Body Contouring

Dr. Jaafer Ameir Al-Ugaily Plastic and reconstructive surgeryjaafer884@gmail.com

• Body-lifting procedures create a firmer, tighter, more rejuvenated appearance for patients who have lax, ptotic tissues.

• Such procedures include brachioplasty, upper back lift, abdominoplasty, lower back lift, and thigh lift.

• Lockwood popularized contemporary body lifting, His surgical concepts were based on anatomical study, including description of the superficial fascial system as the important layer of deep fascia that best holds tension.

• As the need for body-lifting surgery has exponentially increased with a growing massive weight loss population since 2000, procedures described for non–massive weight loss patients have seen amplification and fine tuning.

• More attention has also been paid to volumetric reconstruction beyond lifting, so rather than dispose of redundant tissue, tissue ranging from fat grafts to fasciocutaneous flaps is being recycled to reconstruct deflated, volumetrically challenged bodies.

PREOPERATIVE ASSESSMENT

Medical History• Medical conditions have a well-documented, negative impact

on surgical recovery. • Obesity includes a constellation of medical problems called

metabolic syndrome, including hypertension, dyslipidemia, type 2 diabetes, coronary artery disease, stroke, gallbladder disease, osteoarthritis, obstructive sleep apnea, and cancers.

• Hypertension places patients at risk for postoperative bleeding and associated with coronary artery disease or chronic renal failure.

• Anemia is common in massive weight loss patients, requiring careful attention to postoperative blood levels.

• Asthma may be exacerbated by surgery and oxygen requirements may be greater, resulting in the greater need for blood transfusion.

• Endocrine disorders such as hypothyroidism may impair wound healing.

• Autoimmune disease have impaired wound healing, caused by antiinflammatory medications they take.

• Smoke causes vasospasm and decreases vessel caliber, leading to wound healing problems and seromas.

• History of DVT and pulmonary embolism, is the greatest risk factor for future venous thromboembolism, the most deadly possible outcome after body contouring surgery.

• Other risk factors for venous thromboembolism include obesity, immobility, hormonal therapy, history of cancer, and hypercoagulable states.

• High-risk patients require clearance by doctors specializing in treatment of venous thromboembolism, including hematologists or vascular surgeons.

• Prior surgery must be considered in surgical planning, as scars may devascularize regions dependent on the sacrificed blood supply or may be hiding latent hernias. For example, a right subcostal “Kocher” incision scar may result in a nonhealing abdominal wound after abdominoplasty with aggressive undermining.

• Prior lymph node dissections in the axillary and inguinal regions may put patients at risk for postoperative lymphedema.

Medications• Although certain prescription medications, such as blood

thinners and appetite suppressants, lead to known detrimental issues in surgery, there are a number of nonprescription supplements a patient takes that may hurt outcomes without the patient’s knowledge.

• Patients may not voluntarily share history of use of herbals because they do not consider them to be medications.

• Herbals may cause hypoglycemia increased risk of bleeding; immunosuppression; and hepatotoxicity.

• Herbal medications should be stopped at least 2 to 3 weeks before surgery.

Nutritional Assessment• Optimal nutrition is important for healing for surgical

procedures. • Massive weight loss patients, and particularly those who

underwent Roux-en-Y gastric bypass surgery, are particularly prone to nutritional deficiencies that may be detrimental to surgical outcomes.

• Nutritional deficiencies include protein and vitamin deficiencies, including vitamin B12, folate, vitamins C, thiamine, calcium, vitamin D, vitamin K, iron, zinc, and selenium.

• Laboratory testing including total protein, albumin, transferrin, and total lymphocyte content may help to confirm nutritional deficiency if there is a concern.

Physical Examination• Body mass index is a critically important factor that may

predict complicated outcomes.• Skin redundancy and quality, lipodystrophy, and adherent

folds are noted. • Varicose veins and lymphedema and overall scar evaluation

are important.

Assessment of Patient Goals• After full assessment of the objective factors, an informed

dialogue about surgical planning can take place. • It is important to balance what may be safely accomplished

with patient goals, and to communicate this so the patient understands and appreciates the rationale.

INTRAOPERATIVE CONSIDERATIONS

• Venous thromboembolism prophylaxis must include conservative measures, such as the use of a sequential compression device and compression hose, gently flexing the knees on a pillow, and postoperative application of prophylactic doses of unfractionated heparin or low-molecular-weight heparin for patients admitted to the hospital.

