Abdominal Contour Surgery for the Massive Weight …...Fleur-de-lis patterns described by Castanares and Goethel, 6 and more recently by Dellon, 7 can improve both 454-466-SF_Wallach_fry.qxd

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S C I E N T I F I C F O R U M

Background: Massive weight loss patients often have significant upper midline abdominal fullness that contributes to the over-all abdominal girth. This region frequently is not adequately treated with conventional abdominoplasty techniques.Objective: The author used a fleur-de-lis pattern when performing a full abdominoplasty or circumferential abdominoplasty.The technical refinements of this procedure for massive weight-loss patients are presented, as well as considerations of thetechnique's safety.Methods: A full abdominoplasty pattern was marked, and the inferior incision was lowered along the midline to adjust formons pubis ptosis as necessary. The vertical component of the abdominoplasty was marked as an inverted “V” or triangle todecrease the abdominal girth, and the cephalic portion was “rounded off” to create an inverted “U.” It was important tolower the final incision of the superior margin of the original abdominal pannus resection approximately 2 to 3 cm to allowfor minimal tension at the lower abdominal midline closure. The back and flanks were marked for those patients undergoing acircumferential procedure using a gull-wing type incision, joining it with the anterior abdominal marks. The mid-axillary linewas marked bilaterally. Vertical reference lines were also drawn along the back to aid in aligning the upper and lower backincisions. The back was treated first for those patients undergoing a circumferential procedure, and then the patient was repo-sitioned supine for treatment of the abdomen and flanks.Results: Ten patients whose average weight loss was 137 pounds after gastric bypass surgery underwent abdominal contoursurgery incorporating a fleur-de-lis pattern. Two men and 8 women with ages ranging from 17 to 53 years (average, 39 years)were treated. Seven underwent a circumferential procedure whereas 3 underwent an isolated abdominoplasty. The follow-upperiod ranged from 1 month to 26 months, with an average follow-up of 9.5 months. Five patients had a hernia repair per-formed in conjunction with the abdominal contour surgery. There was no flap loss or wound dehiscence at the inverted “T”closure for any patient. Conclusions: Use of a fleur-de-lis pattern in abdominal body contouring is a safe and effective technique for properly selectedmassive weight-loss patients. It is particularly appropriate for those patients with significant upper midline abdominal fullness.(Aesthetic Surg J 2005;25:454-465.)

Abdominal Contour Surgery for the MassiveWeight Loss Patient: The Fleur-De-Lis Approach

Steven G. Wallach, MDDr. Wallach is Assistant Clinical Professor of Plastic Surgery, Albert Einstein College of Medicine, Bronx, NY; Assistant Adjunct Physician,

Lenox Hill Hospital; and Assistant Attending Surgeon, Manhattan, Eye, Ear, & Throat Hospital, New York, NY.

The number of gastric bypass surgery proceduresperformed in the United States jumped from16,000 in 1992 to 145,000 in 2004.1 The ulti-

mate postoperative result of bariatric surgery programs isoften flaccid skin and variable amounts of excess subcu-taneous tissue. This has led to predictions that many ofthese patients will undergo plastic surgery to improve thecontour of multiple body regions.2

Patients wait at least 1 year after gastric bypasssurgery or until their weight loss has stabilized beforeundergoing body contour procedures. Commonly, theylose in excess of 100 pounds. Some patients may com-plain about intertrigo between the redundant skin foldsthat does not improve with nonoperative treatment.Others are concerned that the redundant tissues limittheir ability to purchase properly fitted clothing. Mostpatients just want improvement in the overall contour oftheir abdomen.

Although some patients can be categorized accordingto the abdominolipoplasty system of classification,3 inmany cases such categorization is not possible because ofthe excessive amount of loose skin and subcutaneous tis-sue that accompany the weight loss. Conventionalabdominal contour procedures, ranging from lipoplastyto a full abdominoplasty, often cannot treat thesepatients adequately. In fact, many patients have skin andsubcutaneous tissue excess of both the vertical and hori-zontal abdominal components, which significantly con-tributes to their overall girth.

