CME Body Contouring Khalid Almutairi, M.D. Jeffrey A. Gusenoff, M.D. J. Peter Rubin, M.D. East Lansing, Mich.; and Pittsburgh, Pa.

Learning Objectives: After reading this article, the participant should be able to: 1. Provide a careful preoperative evaluation. 2. Understand the relevant anatomy. 3. Appreciate and apply the range of procedures that can be applied to address an individual patient’s goals. 4. Focus on patient safety and avoiding complications. Summary: Body contouring has advanced significantly over the past decade, fueled by the increased number of massive weight loss patients and the advent of new fat-reduction technologies. This has impacted both the number of cases performed and the range of procedures. Many innovations are being developed as plastic surgeons meet the evolving needs of our patients. This review covers essential principles of patient selection and safety; anatomical concepts; staging and combining procedures; and select aspects of contouring of the trunk and extremities using excisional techniques, liposuction, and fat grafting.  (Plast. Reconstr. Surg. 137: 586e, 2016.)

T

he emergence of body contouring surgery as a subspecialty of plastic surgery has been greatly influenced by the increasing numbers of massive weight loss patients. The increased prevalence of successful bariatric surgery procedures over the past two decades has resulted in a variety of body contour deformities in the massive weight loss patient that were not commonly seen by plastic surgeons in the past. In addition, weight loss patients have potential metabolic derangements that require special consideration during the screening and evaluation process. Thus, addressing these deformities requires a standardized approach to provide safe and successful surgical care. The subspecialty of body contouring encompasses massive weight loss patients and patients with specific anatomical contour deformities related to pregnancy, aging, or weight reduction from dieting and exercise.

ANATOMICAL CONCEPTS Several anatomical concepts key to body contouring are important to review: Superficial Fascial System The earliest description of the superficial fascial system was by Antonio Scarpas (1752 to 1832) and Petrous Campers (1722 to 1831) almost 200 years From the Department of Surgery, Michigan State University; and the Department of Plastic Surgery, University of Pittsburgh. Received for publication May 23, 2015; accepted October 29, 2015. Copyright © 2016 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000002140

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ago.1,2 In 1991, Ted Lockwood published a landmark article that discussed the finer structure of the fascial framework within the subcutaneous tissues and its surgical importance in body contouring.3 Lockwood’s work was fundamental to the understanding of the superficial fascial system and how it not only invests and divides the fatty layers into superficial and deep compartments, but has a rich network of interconnected fibrous bands within the tissue that impart strength when the subcutaneous layer is repaired.4–8 Markman and Barton studied the superficial and deep layers of fat in the trunk and extremities and found that the superficial layer of fat is more compact and compartmentalized in tight septa attached to the deep dermis.9 Repair of the superficial fascia helps stabilize the wound against distracting tension forces (Figs.  1, 2, and 7).10 The superficial fascial system supports the fat of the body, naturally anchors the adipose tissue to surrounding structures, and provides a load-bearing network that, when repaired, can suspend tissues and reduce tension on the dermal closure.4–8 Disclosure: Dr. Rubin receives royalties from Becon Medical for a device used in the surgical video. The other authors have no conflicts of interest related to any material discussed in this article. Related Video content is available for this article. The videos can be found under the “Related Videos” section of the full-text article, or, for Ovid users, using the URL citations published in the article.

www.PRSJournal.com

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Volume 137, Number 3 • Body Contouring Zones of Adherence Illouz in 1989 introduced the concept of fascial fixed points. These fixed points were further defined by Rohrich et al., who described five regions in which the subcutaneous tissues are consistently firmly adherent to the deep fascia. This represents a condensation of the superficial fascial system. Liposuction should either be avoided or performed cautiously in these areas to prevent contour deformity (Level of Evidence: Therapeutic V) (Fig. 2, right).11,12 This concept is

also important in tissue resuspension during a lower body lift, in which Lockwood advocated disrupting the trochanteric zones of adherence with blunt discontinuous undermining to allow the lateral thigh tissues to be fully mobilized.6 In massive weight loss patients, aberrant fascial thickening in the midabdomen serves as a tethering point and leads to multiple rolls. The surgical release of these points of fixation can have an unfurling effect that improves the appearance of midabdominal rolls (Fig. 3).

Fig. 1. (Left) Chemically decellularized cross-section of the abdominal skin and subcutaneous layer outlining the anatomical architecture of the superficial and deep fascia. The superficial layer serves as a great layer for anchoring the skin flaps and taking the tension off the dermal repair. SSL, superficial subcutaneous layer; DSL, deep subcutaneous tissue. (Right) Superficial fascial system (SFS) exposed by liposuction in the arm. Tissues were treated with liposuction to debulk adipose deposits in the posterior arm before excising skin. With the adipose tissue removed, the architecture of the fibrous skeleton, a network of connective tissue bands within the subcutaneous tissues, is clearly exposed.

