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Body contouring surgery in a massive weight loss patient:

An overview
Prabhat Shrivastava, Aditya Aggarwal, Rakesh Kumar Khazanchi1
Department of Burns, Plastic, Maxillofacial and Microvascular Surgery, Lok Nayak Hospital and Associated Maulana Azad
Medical College, New Delhi-110002, 1Department of Plastic and Cosmetic Surgery, Sir Ganga Ram Hospital,
New Delhi-110060, India
Address for correspondence: Dr. Rakesh Kumar Khazanchi, Department of Plastic and Cosmetic Surgery, Sir Ganga Ram Hospital, New
Delhi-110 060, India. E-mail: [email protected]

ABSTRACT
The number of patients with history of extreme overweight and massive weight loss (MWL) has
risen signicantly. Majority of patients are left with loose, ptotic skin envelopes, and oddly shaped
protuberances, subsequent to weight loss. Redundant skin and fat can be seen anywhere on the
body following MWL. This group of population presents many unique problems and challenges.
Body contouring surgery after MWL is a new and exciting eld in plastic surgery that is still evolving.
Conventional approaches do not adequately cater to the needs of these patients. Complete
history, detailed physical examination, clinical photographs and lab investigations help to plan
the most appropriate procedure for the individual patient. Proper counseling and comprehensive
informed consent for each procedure are mandatory. The meticulous and precise markings based
on the procedure selected are the cornerstones to achieve the successful outcome. Lower body
contouring should be performed rst followed six months later by breast, lateral chest and arm
procedures. Thighplasty is usually undertaken at the end. Body contouring operations are staged
at few months intervals and often result in long scars. Staging is important as each procedure can
have positive impact on adjacent areas of the body. Secondary procedures are often required.
However, proper planning should lead to fewer complications and improved aesthetic outcome
and patient satisfaction.

KEY WORDS
Bariatric surgery, brachioplasty, lower body lift, massive weight loss, morbid obesity, thighplasty,
upper body contouring

INTRODUCTION

n the past decade, there has been an alarming increase

in the prevalence of obesity worldwide. Obesity has
been identified by the World Health Organization as
a global epidemic.[1] In the US, no state had obesity
prevalence rate >20% in 1995; in contrast, by 2005,
only 4 states had obesity prevalence rate of <20%. By
current estimates, approximately 66% of United States
adults are overweight or obese, of which 15 million are
now categorized as morbidly obese. In India too, the
changes in lifestyle, reduction of physical activity with
consequent reduction in energy requirement is leading
Indian J Plast Surg Supplement 2008 Vol 41

to increase in obesity. National Family Health Survey

(NFHS-3) has shown high prevalence of obesity in urban
areas in states of Punjab, Delhi and Kerala.[2] In recent
years, improved surgical and conservative measures have
become available for controlling obesity. Consequently,
there has been an exponential growth in the number
of patients presenting for body-contouring procedures
following massive weight loss.

OBESITY CLASSIFICATION
Body mass index (BMI) of an individual is calculated as
weight in kilograms divided by the square of height in
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meters (kg/m2). American Society for Bariatric Surgery

has classified obesity as per BMI values [Table 1]. BMI up
to 24.9 is considered as normal. Overweight is defined as
a BMI between 25.0 and 26.9 kg/m2, and extreme (morbid
or class III) obesity is defined as BMI exceeding 40 kg/m2.
Individuals with BMI >35 kg/m2 with major co-morbid
condition(s) like obesity related hypertension, diabetes
etc. are also classified as morbidly obese. It has been
recognized that obesity is a chronic disease and any form
of treatment aims at palliation rather than cure.[3].