Traditional belt lipectomy procedures, such as thosedescribed by Gonzalez-Ulloa4 and Muhlbauer,5 can treatthe overhanging pannus but are less effective in improvingthe circumferential laxity contributing to the overallabdominal girth, especially in the regions above the umbili-cus. Fleur-de-lis patterns described by Castanares andGoethel,6 and more recently by Dellon,7 can improve both

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A E S T H E T I C S U R G E R Y J O U R N A L ~ S e p t e m b e r / O c t o b e r 2 0 0 5 455Abdominal Contour Surgery for the MassiveWeight Loss Patient: The Fleur-De-Lis Approach


horizontal and vertical laxity by removing a circumferentialcomponent in the lower abdomen combined with aninverted “V” pattern excision from the upper abdomen.Incorporating the fleur-de-lis pattern for the abdomen withtechniques described for the flank and buttock regions cantreat the circumferential component successfully.8-10

In this article, the author reviews his experience treat-ing massive weight loss patients using the fleur-de-lis pat-tern for both circumferential and isolated abdominoplas-ty, presents the technical refinements of this procedure,and reports on the safety of this technique for properlyselected patients.

Material and Methods

Ten patients underwent surgery using a fleur-de-lispattern; 7 patients underwent a circumferential proce-dure and 3 underwent an isolated abdominoplasty. Thepatients included 2 men and 8 women, aged 17 to 53years (average, 39 years). The average weight loss priorto undergoing body contour surgery was 137 pounds.Four patients had undergone a laparoscopic gastricbypass procedure, and 6 had undergone an “open” pro-cedure using an upper midline abdominal incision. Onepatient had a previous right subcostal incision from an“open” cholecystectomy. The follow-up period forpatients in this study ranged from 1 month to 2 yearsand 2 months, with an average follow-up of 9.5 months.Five patients had a hernia repair performed in conjunc-tion with the abdominal contour surgery.

Preoperative markings

Patients were marked in a standing position. Themarkings were used as a reference point for the excisionduring the surgical procedure, and adjustments weremade during surgery to provide the desired result.

Initially, a full abdominoplasty pattern was marked;this area included the tissue from the superior border ofthe umbilicus to the lowest abdominal crease (Figure 1).The inferior incision was lowered along the midline toadjust for mons pubis ptosis as necessary. This wasmarked in accordance with Baroudi’s9 description, leav-ing a 5- to 7-cm length from the vulvar commissure tothe top of the mons pubis for women. The vertical com-ponent of the abdominoplasty was marked as an inverted“V” or triangle to decrease the abdominal girth. Thewidest portion at the base of the triangle was determinedby using a “pinch test,” and was commonly 10 to 16 cmwide (Figure 2). Rounding off the cephalic portion of the

inverted “V” to be more like an inverted “U” increased theamount of tissue resected from the cephalic portion. Itwas also important to lower the final incision of thesuperior margin of the original abdominal pannus resec-tion approximately 2 to 3 cm to allow for minimal ten-sion at the lower abdominal midline closure (Figure 3).

The back and flanks were then marked for thosepatients undergoing a circumferential procedure. A“pinch test” was performed along the hip region, oftenremoving 12 to 16 cm of tissue at the greatest widthalong the flanks (Figures 4 and 5).8-10 It was importantto evaluate the gluteal cleft and determine the inferiorresection mark first. Often the gluteal cleft is redundantbecause of the lax tissues, and it is a common mistake tomark the incision too high. A gull-wing type incision wasmade in the gluteal crease, and the superior extent of theexcision was marked as well (Figure 6). These markingswere then joined with the anterior abdominal marks tocomplete the incision design.

The mid-axillary line was marked bilaterally (Figure 5).These markings provided a reference point for closure

Figure 1. Illustration of initial full abdominoplasty markings from thesuperior border of the umbilicus to the lowest abdominal crease.Adjustments of the lower line for mons pubis ptosis can be made.


456 A e s t h e t i c S u r g e r y J o u r n a l ~ S e p t e m b e r / O c t o b e r 2 0 0 5 Volume 25, Number 5


when the patient was placed in a supine position, so thatwhen anterior abdominal surgery was performed, theremaining wound could be closed with ease. Vertical refer-ence lines were also drawn along the back to aid in align-ing the upper and lower back incisions for closure, sincethe buttocks tend to rotate away from the midline duringthe excision (the right buttock clockwise, and the left but-tock counterclockwise) and need to be repositioned cor-rectly for the final closure (Figure 6). Final markings of theanterior abdomen are shown in Figure 7. For thosepatients undergoing a full abdominoplasty with a fleur-de-lis pattern, the mid-axillary and posterior markings werenot drawn.