Fig. 2. (Left) The zones of fascial adherence adapted from Rohrich et al. Five fascial adherence zones should be avoided during liposuction to prevent contour deformities. The lateral gluteal depression in red is the anatomical region usually undermined (directly or discontinuously) to achieve significant lifting of the lateral thigh during a lower body lift procedure. (Reprinted with permission from Rohrich RJ, Smith PD, Marcantonio DR, Kenkel JM. The zones of adherence: Role in minimizing and preventing contour deformities in liposuction. Plast Reconstr Surg. 2001;107:1562–1569.) (Right) In massive weight loss patients, fascial thickening in the abdomen with aberrant zones of adherence creates multiple rolls. The variation in the location of these zones of adherence leads to different patterns of skin rolls.

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Plastic and Reconstructive Surgery • March 2016 Blood Supply and Lymphatic Drainage To achieve optimal results and avoid complications, the vascularity of all areas of interest should be well preserved. This is only possible by understanding the angiosomes of each skin territory.13,14 Abdominoplasty vascular zones were originally described by Huger.13 Figure 4 shows the vascular zones of the abdomen, relating to liposuction during abdominoplasty, as adapted from Matarasso et al.15 The lymphatic drainage is equally important, and the dissection and elevation of skin flaps should take into account the preservation of the inguinal lymph node basins, which can be injured when abdominal incisions are marked below the inguinal ligament, as is often seen in massive weight loss patients (Fig.  4). These node basins can also be injured during thighplasty. Surgeons

have speculated that the lymphatic channels in the abdomen can be preserved below the umbilicus by elevating the skin flap superficial to the Scarpa fascia.16–18 Although this maneuver has been credited with reduced seroma rates, it is unclear whether this is attributable to actual preservation of lymphatic function or changing the contact surface beneath the flap to fatty tissue. Innervation Nerves can be injured from improper positioning and padding, and/or surgical trauma. Injury to certain superficial sensory nerves can produce painful and long-lasting neuropathies. In abdominoplasty, the lateral femoral cutaneous nerve emerges superficially approximately 2 cm medial to the anterior superior iliac spine, and dissection in this area should be superficial to protect the nerve (Fig.  4, right) and reduce the risk of developing meralgia paresthetica, which is a syndrome characterized by numbness, tingling, and burning pain on the lateral thigh.19,20 In brachioplasty, the medial antebrachial cutaneous nerve of the forearm emerges in the distal medial third of the arm to supply the medial forearm (Fig.  5). The nerve divides into anterior and posterior divisions around the basilic vein in the distal arm, and can be preserved by keeping the distal third of the brachioplasty flap elevation superficial with an adequate layer of fat left covering the nerve.21 Figure  5 shows relevant sensory nerves in the field of dissection of the lower body lift.

PATIENT SELECTION

Fig. 3. Image adapted from Markman and Barton’s study of the superficial and deep layers of fat in the trunk and extremities. Note that the superficial layer of fat is more compact and compartmentalized in tight septa attached to the deep dermis. SL, superficial layer; DL, deep layer; SQF, subcutaneous fat. (Reprinted with permission from Markman B, Barton FE Jr. Anatomy of the subcutaneous tissue of the trunk and lower extremity. Plast Reconstr Surg. 1987;80:248–254.)

Sound clinical and surgical judgment for selecting patients and staging procedures should be based on a full and detailed medical history, relevant blood tests, necessary imaging, and appropriate consultation with other medical and surgical services. Obesity is defined as body mass index greater than 30 kg/m2, and there is a strong correlation with increased complications in body contouring patients who have surgery with a body mass index greater than 30 kg/m2 (Reference 25 Level of Evidence: Therapeutic, IV).22–25 The medical interview should start with questions related to the patient’s motivation, concerns, and expectations. Unrealistic expectations or unreasonable motivations should be detected. Psychosocial assessment is important, and specific questions regarding psychiatric history and medical treatment should be posed. Signs of body dysmorphic disorder and eating disorder should warrant a full psychiatric assessment (Table 1). The rate of patients presenting for cosmetic surgery with some form of body

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Volume 137, Number 3 • Body Contouring

Fig. 4. (Left) The vascular zones of the abdomen in liposuction. Classic teaching dictates caution when performing liposuction on the central part of an abdominal flap. This concept has been challenged with the advent of the lipoabdominoplasty. The left side shows the blood supply on the unoperated abdomen and the right side shows the remaining blood supply postoperatively after a classic abdominoplasty flap has been elevated. MPA, main pulmonary artery; DSEA, deep superior epigastric artery; SSEA, superficial superior epigastric artery; DCIA, deep circumflex iliac artery; SCIA, superficial circumflex iliac artery; SIEA, superficial inferior epigastric artery; DIEA, deep inferior epigastric artery; SEPA, superficial external pudendal artery; SAL, suction-assisted lipectomy. (Adapted with permission from Matarasso A. Classification and patient selection in abdominoplasty. Oper Tech Plast Reconstr Surg. 1996;3:7–14.) (Right) Important anatomical structures observed during the elevation of the abdominoplasty flap. The green zone reflects the lower part of the abdomen inferior to the lower incision. Superficial dissection will protect the lymph nodes. Note that the superficial inferior epigastric arteries are encountered and carefully ligated, and the lateral femoral cutaneous nerve of the thigh has a variable course below the inguinal ligament, and should be protected by leaving the fascia intact in an approximately 4-cm radius medial to the anterior superior iliac spine. The gray zone is an area of variable undermining to allow access to the rectus fascia and enable skin redraping. The yellow zone is the region where intercostal perforators emerge and there is minimal undermining to preserve the central flap blood supply.