• For those who are morbidly obese or who have a history of venous thromboembolism, measures such as temporary vena caval filters should be considered, and preoperative consultation with a vascular surgeon is important.

• Intraoperative fluid management must be monitored continually.

• Fluid status is gauged by blood pressure and urinary output, and by estimated blood loss.

• If blood loss is thought to be significant, the hemoglobin level should be checked during surgery or in the recovery room immediately after surgery.

• Patients are at elevated risk for hypothermia during body-lift procedures, and measures must be taken to maintain normothermic temperature and reduce time of exposure.

• Heating intravenous fluids, forced warming blankets, and keeping room temperature up are routine.

• Staging attention to body regions to allow coverage should also be considered to avoid exposure.

• Hypothermia increases the risk of postoperative infection and wound healing problems.

• While positioning is important for accessing particular body regions, improper positioning can lead to nerve traction and/or compression, and increase the risk for venous thromboembolism.

• Prone positioning requires the head and neck to be in neutral position, with bumps under the axillary and lumbar regions and padding under the arms and heels.

• While the patient is prone, eyes must be protected from compression with a pillow and/or goggles.

• Whether the patient is prone or supine, the elbows and axilla should be positioned at no greater than 90 degrees to avoid nerve traction.

• If using stirrups for thigh work, extreme flexion between the hip and thigh can increase the risk of venous thromboembolism.

BODY-LIFT PROCEDURES

Brachioplasty

Indications• Brachioplasty is performed for skin laxity in the arm that may

extend to the chest wall, not for lipodystrophy. • Traditional brachioplasty involves incisions along the length of

the upper arm, worked out within the axilla.• Minimal incision brachioplasty for patients with limited skin

excess and conservative goals requires only an axillary approach.

• More extended approaches apply to massive weight loss patients who have a bat-wing deformity, with skin redundancy continuing along the lateral chest wall.

• Markings are performed with the arm elevated at 90 degrees.

• Markings are guided by pinch test and are truly only a guide that may require modification intraoperatively.

• Arms should be placed on well-padded arm boards, at no greater than 90 degrees.

• Breasts may be taped to keep them out of the field, and arms are prepared and draped circumferentially.

• For the limited technique: • an axillary ellipse is created just outside the axilla, as a

buried incision will lose significant impact in addressing laxity.• Liposuction must be judicious, as it may exacerbate

laxity. • Wound closure is layered, drainless , and reinforced

with skin glue.

The traditional technique involves an incision often in the antebrachial groove, with deepening of the incision to the fascia overlying muscle and neurovascular structures. Elevation of the skin and subcutaneous fat follows inferiorly, keeping in mind the tubular nature of the arm.

• Injury to the medial antebrachial cutaneous nerve, which resides near the basilic vein in the distal third of the arm, should be avoided.

• Resection of the skin requires tailor tacking to avoid over resection ,to the axilla

Closure is layered and performed over a drain.

• The extended technique is analogous to the vertical thigh lift, beginning in the distal arm at the elbow, and with graded proximal progression in the plane described in the traditional brachioplasty.• Z-plasty of the axilla avoids contracture. • After addressing the axilla, graded removal continues

down the lateral chest wall to the level of the inframammary fold. • A drain is placed from the distal chest wall up into the

axilla.

UPPER BACK LIFT

• Indications• Upper back lift applies to individuals who sustained massive

weight loss or who have upper back skin laxity, possibly resulting from overaggressive liposuction.

• Upper back lift is best performed at a different time than lower back lift because opposing lines of tension reduce optimal tissue removal and may cause banding across the back, and vascular compromise.

• The patient is marked upright.• Superior and inferior marks are drawn across the upper back,

with the distance between them determined by pinch test and scar location.

• Cross-hatches are made across the horizontal marks to ease closure.

• The excision needs to be tapered anteriorly into the chest region or into a reverse abdominoplasty in the inframammary fold.

• The patient is intubated on a stretcher and turned prone onto the operating room bed, with a small gel roll across the chest and axillary regions and a larger gel roll across the lumbar region.

• Positioning includes arms at no greater than 90 degrees from the body and an egg crate to avoid compression of weight-bearing surfaces.

• The upper incision is made, and the back tissue is elevated inferiorly off the deep fascia.