Operative technique

All patients wore sequential compression devices on thelower extremities. A Foley catheter was inserted and pro-phylactic antibiotics were administered. Anticoagulationmedications were not used. For those patients undergoingcircumferential treatment, endotracheal intubation wasperformed on a stretcher and the patient was then trans-ferred to an operating table in a prone position. The lowerback incision was performed down to the level of the mus-cle fascia. The tissue was elevated to the upper skin mark-

ings or until adequate resection limits were met—that is,when the proper buttock elevation was achieved and thelower back skin and soft tissue redundancy was eliminat-ed. The upper back flap was not undermined, nor was theoperating table flexed. No tension was placed on the clo-sure of the wounds. Cauterization was performed almostexclusively using a coagulation mode to minimize bloodloss in these often anemic patients. Careful hemostasis wasperformed during the excision of the redundant tissue aswell. Two closed suction drains were brought out throughseparate stab incisions along the lateral thigh to facilitatemonitoring of the fluid output and also to minimize post-operative discomfort when the patient was sitting or lyingdown. The superficial fascia system was repaired with 2-0polydioxanone (PDS) suture (Ethicon, Somerville, NJ).The deep dermis was repaired in interrupted fashion using3-0 poliglecaprone 25 (monocryl) (Ethicon) followed byan intracuticular repair using 3-0 monocryl as well.

The excision and closure were performed to the mid-axillary line previously delineated. The excess tissue at themid-axillary line could be temporarily closed using staplesand treated when the abdominal portion of the procedurewas performed. The incision of the lower back and but-tock region was then dressed with steri-strips and dress-

Figure 2. A “pinch test” is performed along the superior border of thepreviously delineated abdominoplasty incision to determine the greatestwidth excision for the upper abdominal midline.

Figure 3. Working with the markings made in Figure 2, an inverted “V”or triangle is drawn on the upper abdominal midline. The upper portionis often “rounded off” to be more of an inverted “U” shape. The mark-ings are carried 2 to 3 cm below the original triangle markings to allowfor minimal tension on final closure.




ing sponges; 1010 steridrapes (3M, St. Paul, MN) wereplaced over the dressing to minimize soilage during theabdominal portion of the procedure. The patient was thenpositioned supine. This was accomplished by turning thepatient over carefully on the same operating table, or bytransferring the patient to a second operating table.Transferring the patient to a second operating table wasoften easier.

The anterior abdominal portion of the procedure wasperformed in a similar fashion for both the circumferen-tial and isolated abdominoplasty. The umbilical stalk wasfirst circumscribed from the surrounding abdominal pan-nus. The lower abdominal incision was made extendingto the mid-axillary line or, if the back was treated, to theprevious incision lines laterally. The flap was underminedat the level of the anterior rectus sheath and continuedcephalically to the xyphoid centrally and the costal mar-gins laterally. The elevated flap was divided along themidline in a vertical fashion. The operating table waseither left flat or slightly flexed to approximately 5 to 10degrees for those patients who underwent a circumferen-

tial procedure, and to 20 to 30 degrees for those whounderwent an isolated abdominoplasty procedure. Theredundant tissue was then excised, after checking that thefleur-de-lis markings would meet at the lower midline.The midline diastasis was routinely plicated using inter-rupted figure-of-eight 0-Ethibond sutures (Polyester)(Ethicon), unless a hernia repair limited the plication. Themidline repair was performed only to tighten the fascia,but it may help to narrow the waistline, as in a cosmeticabdominoplasty. The umbilical stalk was not commonlysecured to the fascia unless the stalk was unusually longand the abdominal flap was significantly thin. Two addi-tional closed suction drains were brought out throughstab incisions in the mons pubis region.

The closure was performed in the same manner as theback wound, without significant tension. The umbilicuswas inset in the midline vertical closure after a rim ofabdominal flap skin was excised to match the circumfer-ence of the umbilical stalk. The umbilicus was thensecured with 3-0 Poliglecaprone 25 (monocryl) (Ethicon)in the deep dermis and a running 4-0 Poliglecaprone 25

Figure 4. A “pinch test” is used along the flank rolls and marked forexcision if a circumferential procedure is performed.

Figure 5. Mid-axillary lines are marked to serve as reference points forclosure when the patient is placed in a supine position.




(monocryl) (Ethicon) at the intracuticular level. A steriledressing was applied using steri-strips and dressingsponges along the incisions. A xeroform strip (TycoHealthcare, Mansfield, MA) was placed in the umbilicalstalk, and an abdominal binder was then applied.

