the pull created by the circumferential excision ( Fig. 7.7 ) .

  

Three factors seem to affect the presentation of patients seeking truncal contouring procedures: the BMI at presentation, the fat deposition pattern, and the quality of the skin/fat envelope.

• MWL patients will present to the plastic surgeons at different BMI levels ( Fig. 7.8 ) .

  

• The type of deformity that an MWL patient presents with also depends on their particular fat deposition pattern. Humans are born with a genetically controlled pattern of fat deposition, as well as a fat loss pattern. Females generally tend to store fat in the extraperitoneal space, the lower abdomen, hips, and thighs – a pattern often referred to as “pear shaped” ( Fig. 7.9 ) . Males tend to store fat more centrally in what is often referred to as an “apple-shaped” configuration, where fat is deposited intraperitoneally and in the flanks (or “love handles”), and less fat is deposited in the thighs (see Fig. 7.9 ).

  

• The skin/fat envelope is important in determining what must be done to meet patient goals. Some patients present with very pliable and thin skin/fat envelopes, while others will present with very thick, non-pliable tissues.

A concept that is helpful in examining these patients is the “translation of pull” ( Fig. 7.10 ) .

• The lateral abdominal tissues are pinched, simulating the effects of the lateral abdominal resection of a bodylift/belt lipectomy on the distal thigh, which can be predictive of the final result with a certain degree of accuracy.

• If the pinch demonstrates very little translation of pull to these areas, as in the case of patients who present with high BMIs and thick, non-pliable skin/fat envelopes, this can be used to predict the final result.

• As a general rule, the greater the BMI drop, the more translation of pull will be present.

Almost all present with a “hanging panniculus” ( Fig. 7.11 ) .

Almost every patient will present with a “ptotic mons pubis”.

The waist, which is the narrowest aspect of the lower trunk between the ribs and the pelvic rim, can be blunted in many MWL patients by the hanging skin/soft tissue envelope, as it drapes from the ribs to below the pelvic rim.

The anterior and lateral thighs are usually ptotic.

The buttocks are usually ptotic due to the effects of the weight gain/loss process. This can present with a lack of demarcation between the lower back and buttocks ( Fig. 7.12 ) .

Many patients present with back rolls. Some are located in the lower back and may be improved with bodylift/belt lipectomy. Some present superiorly, usually contiguous with breast rolls, and are not affected by bodylift/belt lipectomy and must be addressed through upper bodylift procedures ( Fig. 7.13 ) .

A detailed weight history is essential in patients who present for lower truncal contouring. It is important to ascertain the etiology of their lower trunk abnormalities, which include aging, child birth, skin laxity due to sun exposure, and MWL. If the main cause is weight loss, then the following questions should be answered:

• What was their greatest weight?

• How did they lose weight?

• What was their lowest weight?

• How long have they been at their present weight?

• Do they think they are going to lose more weight?

• Are they prone to “heroic methods” of weight loss?

A careful history of all significant medical problems, including nutritional habits, nutritional supplementation requirements, and nutritional deficits, should be obtained.

Some surgeons my require psychiatric clearance for each belt lipectomy/bodylift patient to emphasize the extensive nature of the surgery to the patient as well as alerting the mental healthcare provider that their services may be required in the postoperative period.

The following points should be carefully noted on physical examination:

• The degree of skin laxity.

• The amount of subcutaneous fat.

• The translation of pull, as described above.

• The presence of scars (e.g., subcostal cholecystectomy scars may jeopardize the flap vascularity, and vertical midline scars may limit abdominal flap inferior mobility).

• Waist definition.

• The presence of abdominal or back rolls.

• The degree of rectus diastasis and/or the presence of hernias.

• The amount of intra-abdominal content must be noted. This can be assessed with the patient lying supine and relaxed. If the abdominal contour is scaphoid and the abdominal wall falls below the rib cage, then it would be expected that rectus fascia plication will be effective in flattening the contour. If the abdominal tissues are above the level of the ribs, then it can be presumed that intra-abdominal contents are large enough to prevent effective plication (see Fig. 7.9 ).

• The degree of buttocks projection and ptosis.

• The degree of anterior and lateral thigh lipodystrophy and ptosis.

• An extensive set of labs should be obtained as early as possible in the care of the patient because it may take some time to correct abnormalities. These labs should include a complete blood count, blood urea nitrogen, creatinine, electrolytes, glucose, urinalysis, liver function tests, iron, calcium, albumin, pre-albumin, total protein, vitamin B, magnesium, and thiamine.

• Chest X-ray and electrocardiogram are obtained if indicated.

When contemplating circumferential dermatolipectomy of the lower trunk, a thorough understanding of abdominal wall blood supply is critical.

Subcutaneous abdominal fat is divided into superficial and deep layers by the superficial fascial system (Scarpa fascia).

• In thin patients, the two layers are fairly close to each other in thickness. In patients who have a high BMI, the superficial layer is often much thicker than the deep layer.

Zones of adherence: areas within the trunk where the skin/fat envelope is tethered to the underlying musculoskeletal anatomy, restricting either descent or elevation, which can occur with aging, weight fluctuation, or surgical manipulation.

• Act like “hooks” for the skin/fat envelope to hang on to as it falls down, especially after the skin has been stretched by excess weight and then deflated by weight loss ( Fig. 7.14 ) .

  

• Strong zones of adherence include zones overlying the spine, sternum, and bilateral inguinal region.

• Weak/variable zones of adherence include zones over the midline linea alba of the abdomen and in the horizontal suprapubic crease.

• Other important zones of adherence: between the hip and lateral thigh.