• The degree of tissue removal is guided by marking and finalized with tailor tacking.

• Drains are placed laterally on each side, incision is closed in layers and skin glue seals the incision line.

• The patient is then turned supine to taper the back closure anteriorly.

LOWER BACK LIFT, WITH AUTOLOGOUS GLUTEAL AUGMENTATION

• Indications• Lower back lift is performed in patients who have skin laxity of

the back, including those who are thin or who have sustained massive weight loss.

• Many of these patients have “saddlebag” collections of fat, and liposuction will not only enhance contour but also improve lifting of the outer thigh.

• Volume loss in the buttock may also be of concern, with pain on sitting from lack of padding.

• Performing a belt lipectomy without attending to gluteal reconstruction may result in a flat buttock without any waist definition.

• The patient is marked in the standing position. Superior and inferior marks are drawn across the lower back, and the distance between them is determined by pinch test and ultimate scar location.

• If gluteal augmentation is planned, the proposed gluteal flaps are drawn between these marks and need to be low enough to allow rotation low into the buttock region.

• Cross-hatches are made across the horizontal marks to ease closure: one set of marks defines the border of the gluteus and another set marks the midaxillary line.

• The marks are tapered anteriorly to transition a smooth closure if the back lift is performed as a standalone procedure, or into abdominoplasty markings if a circumferential belt lipectomy is planned, or into thigh-lift marks.

• If planned, liposuction of the outer thigh is marked.

The patient is intubated on the stretcher and turned prone onto the operating room bed, as described for upper back lift.

• If liposuction of the outer thigh is planned, tumescent solution is first infused into the outer thigh.

• If autologous gluteal augmentation is not planned, an incision is made at the superior marking, and undermining on the gluteal fascia is performed to the level of the marking.

• Liposuction should be complete before upward suspension. • Tailor tacking is performed to determine the tissue to be

removed, and layered closure over drains is performed.

• If autologous gluteal augmentation is planned, the gluteal flaps are deepithelialized after tumescent solution is infiltrated into the outer thighs.

• Back tissue that will not be recycled is removed, with the vascularity of the autologous gluteal augmentation flaps maintained.

• Pockets are designed over the gluteal muscles and deep into the buttock area under which the flaps will be rotated.

• The pockets must be dissecte inferiorly and medially to avoid high and lateral placement of the flaps.

• The lateral limit of dissection is guided by the preoperative markings.

• The flap tissue is then laterally and medially released off of the underlying fascia, avoiding cauterization of arterial perforator vessels and allowing the tissue to rotate laterally 90 degrees and down into the dissected pockets.

• The flaps are stabilized in their rotated position to the gluteal muscles with sutures.

• The back incision is closed in layers and skin glue seals the wound closure.

• The patient is then turned into the supine position to transition the back closure. Abdominoplasty may be performed for a circumferential belt lipectomy.

• Thigh lift may also be performed, constituting a total lower body-lift procedure.

THIGH LIFT/ Proximal Thigh Lift

• Indications• Patients who are thin with skin laxity and those who have

sustained massive weight loss with laxity of the upper half of the thigh and good skin quality are good candidates for proximal thigh-lifting procedures, with scars hidden in the groin creases.

• Lockwood’s thigh-lift procedure was limited to patients with minimal to moderate laxity with supine positioning only.

• Lockwood’s thigh lift may be extended into the posterior, infragluteal thigh and superiorly into the abdomen for enhanced skin removal, and is known as the anterior proximal extended thigh lift.

• The extended procedure addresses skin redundancy of the thigh and the infragluteal area.• This procedure also allows thinning of a wide mons

pubis. • Proximal thigh lift is not the procedure of choice for

patients with significant skin laxity, poor skin quality, and skin excess down to or below the knee. • This is also not the procedure for the obese patient with

significant thigh lipodystrophy.

• Patients are marked standing. • The groin crease is marked symmetrically along the mons

pubis edge or within the lateral mons pubis to narrow it, and the outer portion of the crescent excision is guided by pinch test to delineate the skin to be excised.

• To increase skin removal, the incision continues posteriorly into the infragluteal crease and superiorly into the abdomen, and this is marked.

• If there is an upper thigh fold, the marking should fall just above the fold to avoid overresection.

• Anesthesia is induced on the stretcher, and a urinary catheter is placed.