WEIGHT REDUCTION STRATEGIES /

MODALITIES
Although regulating dietary intake of calories (low
calorie / very low calorie diets), regular exercise,
behavior modifications, pharmacotherapy (fenfluramine,
phentermine) and herbal medications can achieve modest
weight reduction, statistics reveal a high incidence of
relapse with >90% of such individuals regaining weight. [4,5]
Since its inception in 1966, bariatric surgery continues
to offer the greatest degree of sustained weight loss to
the morbidly obese.[6,7] It has been acknowledged as the
riskiest, but the most efficacious weight loss method.
In the US, the number of bariatric procedures increased
from 13,000 in 1998 to nearly 200,000 in 2006.[8]
Improved peri-operative and long-term care and
refinements in technique have rendered bariatric surgery
an increasingly safe and reliable method of weight loss.
Bariatric surgery is also being performed in people who
are severely obese (BMI 35 - 40).[9] This upward trend
has created a large population of post-bariatric weight
loss patients who approach a normal BMI range, and they
want to look as normal as possible.

BARIATRIC SURGERY PROCEDURES

An understanding of various bariatric surgical procedures
Table 1: Obesity classification by American Society for
Bariatric Surgery
BMI value (kg/m2)
18.5-24.9
25.0-26.9
27.0-29.9
30.0-34.9
35.0-39.9
40.0-49.9
50.0-59.9
60.0 +

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Category
Normal
Overweight
Mild obesity
Moderate obesity- Class I
Severe obesity- Class II
Extreme (morbid) obesity- Class III
Super obesity
Super-super obesity

is important in evaluating the patient for body-contouring

procedures. Three main categories of bariatric surgical
procedures are: restrictive, malabsorptive and the
restrictive-malabsorptive.
Purely restrictive procedures produce satiety by creating
a small gastric pouch with a restricted outlet, and include
horizontal gastroplasty, gastric partitioning, silastic ring
gastroplasty, and the vertical banded gastroplasty (VBG).
The Bioenterics LAP-BAND System (adjustable gastric
banding), approved by FDA in 2001 has nearly replaced
VBG as a purely restrictive procedure. The band is placed
laproscopically and is considered as the least invasive
of all the bariatric procedures. The band diameter
can be changed by adjusting a balloon connected to a
subcutaneously placed access port.
Malabsorptive procedures include jejunoileal bypass (JIB),
biliopancreatic diversion (BPD), duodenal switch (DS)
operation etc. Most of the nutrient absorptive surface
of the gastrointestinal tract is bypassed by creating an
anastomosis from the proximal to the distal small bowel.
Although, these procedures achieve rapid and significant
weight loss, they carry a high risk of long-term nutritional
and metabolic complications. Therefore they are in
limited use and typically are reserved for the patients
with BMI > 50 kg/m2.
The most popular combination restrictive-malabsorptive
procedure has been Roux-en-Y gastric bypass (RYGB). The
weight loss in standard RYGB is primarily by restriction
of food intake which results from the creation of small
gastric pouch with a 1 cm outlet. Malabsorption with
RYGB is due to the bypass of the fundus, duodenum,
and the proximal jejunum. Laparoscopic RYGB and the
Lap-band procedure have become the most commonly
performed bariatric surgery operations today.

CONTOUR DEFORMITIES AFTER MASSIVE

WEIGHT LOSS [FIGURES 1AH]
Massive weight loss (MWL) is defined as 50% or greater
loss of the excess weight.[10] The contour deformities after
bariatric weight loss encompass diverse and unexpected
manifestations that potentially involve every area of
the body. After a rapid and massive weight loss , there
is a sudden change in BMI which leads to skin and soft
tissue excess and poor skin tone. There is often a deflated
appearance more pronounced in the breasts, buttocks
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Shrivastava et al.