Fig. 5. (Left) Important anatomical structures observed during brachioplasty. The basilic vein is an important landmark, especially in the distal third of the arm where the medial antebrachial cutaneous nerve is in proximity. (Right) The lower body lift incision is marked, and the superior cluneal sensory nerves can be avoided by keeping the dissection superficial around the sacrum.

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Plastic and Reconstructive Surgery • March 2016 Table 1.  DSM-5 Diagnostic Criteria for Body Dysmorphic Disorder* A. Preoccupation with perceived defect(s) or flaw(s) in physical appearance not observable or that appear(s) slight to others. B. At some point during the course of the disorder, the person has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, or reassurance seeking) or mental acts (e.g., comparing their appearance with that of others) in response to the appearance concerns. C. The preoccupation causes clinically significant distress (e.g., depressed mood, anxiety, shame) or impairment in social, occupational, or other important areas of functioning (e.g., school, relationships, household). D.  The appearance preoccupations are not restricted to concerns with body fat or weight in an eating disorder. DSM-V, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. *Adapted from Phillips KA, Wilhelm S, Koran LM, et al. Body dysmorphic disorder: Some key issues for DSM-V. Depress Anxiety 2010;27:573–591.

dysmorphic disorder has been reported as between 5 and 15 percent.26–28 Crerand et al. reported that 91 percent of medically treated patients with body dysmorphic disorder did not show any improvement in their symptoms.29 Another concern is that certain antipsychotics and antidepressants can increase the risk of bleeding. For example, selective serotonin reuptake inhibitors can lead to a four-fold increased risk of bleeding in cosmetic surgery. Therefore, it is recommended that the treating physician be consulted about withholding any neurotropic medications.30 Information about recent weight loss or gain and method of weight loss should be documented (Table  2). Although many bariatric patients lose 70 percent of their excess body weight, it is not uncommon to observe significant fluctuation in weight after bariatric surgery, and up to 10 percent of patients might not experience weight loss following bariatric surgery.31,32 Weight should be stable for at least 3 months before body contouring.33 Proper nutritional assessment with correction of deficiencies is crucial to the healing of large surgical wounds. Protein malnutrition can be common in bariatric patients, who often have food intolerances. Low albumin levels; iron deficiency; and vitamin A, D, E, and K deficiency are all common and can lead to poor wound healing and increased blood loss if not corrected. Information about history of thrombotic events and tobacco use is also key to the interview. Table 2.  Important Historical Questions for the Body Contouring Patient Current weight, lowest weight, and highest weight (with calculation of current BMI, lowest BMI, and highest BMI) Method of weight loss (surgical vs. nonsurgical) If surgical weight loss, type of procedure Goal weight Weight changes in the past 3 mo Nutritional history (protein, multivitamins, and iron supplementation) Pregnancy history Previous DVT or coagulopathy history Tobacco use BMI, body mass index; DVT, deep venous thrombosis.

Documenting comorbidities related to medical and surgical history, and a head-to-toe review of systems with particular attention to ruling out endocrinopathies and hematologic conditions, especially hereditary coagulopathies, are important.34 Any active or suspected pulmonary or cardiac disease should be further evaluated. Consultation with an internist, primary care physician, or other surgical specialist may be indicated to stratify a patient’s risk and to medically optimize patients for the lowest risk for complications. During a complete physical examination, each body region should be assessed for thickness of the subcutaneous layer, and the abdomen should be examined for the presence of hernias. Excessive laxity, striae, and intertriginous rash should be noted and documented. The Pittsburgh Rating Scale defines deformities across different anatomical regions and provides a guide for documenting these findings.35

PATIENT SAFETY CONSIDERATIONS Informed Consent The process of obtaining informed consent mandates that the patient and the surgeon have a detailed discussion about the planned procedure. The surgeon should be forthcoming in volunteering information with regard to recovery and possible complications.36 For excisional procedures, the surgeon should emphasize the tradeoff of accepting permanent scars in exchange for better contour. A comprehensive list of potential complications should be included in the informed consent. Table 3 shows an example of a detailed list of adverse events that can occur with abdominoplasty. Smoking It is well known that tobacco is a risk factor for surgical complications.37–39 In a survey by Rohrich et al., 75 percent of surgeons required their patients to abstain from smoking for at least 4 weeks,37 though only 17 percent would confirm compliance with a preoperative negative urine