Postoperative care

The patient was extubated and transferred to a hospi-tal bed in the same final position as on the operatingtable. Most patients remained in the hospital for 1 night.They were instructed to get out of bed to a chair, withassistance, the night after surgery, and they usually wenthome the following morning. The sequential compres-sion devices were maintained until the patient was fullyambulating, and the Foley catheter was removed thenight after surgery. A clear liquid diet was started thenight after surgery and advanced as tolerated. The

patients were instructed to wear an abdominal binder forthe next 3 to 6 weeks continuously. Normal activity andexercise regimens were gradually introduced during thefollowing 3 to 6 weeks. All patients were maintained onoral antibiotics while the drains were in place. Drainswere routinely removed after there was less than 30 mLdrainage in a 24-hour period. This commonly occurredafter 2 to 3 weeks.

Results

All patients were satisfied with their results (Table).One patient had a wound dehiscence along the hipregion 16 days after surgery that healed secondarily. Onepatient had a 1 ✕ 1-cm flap loss in the gluteal crease thathealed without surgical intervention. One patient devel-oped meralgia paresthetica, most likely from poorpadding when placed in a prone position. There was noflap loss or wound dehiscence at the “inverted T” closurefor any patient. There were no infections, hematomas, orseromas. One patient required a transfusion of 2 units;this was a patient who had undergone previous brachio-

Figure 7. Final markings of the abdomen. The inverted “U”-shaped area iscarried inferiorly approximately 2 to 3 cm below the original marking ofthe abdominal closure to account for length discrepancies when reapproxi-mating the midline. This facilitates the closure in the midline and minimizesthe tension.

Figure 6. A gull-wing incision is designed in the gluteal crease. It isimportant to keep the incision line low. Lifting the buttocks superiorlywill facilitate marking the lower gluteal incision more accurately andminimize the risk of a superiorly placed scar. A “pinch test” is also per-formed in this region to determine the extent of excision. Reference linesare drawn to correctly align the final closure. The gull-wing incisiondesign is then joined with the flank and anterior abdominal markingsfold posteriorly, and connected to the anterior abdominal markings.




plasty and mastopexy 3 months prior to her circumferen-tial abdominal procedure and had a low-normal hemo-globin count prior to her circumferential abdominal pro-cedure. All patients were treated in a hospital setting.Most stayed 1 night in the hospital; 2 patients stayed 2nights. Typical cases are shown in Figures 8 through 11.

Discussion

The fleur-de-lis approach accomplishes many of theaesthetic goals of abdominal contour surgery for themassive weight-loss patient. It includes a vertical and lowhorizontal excision, resulting in the improvement of theabdominal girth and upper abdominal contour, and alsoremoving an overhanging pannus. In addition, monspubis ptosis and flank and buttock contour deformitiescan be treated at the same time. Even though anabdominoplasty with/without a circumferential compo-nent may improve the vertical component moderately,the fleur-de-lis pattern improves this area further.

Gastric bypass surgery can result in vitamin and min-eral malabsorption.11 Patients can have a low hemoglo-bin count from the bypass procedure even after takingsupplemental vitamins and iron. This is an importantconsideration for all patients undergoing further surgery,especially for those patients undergoing a circumferentialabdominal procedure that could result in significant

blood loss. Using the coagulation mode on the cautery asopposed to the cutting mode has helped minimize theblood loss in my patients. Even with meticulous hemosta-sis, a significant amount of blood is probably lost, giventhe amount that remains in the excised specimen.

I have found that many patients who have had laparo-scopic gastric bypass with 4 to 5 stab incisions preferred tohave a fleur-de-lis technique because of the contourimprovement it affords, even though it requires more inci-sions. For those patients who have undergone “open”techniques, the upper abdominal scar already exists and,in fact, may hinder the redraping of the soft tissues bytethering the superior flap as it is pulled inferiorly duringfinal tailoring. This technique can also be applied to olderpatients in whom scars are less of a problem, and whomay have greater abdominal tissue laxity. In turn, thegreater laxity will potentially reduce lateral tissue under-mining so that the flap maintains better vascular perfusion.