and the face. The skin and the soft tissues fail to retract
completely and become redundant, collapsing inferiorly
and inferomedially from the characteristic areas of fat
deposition. In the upper trunk, the redundant tissues from
the axilla and flank contribute to the upper and mid back
rolls and flank rolls. There occurs varying degrees of
breast ptosis and excessive skin under the upper arms.
In the lower trunk, the redundant tissues of the lower
abdomen and the pubic area fall directly towards the inner
thighs. There can be enormous overhanging pannus that
disrupts the silhouette. The collapse of the redundant
tissues from the lower abdomen, mons pubis, buttocks
as well as from the medial thigh itself contribute directly
to the excess tissues along the thighs resulting in both a

vertical and horizontal tissue excess. Striae are present

throughout the torso. Moreover, women tend to have
large amounts of cellulites as well, particularly along the
hip region. Often there is pain, irritation and intertrigo
under the massive skin folds.
Pittsburgh rating scale
Song et al,[11] have designed an all inclusive and illustrative
classification system that helps in systematically assessing
and quantifying the level of deformities in each particular
region. Ten anatomical areas delineated for analysis
include arms, breasts, abdomen, flank, mons, back,
buttocks, medial thigh, hips/lateral thighs, and lower
thighs/ knees. Because of their complexity, face and neck

Figure 1: A 26-year-old female after weight loss of 90Kg by dieting and exercise. Figs. 1A to H are preoperative pictures showing contour deformities after massive
weight loss. Figs. 1L to S are pictures showing the result after ve body contouring procedures which included a circumferential belt lipectomy, upper body contouring,
augmentation mastopexy, lateral thoracic and abdominal excisions, brachioplasty and thighplasty

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regions have been excluded. A four point grading scale is

designed for each region: grade 0- normal range, grade
1-mild deformity, grade 2-moderate deformity, and grade
3-severe deformity. Generally, a mild deformity would
require non-excisional or a minimally invasive procedure;
a moderate one would need an excisional procedure
while a severe deformity would require combinations
of excision, lifting and would involve large areas of
undermining.
The Pittsburgh rating facilitates the preoperative planning
and is a useful tool in quantifying the improvement in
appearance attributable to surgical manipulation.

PREOPERATIVE WORKUP OF A PATIENT

WITH MWL
Clinical and lab evaluation
A comprehensive preoperative evaluation is mandatory
because the body-contouring procedures following MWL
are often extensive with the potential for significant
morbidity and even mortality.[12,13] The emphasis should
be on several areas: weight loss history, type of bariatric
procedure done, diet and exercise habits, residual medical
problems, co-morbid states, physical examination and
laboratory studies. A Plastic surgeon must ensure that
the patient is weight stable (not more than 1 to 2 lbs
per month fluctuation over 3-6 months, before surgery)
at the time of undergoing body contouring. Usually,
weight loss stabilizes within 18-24 months following
bariatric surgery. If the body contouring procedures are
performed on a patient with ongoing weight loss, there
would definitely be early recurrence of tissue laxity.

Besides evaluating the deformities of aesthetic and

functional concern, incisional hernia(s) and features of
nutritional deficiency, if any, should be looked for and
documented. Areas of adhesion where overlying skin
and soft tissues do not slide, should be noted. The flap
perfusion past these lines of adhesion can jeopardize
the flap circulation. For lap-band patients, the access
port should be palpated and its location recorded as it
may require relocation on the abdominal wall during
an abdominoplasty operation. The lab tests should be
done at least 4 weeks prior to the surgery to allow for
enough time to address and correct any deficiencies. The
list should include CBC, serum electrolytes, prothrombin
time, partial thromboplastin time, serum albumin and
per-albumin levels, ECG and chest radiograph. Besides
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these, the values for micronutrients (iron, vitamin B1 and