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Volume 137, Number 3 • Body Contouring Table 3.  Example of Complication List for Abdominoplasty Informed Consent Infection Bleeding Fluid collections (seroma) Skin necrosis or nonhealing areas of skin on the abdomen Permanent scar, which may be wide, have areas of persistent thickness, and differ in color from surrounding skin Scar may not be completely concealed by clothing, especially with changing fashion styles Recurrent looseness of skin Asymmetric or irregular contour of the abdomen Umbilicus (belly button) may be higher or lower than expected, and may not be exactly in the midline Loss of blood supply to the belly button with poor healing or even complete loss of the belly button Asymmetry in scar position or contour Persistent skin creases, skin folds, and/or irregular contour Change in position of pubic hairline Pulling or tightness of the pubic region Tightness of the abdominal wall that can result in respiratory difficulty Numbness in the lower part of the abdomen that can be permanent Wound healing problems such as wound separation, that may require treatment with gauze dressings, or even additional surgery Venous thromboembolisms, which are blood clots that can occur in the legs and/or travel to the lungs

cotinine test. The decision to operate on active smokers remains an area of controversy, and many surgeons prefer to delay surgery.37–39 Preoperative and Intraoperative Safety Measures Hypothermia should be prevented with preoperative and intraoperative use of body warmers, warm blankets, and warm fluid irrigation.20,40–44 Hypothermia has recently been reported as an independent risk factor for seroma.41 Surgical-site infections should be prevented at every step, with appropriate preoperative disinfection, perioperative antibiotics, and close glycemic control in diabetics. Preoperative antibiotics should be given 1 hour before making the incision.42,45,46 Clear and early communication with the anesthesiologist is crucial. Fluid replacement should be maintained at the patient’s maintenance needs, and gauged against urinary output when a bladder catheter is in place. Venous Thromboembolism Prophylaxis Among plastic surgery procedures, body contouring operations have a higher incidence of thrombotic complications. According to data accrued between 2001 and 2006 from the American Association for Accreditation of Ambulatory Surgery Facilities, abdominoplasty had the highest frequency of death secondary to pulmonary embolism in an office-based surgery facility.47 A number of studies have attempted to clarify how venous thromboembolism prophylaxis should be managed in plastic surgery.48–54 In 2011, the American Society of Plastic Surgeons Venous Thromboembolism Task Force recommended a three-prong approach to the reduction of venous thromboembolism by (1) assessing risk in all patients, (2)  considering

preventative measures including use of mechanical and chemical prophylaxis, and (3) patient education. One of the factors that may cause plastic surgeons to avoid chemoprophylaxis is bleeding risk. The American Society of Plastic Surgeons Venous Thromboembolism Task Force summarized the findings of published studies, two of which included body-contouring patients, to examine risks of chemoprophylaxis. The first study, by Hatef et al., had a higher incidence of hematoma and transfusion with use of enoxaparin, which was prescribed to moderate- to high-risk patients immediately preoperatively or intraoperatively and subsequently two times per day.55 The second study, by Pannucci et al.,48 used a weight-adjusted once-a-day regimen of enoxaparin given once daily starting 6 to 8 hours postoperatively, and reported no increased risk of reoperative hematomas. Specific guidelines for plastic surgery patients are limited by the availability of evidence. Pannucci et al.51 showed that plastic surgery patients with a Caprini score of 7 or greater have reduced venous thromboembolism rates with chemoprophylaxis. In February of 2012, the American College of Chest Physicians published their 9th Edition Recommendations for venous thromboembolism prophylaxis, a well-respected evidence-based source. In nonorthopedic procedures (patients undergoing general, gastrointestinal, urologic, gynecologic, bariatric, vascular, plastic, or reconstructive surgery) based on a body of literature ranging from a moderate to low level of evidence and grouping analogous procedures together, they recommend chemoprophylaxis at a Caprini score of 3 to 4 (moderate risk). Their recommendations for plastic and reconstructive surgery are summarized in Table 4.54,56 We recognize that plastic surgery procedures are grouped nonspecifically with procedures in other specialties.

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Plastic and Reconstructive Surgery • March 2016 Table 4.  American College of Chest Physicians Recommendations for Venous Thromboembolism Prophylaxis in Patients Undergoing General, Gastrointestinal, Urologic, Gynecologic, Bariatric, Vascular, Plastic, or Reconstructive Surgery* 1. For general and abdominopelvic surgery patients at very low risk for VTE (~0.5%; Rogers score, 7; Caprini score, 0), we recommend that no specific pharmacologic (grade 1B) or mechanical (grade 2C) prophylaxis be used other than early ambulation. 2. For general and abdominopelvic surgery patients at low risk for VTE (~1.5%; Rogers score, 7–10; Caprini score, 1–2), we suggest mechanical prophylaxis, preferably with intermittent pneumatic compression, over no prophylaxis (grade 2C). 3. For general and abdominopelvic surgery patients at moderate risk for VTE (~3.0%; Rogers score, >10; Caprini score, 3–4) who are not at high risk for major bleeding complications, they suggest low-molecular-weight heparin (grade 2B), lowdose unfractionated heparin (grade 2B), or mechanical prophylaxis, preferably with intermittent pneumatic compression (grade 2C), over no prophylaxis. 4. For general and abdominopelvic surgery patients at high risk for VTE (~6.0%; Caprini score, ≥5) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with low-molecular-weight heparin (grade 1B) or low-dose unfractionated heparin (grade 1B) over no prophylaxis. We suggest that mechanical prophylaxis with elastic stockings or with intermittent pneumatic compression should be added to pharmacologic prophylaxis (grade 2C). VTE, venous thromboembolism. *Adapted from Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuunemann HJ. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141:7S–47S.