The goal of aesthetic surgery is to provide the bestresult with a low complication rate. In general, the relativecontraindications are similar to those for abdominoplasty.Patients with significant cardiovascular disease, hemato-logic or metabolic disorders, or thromboembolic diseaseshould not be considered for this surgery.12 The thresholdfor performance of a fleur-de-lis abdominoplasty or cir-cumferential procedure should be higher than for those

Table. Results of fleur-de-lis abdominoplasty after gastric bypass surgery

Patient Transfusion No. Sex Age TWL Surgery Hernia LOS (units required) Complications Follow-up (mos)

1 F 45 202 CFDLA – 2 0 0 262 F 34 117 CFDLA – 1 0 0 33 F 35 112 CFDLA + 2 0 0 144 F 45 125 CFDLA – 1 2 0 85 M 53 210 CFDLA + 1 0 Wound dehiscence 16

16 days post-surgery6 F 47 107 CFDLA – 1 0 Meralgia 13

Paresthetica7 F 28 106 FDLA – 1 0 0 18 M 17 162 FDLA + 1 0 0 49 F 48 101 FDLA + 1 0 0 710 F 36 130 CFDLA + 1 0 1-cm skin 3

breakdown posterior

TWL, Total weight loss in pounds prior to abdominal contour surgery; LOS, length of stay in the hospital in number of days; CFDLA, circum-

ferential fleur-de-lis abdominoplasty; FDLA, fleur-de-lis abdominoplasty; (+), patient required hernia surgery; (–), patient did not require her-

nia surgery.




patients undergoing a standard abdominoplasty; thepatients should be in very good health.

Smokers are not treated unless they have stopped forat least 3 to 4 weeks prior to surgery.13,14 In general, mor-bidly obese patients who undergo surgery have significantrisk for complications.15-17 However, it has been reportedthat abdominoplasty patients who have had prior gastricbypass surgery and are no longer obese do not have anincreased risk of complications as compared to non-obesepatients.16 Patients who are considering a future pregnan-cy should probably delay having this procedure. As is thecase after a standard abdominoplasty, the result would becompromised by the usual body changes that occur frompregnancy; this translates into having recurrent loose skinand muscular weakness.18,19

Abdominal wall scarring is a risk factor that has to bereconciled for each patient. Many scars, such as thoseresulting from a previous McBurney’s incision for appen-dectomy, lower transverse abdominal incisions,Pfannensteil’s incisions, and umbilical hernia incisions,can be incorporated into the design of the resectedabdominal tissue. In fact, many Kocher subcostal inci-sions from an open cholecystectomy and midline verticallaparotomy scars can also be incorporated into thedesign of the fleur-de-lis procedure without jeopardizingthe viability of the flaps. A chevron scar or upper midlinetransverse scar is a contraindication. Previouslaparoscopy resulting in 4 to 5 small stab incisions is nota contraindication.

Abdominal scars increase the risk for hernia. It has beenreported that 8.6% of patients who undergo an open gas-tric bypass and 0.5% of those who undergo a laparoscopicapproach develop an incisional hernia.20 Interestingly, thereis a more than 30% recurrence rate following repair.21

Abdominal contour surgery is often performed in conjunc-tion with the herniorraphy. In this series, 50% of patientshad a hernia repair in conjunction with the fleur-de-lis pro-cedure; 80% (4/5) were identified prior to surgery. Somehernias may not be palpable or symptomatic and are dis-covered while elevating the abdominal flap. Therefore,greater attention should be given to avoidance of injury tointraperitoneal organs while the flap is elevated. In addi-tion, the hernia repair may affect the final contour becauseit may limit adequate diastasis repair, jeopardize the umbil-ical stalk survival, or as in 1 patient treated in this series,require the umbilical stalk to be excised.

Patients are offered options for treatment based on theirphysical examination and general medical condition. This

includes a full abdominoplasty and belt lipectomy, with orwithout a fleur-de-lis pattern. Patients can be downstagedto a less invasive procedure as a result of their overall med-ical condition, their desire for less scarring, potentiallyshorter recuperation, and potentially lower morbidity.22