• Foot pumps are placed on the feet for thromboembolism prophylaxis, initiated before anesthesia induction.

• The patient is turned onto the operating room bed into the prone position, which ideally should have padded leg extension bars .

• The legs should be stabilized on the spreader bars throughout the procedure.

• If back lift is planned, that should be completed before the thigh lift, as the thigh lift incisions may be elevated with back lift.

• Incision is made in the infragluteal crease. • The lower incision line is then made to allow closure without

too much tension. • The skin is removed over the

fascia overlying the thigh muscles, and soft-tissue padding is maintained on the ischial bone.

• The inferior thigh skin flap is approximated from the Scarpa fascia layer to the ischial periosteum using no. 1 braided permanent suture.

• An adequate periosteal bite must be ensured by pulling on the suture and confirming lack of mobility.

• Closure is performed in layers and sealed with skin glue.

• The patient is then turned supine. • If an anterior- only, Lockwood thigh lift is planned, this would

be the start of the procedure. • If abdominoplasty is planned, it must take place first, followed

by the thigh lift, as incision lines may migrate up with abdominoplasty.

• The deep layer of the abdominoplasty should be closed, but the more superficial layers lateral to the pubis should not be closed, as the thigh lift may merge into this portion of the incision.

• The incision is then made along or within the lateral pubis if the pubis needs to be narrowed.

• The incision from the infragluteal crease is extended anteriorly for several centimeters, and the closure progresses from posterior to anterior in a stepwise, tailor tack fashion to avoid overresection.

• The thigh Scarpa fascia layer is approximated to the pubic periosteum with no. 1 interrupted braided nonabsorbable suture.

• A good bite of periosteum must be taken and confirmed by pulling up on the suture, which should not give with pulling.• Ultimately, the closure is extended superiorly into the

abdominal incision. • Layered closure and tissue glue follows. • No drains and no dressings are necessary.

Extended Thigh Lift

• Indications• This procedure addresses skin excess of the thigh extending

from pubis to knee that cannot be addressed with a proximal procedure alone.

• This is the procedure of choice for patients with significant skin laxity, poor skin quality, and skin excess down to or below the knee.

• Patients must understand and accept the scar that accompanies this procedure.

• Markings• Patients are marked standing. • Vertical incisions are marked along the inner thigh, guided by

pinch testing. • Cross-hatches are drawn to ultimately assist in closure. • The goal is to have the scar on the thigh fall along the medial

thigh so that it is not visible.

• Details of the ProcedureTo best execute this procedure, an operating room table with leg extender bars is recommended.

• The legs need to be well-padded and stabilized on these bars, which are spread to allow best access for excision and closure.

• Foot pumps are necessary for venous thromboembolism prophylaxis.

• An incision is made distally, defining the anterior and posterior incisions, and performed in a stepwise fashion proximally, guided by hatch marks.

• The depth of excision should be just below the Scarpa fascia but above the level of the saphenous vein.

• The Scarpa fascia is approximated progressively, and closure should be performed over a drain.

• As excision progresses proximally, the markings are adjusted as needed.

• As the pubis is approached, resection occurs from proximal to distal to meet the distal resection.

• Excision in the groin area is very shallow to avoid injury to lymphatics and venous structures.

• The thigh is closed in a layered fashion, with skin glue placed on the incision closure to prevent the need for dressings postoperatively.

Early Postoperative Management

• There is no evidence-based guideline on postoperative antibiotic use after body lift.

• In the setting of drains and concerns about infection, oral antibiotics are warranted.

• If there is any evidence of infection, culture swab and treatment with oral antibiotics preferably guided by culture is recommended.

• The patient returns within 1 week after surgery for the first postoperative visit.

• As drain outputs drop, the drains are removed. • Although ambulation is recommended after surgery, limitation of

physical exertion for the body region of interest often persists for 1 month.

• Patients may shower several days after the procedure. • Scar management should be discussed.

• Edema must be managed particularly after surgery on the arms or legs. • Edema is particularly common with extended thigh lifts. • Compressive wrapping from distal to proximal and elevation may be

performed by the patient. • If edema is prolonged, lymphedema treatment should be assisted by a

specialist.• Good nutrition is a priority after large excisional lifting procedures,

Protein and vitamin intake should be optimized, and salt and fat intake should be minimized.