Staging and Combining Procedures There are numerous body contouring procedures, and combining too many procedures at once has the potential for increased risk. Decisionmaking should be reached mutually between the patient and the surgeon, and should be based on realistic expectations of what could be performed safely at once; this is typically dictated by the patient’s medical status, current and delta body mass index (change from maximum body mass index to current body mass index), weight loss history, comorbidities, smoking status, nutritional status, surgeon’s experience, and opposing vectors of pull between adjacent procedures. Additional factors include the operative setting and composition of the surgical team. The same variables that influence whether procedures can be safely combined will also impact a reasonable procedure length. In well-selected patients undergoing multiple procedures, Coon et al. reported that complications per procedure remained the same, and systemic complications were no different (Reference 61 Level of Evidence: Therapeutic, III).57–64 In our practice, massive weight loss patients with a body mass index under 30 and a good medical profile may be offered a first-stage lower circumferential body lift, along with one upper body procedure. Typically, after 3 months, a second-stage vertical medial thigh lift and another upper body procedure could be performed (Fig. 6). Certain combinations of procedures work well together, whereas other combinations require caution (Table 5).

UPPER EXTREMITY CONTOURING Upper arm procedures can range from simple posterior compartment liposuction to

long-scar brachioplasty with liposuction. The decision to choose a procedure depends on the amount of skin laxity and the thickness of the fatty compartments. The Teimourian classification is widely accepted and can aid in decision-making (Table  6).65 There is controversy with regard to longitudinal scar placement; some surgeons prefer a posterior location and others prefer a bicipital groove location.65–68 The important points in brachioplasty are to avoid injury to the medial antebrachial cutaneous nerve and to avoid overresection, which may lead to excessive tension or inability to close the wound. Longitudinal scar brachioplasty is the most commonly preformed brachioplasty procedure in the massive weight loss patient population.67 Short-scar procedures are better suited for non– massive weight loss patients.69,70 Figure 7 shows a bicipital groove long-scar brachioplasty.

UPPER TRUNK CONTOURING Breast Procedures Although a detailed discussion of breast reshaping procedures is outside the scope of this review, we mention this topic in the context of (1) combining breast operations with other body procedures, (2) using adjacent tissues for breast volume augmentation, and (3) combining liposuction with breast fat grafting. The critical issue in deciding to combine breast reshaping with abdominal contouring, especially with massive weight loss patients but also normal body mass index cosmetic patients, is the stability of the inframammary fold. If the inframammary fold is very mobile, it may be displaced by the pull of an abdominoplasty. This would

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Volume 137, Number 3 • Body Contouring

Fig. 6. Example of combined procedures executed in a staged fashion. A 38-year-old woman desired total body contouring after a weight loss of 209 pounds. (Above) Preoperative views. (Center) Postoperative views 5 months after the first stage, consisting of fleur-de-lis abdominoplasty, lateral thigh/buttock lift, and brachioplasty. (Below) Postoperative views 9 months after the second stage, consisting of dermal suspension and parenchymal reshaping mastopexy, upper back lift, and vertical medial thigh lift.

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Plastic and Reconstructive Surgery • March 2016 Table 5.  Guidelines for Selecting Procedure Combinations* Caveats and Pitfalls Generally favorable combinations of procedures   Abdominoplasty and mastopexy   Abdominoplasty and brachioplasty   Circumferential lower body lift and brachioplasty   Circumferential lower body lift and mastopexy   Transverse upper body lift/torsoplasty and mastopexy   Mastopexy and brachioplasty   Mastopexy and vertical thigh lift   Brachioplasty and vertical thigh lift Combinations that require caution in planning   Circumferential lower body lift and vertical thigh lift   Circumferential lower body lift and transverse upper body lift   Transverse upper body lift/torsoplasty and brachioplasty

A loose inframammary fold may be displaced during abdominoplasty and impact planned markings for mastopexy Brachioplasty concurrent with another procedure may limit a patients ability to get out of bed independently in the early postoperative period

There is a high magnitude of recovery for this combination and opposing vectors of tension Opposing vectors of tension may result in displacement of scar position Extension of brachioplasty scar inferiorly onto lateral chest may result in confluence of scars (T point) that is prone to breakdown

*Reprinted with permission from: Rubin JP. Principles of plastic surgery after massive weight loss. In: Thorne CH, Chung KC, Gosain A, et al., eds. Grabb and Smith’s Plastic Surgery. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health; 2014:713–720.