In his discussion of the potential for necrosis of theflap using a “T” closure, Huger23 states, “If the techniqueof midline lower wedge removal is chosen, all too oftenthe unilateral blood supply to the right angle marginsclosed at the midline to the pubis is inadequate to sustaintissue viability at the point of closure.” His study andothers have raised concerns about using a fleur-de-lis pat-tern.23,24 In this series, there were no central flap losses. Ibelieve that an important reason for this success is properpatient selection. There were no active smokers in thisgroup, nor any patients with medical conditions thatcould predispose to delayed wound healing. One patientdid have a right subcostal scar from a cholecystectomy.Alternative excision patterns were discussed with thepatient preoperatively and re-evaluated intraoperatively,but fortunately were not necessary during the procedure.The cholecystectomy scar was incorporated into the ver-tical excision. Another very important reason why therewas no central flap loss was the minimal amount of ten-sion put on the flap during final closure. Most of theredundant tissue was removed in a vest-over-pantsapproach, so that the excision was not compromised andthere was no significant tension upon closure.25 On theother hand, the abdominal flap was undermined exten-sively to the costal margins bilaterally and up to thexyphoid centrally, as I customarily do when performing afull abdominoplasty. Six of the 10 patients described hadan upper midline vertical scar already present from theirprevious bariatric procedure. In theory, the scar mayhave contributed to a delay phenomenon of the upperabdominal flap and perhaps contributed to its overallviability.26 Further investigation is probably warranted tolook at the numerous variables.

I do not perform lipoplasty of the elevated flaps duringa circumferential abdominoplasty because I believe thepotential for seroma formation is increased, given thelarge undermined area.12,27-29 Several investigators havesuggested using quilting sutures or fibrin sealant to limitthe “dead space” created during abdominoplasty; thismay reduce the rate of seroma formation in patientsundergoing abdominoplasty combined with lipoplasty.30-32

In addition, the undermined flaps may become devascular-ized when combined with lipoplasty, potentially increasing




Figure 8. A, C, E, Preoperative views of a 34-year-old woman after a 117-lb weight loss. B, D, F, Postoperative views 3 months after circumferentialfleur-de-lis abdominoplasty.

A B

C D

E F




Figure 9. A, C, E, Preoperative views of a 45-year-old woman after a 125-lb weight loss. B, D, F, Postoperative views 7 months after circumferentialfleur-de-lis abdominoplasty. Patient had a previous brachioplasty and mastopexy.

A

C

E

B

D

F




A

C

E

B

D

F

Figure 10. A, C, E, Preoperative views of a 47-year-old woman after a 107-lb weight loss. B, D, F, Postoperative views 6 months after circumferentialfleur-de-lis abdominoplasty.




the risk of flap loss or dehiscence.23,24,33,34 In this series, 1patient had a wound dehiscence along the flank 16 dayspostoperatively, and another had a 1-cm distal flap loss inthe gluteal crease that healed secondarily.

Finally, I try not to perform multiple procedures inconjunction with a fleur-de-lis circumferential abdomino-plasty. This procedure usually takes 5 to 6 hours withone resident assistant. Most patients in my seriesrequired only 1 night in the hospital, and only 1 requireda transfusion of 2 units of packed red blood cells. Thissingle patient was treated early in the series, and hadundergone a mastopexy and brachioplasty approximately3 months earlier. She also had a low-normal hemoglobincount prior to the abdominal contour surgery, and, in

retrospect, surgery should have been delayed until thehemoglobin level was higher. Furthermore, performingmultiple procedures along with the circumferentialabdominoplasty increases the operating time, whichcould cause further blood loss in these often borderline-anemic patients and, in turn, increase the risk for morecomplications.12,35

Conclusion

The fleur-de-lis pattern for abdominal contour surgeryis an option for treating properly selected post-bariatricsurgery patients. It is especially appropriate for thosepatients who have significant upper midline abdominalexcess that contributes to the overall girth. The complica-

Figure 11. A, C, Preoperative views of a 17-year-old man with a large ventral hernia and a 162-lb weight loss. B, D, Postoperative views 2.5 monthsafter fleur-de-lis abdominoplasty.

A

C

B

D




tion rate reported in this review is consistent with thosereported classically in the abdominoplasty literature.21,35,36

The technical nuances of the procedure have been present-ed and, along with the results, support the conclusion thata safe and consistent outcome can be achieved using thistechnique in the appropriate candidate. ■

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The author gratefully acknowledges Liguo Liang for the original artwork.

Accepted for publication May 12, 2005.

Reprint requests: Steven Wallach, MD, 1049 5th Avenue, Suite 2D, New York, NY 10028.

Copyright © 2005 by The American Society for Aesthetic Plastic Surgery, Inc.1090-820X/$30.00

doi:10.1016/j.asj.2005.06.001

C O M M E N T A R Y

by Gustavo A. Colon, MDMetairie, LA

It is an honor to be able to comment on this new conceptas presented by Dr. Wallach for the treatment of weightloss patients. I agree that weight loss patients do havesignificant upper midline abdominal fullness, which cre-ates a problem not only for the anterior abdominal wall,but also for the back.


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