• Patients should remain well hydrated. • Dry mucous membranes and a wan appearance with low energy after

body-lift procedures should serve as a red flag.• Patients may suffer some depression after these operations that also

may impact their appetite and nutritional status.

COMPLICATION MANAGEMENT

• The most common complications seen after surgery include wound healing problems, seromas and lymphoceles, infections, venous thromboembolism, lymphedema, hematomas, and nerve injury.

• Wound healing problems are relatively frequent after body contouring surgery and are more likely in patients with obesity, diabetes, endocrine disorders, Ehlers-Danlos syndrome and autoimmune disease, advanced age, and peripheral vascular and coronary artery disease.

• Wound healing problems also may occur secondary to scarring that impairs circulation to the surgical site.

• In the case of necrosis and eschar development, dead tissue should be de´brided to optimize healing and reduce risk of infection.

• Large tunneling wounds may initially be treated with wet to- dry dressings; and once the wounds are clean, vacuum-assisted closure may be applied to optimize healing by decreasing edema and bacteria counts and drawing the wound edges together through application of negative pressure.

Seromas• are fluid collections that develop under the skin with

undermining and/or significant skin removal. • Closed drains placed at the time of surgery drain fluid that

may develop after surgery.• If drains are removed prematurely, seromas may develop. • Seroma formation is exacerbated by shear forces. • They are more common in patients who are obese, who have

had significant tissue removal, who have low albumin levels, and who have conditions that put them at risk for wound healing problems.

• Seroma collections become clinically evident with ballotable fluid, fullness, or discomfort.

• They may become infected, causing redness, pain, and fever.

• Needle aspiration combined with compression with foam and binder or wrap serves as the initial treatment, aspiration may be performed serially.

• If fluid continues to recur, a drain may be placed. • If this drain continues to drain, or if drains placed during surgery continue

to have high outputs impairing their removal, sclerosis may be initiated. • Popular sclerosants include doxycycline and bleomycin.• If serial sclerosant treatments fail, surgery may be performed. • Surgery may include removal of the seroma wall, quilting sutures, or

open treatment with a vacuum-assisted closure dressing to allow secondary closure.

• If located in a region where lymphatics are dense, such as the knee, groin, elbow, or axilla it may be unclear whether the seroma is actually a lymphocele.

• If repeated aspirations and compression are inadequate, ligation of leaking lymphatics may be aided by Lymphazurin dye injection in the extremity of concern.

Infection• Infection occurs less frequently than wound healing problems

and seroma. • Inciting bacteria typically reside on the skin, such as

Staphylococcus aureus, Streptococcus, and Corynebacterium. Methicillin-resistant S. aureus, increasingly prevalent in the community and hospital, should be considered.

• Candida infection should not be forgotten in the setting of antibacterials and continued cellulitis.

• Wound culture is important in defining the organism, and susceptibility to antimicrobials best guides treatment.

Venous Thromboembolism• The possibility of venous thromboembolism must be

considered if a patient has a swollen, painful extremity. • Venous duplex study should be performed, and if results are

positive for deep venous thrombosis, anticoagulation treatment must be instituted with observation in the hospital.

• If the patient complains of dyspnea or shortness of breath, a pulmonary embolism must be considered and a spiral ct scan ordered for diagnosis.

• Venous thromboembolism can kill a patient, so even if it is low on the differential diagnosis, the possibility must be pursued.

Lymphedema• Lymphedema occurs because of obstruction of lymphatic

outflow from surgical scars. • This may occur after brachioplasty, with swelling in the

forearm, or after thigh lift and/or abdominoplasty, with swelling in the lower extremities.

• Compression therapy, massage, and physical therapy are beneficial in treating lymphedema, and usually a successful outcome will occur.

• Deep venous thrombosis must be ruled out in the patient with lymphedema.

• Hematoma• Postoperative bleeding may occur, resulting in hematoma

formation. • Patients with hypertension or who use blood thinners, including

herbal preparations, are more likely to suffer from hematoma.• Active bleeding often occurs within 24 hours of surgery when

the patient is still in the hospital, and may manifest itself through dizziness, syncope, high drain output with gross blood, or anemia on laboratory tests.

• In general, the diagnosis is clinically obvious and requires immediate return to the operating room to coagulate the bleeding vessel.

• Pervasive bleeding may occur from medical causes unknown before surgery, and in this case, medical/hematology evaluation may be appropriate.

Thank you