Table 6.  Teimourian Classification* Group 1 2 3 4

Description Minimal to moderate subcutaneous fat with minimal skin laxity Generalized accumulation of subcutaneous fat with moderate skin laxity Generalized obesity and extensive skin laxity Minimal subcutaneous fat and extensive skin laxity

*Adapted from Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102:545–551, with permission.

require either staging the operations or having a plan for adjusting the breast markings once the abdominoplasty is completed. Lateral chest wall tissue can be mobilized into the breast mound during mastopexy, as seen with dermal suspension flaps described by Rubin et al.71–73 This corrects the lateral chest skin roll and enhances breast shape and volume. Lastly, the increasing popularity of breast fat grafting is accompanied by liposuction harvest of hundreds of cubic centimeters of donor fat. We must remember that this harvest now becomes an aesthetic procedure in itself.

ABDOMINAL CONTOURING PROCEDURES Panniculectomy This is a functional procedure that involves limited skin and subcutaneous resection to relieve symptoms of intertrigo. Rectus diastasis is not repaired, and many surgeons do not preserve the umbilicus in this procedure.

Upper Body Rolls Upper back rolls can be excised with a transverse scar on the upper back, or with bilateral longitudinal or oblique scars on the lateral chest. Correction of upper back rolls can be performed with breast reshaping or gynecomastia correction, and a circumferential approach may be used.74

Abdominoplasty The main goals for abdominoplasty are to improve the overall abdominal contour through careful analysis of the deformity, selectively impacting skin and fascial components, and leaving a well-concealed scar with a natural appearing umbilicus.75 Rohrich et al. reported that the umbilicus is situated perfectly in the midline in only 1.7 percent of patients.76 The indications for this procedure include redundant flaccid skin, excessive adipose tissue, muscular diastasis and musculoaponeurotic laxity, scar deformities, and striae. If a hernia is to be repaired during abdominoplasty, it is important to reestablish the muscular anatomy of the abdominal wall. Abdominal contouring evolved over a century ago. In 1899, Kelly described the use of a large horizontal abdominal incision to remove redundant skin while repairing abdominal hernias.77 Babcock in 1916 suggested a vertical midline incision.78

Fig. 6. (Continued). (Reprinted with permission from Coon D, Michaels J V, Gusenoff JA, Purnell C, Friedman T, Rubin JP. Multiple procedures and staging in the massive weight loss population. Plast Reconstr Surg. 2010;125:691–698.)

Traditional Abdominoplasty Described by Vernon, Regnault, Pitanguy, and Psiliak, this procedure involves a transverse incision and wide undermining of the abdominal flap. It provides excellent skin draping centrally,

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Volume 137, Number 3 • Body Contouring

Fig. 7. (Left) Preoperative marking for right arm bicipital groove long-scar brachioplasty. Point A is the dome of the axilla behind the edge of pectoralis, point B represents the extension onto the lateral chest wall, and point C is the extension of the bicipital groove scar toward the elbow. In this design, the elbow can be crossed because the scar is midaxial. (Center) Three months after brachioplasty, showing arm contour and scar appearance. (Right) One year after brachioplasty, showing arm contour and scar maturation.

although some criticize the traditional technique because of mons shape distortion79–81 (Fig.  8, above, left). High-Lateral-Tension Abdominoplasty Described by Lockwood as a refinement of standard abdominoplasty, the high-lateral-tension abdominoplasty technique is based on the concept that epigastric skin excess is both horizontal and vertical in nature. Lockwood recommended excising less skin centrally, and focusing most of the skin resection laterally. The main advantage of this technique is the correction of the horizontal laxity, less distortion of the mons, and a tightening effect on the anterior thigh. High-lateral-tension abdominoplasty requires meticulous closure of the superficial fascial system layer, and the scar is higher and longer laterally8 (Fig. 6, above, right). Miniabdominoplasty The miniabdominoplasty was first described by Greminger.82 This procedure resects skin below the umbilicus and serves to correct limited infraumbilical skin laxity. Few patients are actually good candidates for this procedure (Fig.  8, below, left). Umbilical Float Abdominoplasty Transection of the umbilical stalk with preservation of the skin supply to the umbilicus is an option for treatment of a high or tethered umbilicus.15 This operation combines elements of a miniabdominoplasty (no umbilical scar) with the ability to tighten the epigastrium. In addition, rectus plication is possible with this technique.

Lipoabdominoplasty Described by Saldanha et al., this procedure substitutes wide lateral undermining with liposuction to preserve the lateral perforators to the skin flaps, and provides good draping of the central abdominal flap. In theory, this preserves the lateral blood supply to the flap. Proponents of this technique believe that it provides excellent skin redraping without compromising blood supply to the abdominoplasty flap.83 This operation sets a new perspective on combining liposuction with abdominoplasty. Vertical Abdominoplasty The fleur-de-lis abdominoplasty is aimed at correcting epigastric skin laxity and is very useful in certain massive weight loss patients. This technique is excellent for correcting epigastric skin laxity and multiple abdominal folds. A disadvantage of this technique is the addition of a midline vertical scar. There should be very limited undermining outside of the central skin excision to protect the blood supply84,85 (Fig. 8, below, right). [See Video, Supplemental Digital Content  1, which demonstrates the technical maneuvers for successful marking and resection of a vertical abdominoplasty. Undermining is performed only within the area of intended resection (0:14). With the operating table flexed, the triple point is established by use of an inverted towel clip and a pinch test, and then the location is marked with staples to preserve orientation (0:27). The lower abdominal flap is marked for resection using a flap marking technique (0:37). A key element is that resection is

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Plastic and Reconstructive Surgery • March 2016

Fig. 8. (Above, left) Traditional abdominoplasty incision (dotted line) and area of skin undermining (yellow). (Above, right) High-lateral-tension abdominoplasty as described by Lockwood, with limited area of undermining (yellow). (Below, left) Miniabdominoplasty resection. (Below, right) Vertical scar abdominoplasty with limited undermining beyond the excision site.

performed and marked in two separate axes with preservation of the triple point throughout the entire procedure. Once the lower abdominal flap is resected, the triple-point orientation is secured in place with sharp towel clips (1:02). Next, the lower abdominal incision is also secured in place with sharp towel clips (1:17). This ensures that the lower abdominal wound will not be distracted open when tension is placed on the midline skin for marking of that resection (1:26). Tension is then placed on the midline skin using sharp towel clips, and a pinch test is used to confirm the markings on the table (1:36). Because the location of the triple point has been firmly secured with sharp towel clips, the marking of the resection can be drawn right to the triple point (1:42). This video is available in the “Related Videos” section of the

full-text article on PRSJournal.com or at http:// links.lww.com/PRS/B620.] Reverse Abdominoplasty First described by Robello and Franco, some authors limit its use to patients with existing scars in the submammary region and previous abdominal wall contour surgery. Besides the superiorly based scar, a relative disadvantage is reliance on tissue suspension to the chest wall, and any loosening of the tissue fixation can result in recurrent skin laxity. It can also obliterate the inframammary crease, and it often requires crossing the midline at the sternum.86,87 An advantage is the ability to tighten the epigastric region without a vertical scar, and even the ability to mobilize abdominal tissue into a breast reshaping procedure.

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Volume 137, Number 3 • Body Contouring

Video. Supplemental Digital Content 1 demonstrates the technical maneuvers for successful marking and resection of a vertical abdominoplasty. Undermining is performed only within the area of intended resection (0:14). With the operating table flexed, the triple point is established by use of an inverted towel clip and a pinch test, and then the location is marked with staples to preserve orientation (0:27). The lower abdominal flap is marked for resection using a flap marking technique (0:37). A key element is that resection is performed and marked in two separate axes with preservation of the triple point throughout the entire procedure. Once the lower abdominal flap is resected, the triple-point orientation is secured in place with sharp towel clips (1:02). Next, the lower abdominal incision is also secured in place with sharp towel clips (1:17). This ensures that the lower abdominal wound will not be distracted open when tension is placed on the midline skin for marking of that resection (1:26). Tension is then placed on the midline skin using sharp towel clips, and a pinch test is used to confirm the markings on the table (1:36). Because the location of the triple point has been firmly secured with sharp towel clips, the marking of the resection can be drawn right to the triple point (1:42). This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/B620. Copyright © J. Peter Rubin, M.D.

Monsplasty The mons is ptotic in most weight loss patients, and surgical correction of the ptotic mons has been described, especially with suspension techniques.88–90 We offer it to patients with significant mons ptosis who require fascial resuspension to recreate the aesthetic unit of the mons, along with selective use of sharp lipectomy to reduce the thickness of the suprapubic tissues.88

THIGH, BUTTOCK, AND LOWER EXTREMITY CONTOURING Lower Body Lift Procedures There are many recommended procedures for correcting lower body contour deformities; belt lipectomy (sometimes referred to as

circumferential abdominoplasty) and circumferential lower body lift are among these procedures. Belt lipectomy incisions differ from the lower body lift in that they are typically placed higher than a lower body lift. Belt lipectomy traditionally has more impact on waist shape and less pull on the lateral thighs.5,6,91,92 A lower body lift incision allows direct shaping of the buttocks and a strong vertical pull on the lateral thighs. Central deepithelialized dermal pedicles can be incorporated to augment the buttocks.93 Medial Thigh Lift Procedures Although the lower body lift corrects lateral thigh laxity, it does little to address skin laxity in the medial thigh. Two procedures are described to contour the medial thigh, the vertical excision and the

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Plastic and Reconstructive Surgery • March 2016 horizontal excision. The vertical excision provides more reliable results in correcting medial thigh skin laxity. Some authors advocate the use of liposuction at the excision site. Although a transverse-only medial thigh excision is appealing, this procedure is very underpowered and only corrects skin laxity in the uppermost part of the medial thigh.95 Anchoring to Colles fascia, as described by Lockwood, helps suspend the tissues after transverse resection, but it is vital to understand that the force of pull is not transmitted to the distal thigh. Aggressive transverse medial thigh lift can lead to significant cosmetic and functional problems and is not a substitute for a vertical thighplasty if that operation is indicated.

LIPOSUCTION AND FAT GRAFTING FOR BODY CONTOURING Liposuction Liposuction can be used in nonobese patients to treat selected areas of adiposity resistant to normal diet and exercise and is also a great adjunct in many body-contouring procedures (e.g., abdominoplasty, brachioplasty, and thighplasty). Grafting of the aspirated fat enables redistribution of native tissues. Suction-Assisted Lipectomy Suction-assisted lipectomy uses mechanical forces to avulse and aspirate parcels of fat within the subcutaneous tissue with continuous negative pressure.96,97 Power-Assisted Liposuction Power-assisted liposuction uses a powered cannula that moves in a reciprocating fashion to assist the surgeon in breaking down fibrous tissue and fat. Ultrasound-Assisted Liposuction Ultrasound-assisted liposuction uses ultrasound vibration of the cannula to break down connective tissue and emulsify fat. The thermal energy produced has been reported to help with skin tightening but also has been associated with higher rates of complications. Currently, some authors reserve ultrasound-assisted liposuction for tissue areas with more fibrous and dense connective tissue. Newer generation devices have smaller diameter probes that can disperse energy in variable patterns.97–99 Laser-Assisted Liposuction Laser-assisted liposuction can be used to treat defined areas in the body, with claims of producing skin tightening and thermal coagulation to minimize bleeding. It is unclear whether these devices have an advantage over other liposuction technologies.95,100

Table 7.  Liposuction Fluid Resuscitation Guidelines* Small-volume aspirations (5 liters)   Maintenance fluid†   Subcutaneous infiltration   0.25 ml of intravenous crystalloid per milliliter of aspirate >5 liters *Adapted from Rohrich RJ, Beran SJ. Is liposuction safe? Plast Reconstr Surg. 1999;104:819–822. †Amount of fluid to be replaced from preoperative, nothing-bymouth status.

Wetting Solutions The concept of fluid infiltration was developed by Klein.101 This modification enabled aggressive liposuction previously possible only under general anesthesia and limited blood loss. Klein introduced the concept of lower concentrations of local anesthetic and epinephrine combined with a higher ratio of injection to aspirate (3:1).100,102–105 Table 7 shows guidelines for intravenous fluid resuscitation.104 Liposuction Deformities An increasing number of patients are presenting to plastic surgeons for revision of secondary liposuction deformities. This upward trend is closely related to newer techniques such as laser liposuction, water liposuction, injection lipolysis, and mesotherapy. These deformities range widely from skin irregularities to more serious complications related to thermal damage. A method of redistributing the fat within the subcutaneous layer, termed “SAFELipo,” has been advocated by Wall to correct liposuction deformities, this technique is designed to reduce the risk of vascular damage to abdominoplasty flaps by performing a circumferential liposuction of the trunk with abdominoplasty, using a SAFE (i.e., separation, aspiration, and fat equalization) method.106 Fat Grafting in Body Contouring Fat grafting in body contouring has found the greatest applications in buttock augmentation. Mendieta has characterized aesthetic units of the buttock with guidelines for augmenting selective areas for optimal outcomes.107–109

COMPLICATIONS Early Complications Wound Dehiscence Wound dehiscence and delayed wound healing are the most common complications, usually self-limited, and treated effectively with local

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Volume 137, Number 3 • Body Contouring wound care.25 Seroma formation is a common problem.17,111–115 The rate of seroma in body contouring is reported in many series to range from 5 to 15 percent. Some authors advocate the use of doxycycline injected through the drain to treat increased prolonged fluid drainage. Although strong evidence is lacking, the recommended dose is 250 mg of doxycycline in 50 to 100 cc of normal saline, depending on the size of the seroma.116,117 Pollock et al. published a series of compelling articles on the use of progressive tension sutures to reduce the rate of seromas, although this adds time and complexity.118–123 The reported rate of hematoma for body contouring is between 1 and 5 percent, and varies with procedure preformed.113 The reported rate for wound infection in body contouring ranges from 5 to 8 percent. Most wound infections are superficial in nature and respond well to oral antibiotics.25,113 Early postoperative neuropathies are rare in body contouring and can be minimized by careful attention to positioning and padding. Late Complications Scarring is a key issue for patients, and scars can migrate, thicken, widen, and hypertrophy. In addition, scar contracture can occur in brachioplasty and may require surgical release. Edema in the lower and upper extremities is usually managed by elevating the limbs, application of compressive wraps or garments, and lymphatic massage. Lymphedema is a distressing late complication and is more common in the lower extremities than in the upper extremities after excisional procedures. Recurrent skin laxity is a vexing problem in the massive weight loss patient and can lead to revision. Other aesthetic complications can include asymmetry and overresection or underresection of tissues.

CONCLUSION Body contouring procedures have a tremendous impact on the lives of our patients through the strategic reshaping of the trunk and extremities. A thorough understanding of the evaluation, surgical options, and perioperative management of the body contouring patient will maintain safety and optimize outcomes. J. Peter Rubin, M.D. Department of Plastic Surgery University of Pittsburgh Scaife Hall 6B 3550 Terrace Street Pittsburgh, Pa. 15261 [email protected]

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Body Contouring.

After reading this article, the participant should be able to: 1. Provide a careful preoperative evaluation. 2. Understand the relevant anatomy. 3. Ap...
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