B12, folate, calcium, and vitamin D) may also be obtained
guided by history, physical examination and type of
bariatric procedure.
A written clearance should always be obtained from
cardiologist, pulmonary physician and psychiatrist.
Patients who are dissatisfied with their postoperative
results following body contouring have used their
preoperative psychiatric history as a part of their
legal action against the plastic surgeon, arguing that
their psychiatric condition prevented them from fully
understanding the procedure and its potential outcomes.
It is strongly recommended that plastic surgeons must
obtain, preoperatively, a written confirmation from the
treating psychiatrist that the patient is psychiatrically
stable. This would offer protection to the surgeon in such
adversities.
Pre-anaesthetic checkup should be done by a senior
anaesthetist preferably with experience in managing
MWL patients. Other areas of concern which should be
discussed in detail with the patient include motivations
and expectations, appearance and body image concerns.
Informed consent
Many patients who have lost massive amounts of weight
hold unrealistic expectations that the body contouring
surgery will result in a total body transformation. Such
patients are more likely to express disappointment and
dissatisfaction with their postoperative result. The plastic
surgeon should make the patient understand that bodycontouring surgery produces large and visible scars. It is
vital to review the exact placement of these scars with the
patient. The patient must understand that visible scars
are necessary for improved appearance in clothing. There
is definite possibility of skin irregularities and residual
deformities in body shape. Surgery may improve body
contours; it will not result in a perfect body shape.

The patients must understand that how-so-ever tight

the skin may be pulled, over time there will be a degree
of relaxation which will contribute to scar migration
and some loss of contours. To some degree, relapse is
expected. Secondary procedures in MWL patients are
common and the revision policy should be made clear
to the patient. In addition, the insurance concerns and
the possible complications like seroma, hematoma,
infection, dehiscence, lymphoedema, asymmetry,
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Shrivastava et al.

contour irregularities, unacceptable appearance /loss of

umbilicus, vulvar distortion, sensory / motor loss, deep
vein thrombosis, cardiac and pulmonary complications,
detrimental effects of smoking on wound healing etc.
should also be discussed with the patient.
Patients also need to be counseled that body contouring
surgery after MWL is a process rather than a one time
event, and hence multiple, often staged procedures
may be necessary to meet their goals, each of which
would encompass further risk, recovery time and often
expense. Family members should also be fully informed
as to the risks of surgery. It is helpful to have a photo
album of previous successful cases to demonstrate what
the patient can anticipate immediately postoperatively as
well as in the long-term.
Scar placements
Patients who have experienced massive weight loss
following bariatric surgery develop myriad of contour
deformities all over the body. Most would readily accept
surgical scars in any location for improved contours.
However, proper selection of the operative procedure and
meticulous markings are immensely helpful in ensuring
best placement of scars. The location and extent of any
previous scars, the need for subsequent procedures at
a later date and the degree of tissue laxity above and
below the proposed scars must always be kept in mind
while planning the incisions. An open cholecystectomy
subcostal scar is a contraindication to extensive flap
undermining. The vertical midline scar of open gastric
bypass should preferably be incorporated in the operative
design. The situation and length of the scars should be
clearly discussed with the patient during consultation.
Markings and photographs
As with all body contouring operations, the markings
form the cornerstone of a successful outcome. Meticulous
and precise markings should be done for the selected
procedure at least one day prior to the scheduled date
for surgery, and the patient should be photographed in
all the standard views after the markings. This provides
the surgeon an opportunity to evaluate the photographs
to reassess the deformities. Suitable adjustments should
be made, if need be, the next day during surgery. Hatch
marks should always be made above and below the
incision lines to bring the tissues in proper alignments
at the time of closure. The similar views of the patient
should be taken post-operatively (immediate and longIndian J Plast Surg Supplement 2008 Vol 41

term post-op) with same background and illumination.

Such albums are very useful and handy for education of
the patient and the plastic surgeons as well [Figures 1
and 2].
Role of liposuction
There are differing schools of thought on the role and
staging of liposuction in MWL patients. Some surgeons
prefer to perform simultaneous liposuction arguing that
it allows one area to be treated and rejuvenated in one
sitting while eliminating the need for extra surgery.
However, significant oedema caused by the procedure
can not only reduce the vascularity of the flaps, it may
even compromise the final outcome. Others opt to
perform liposuction six months prior to the excision.
Debulking of the area is thus achieved and the potential
risks to the flaps due to resultant oedema are also
eliminated. The demerits are an extra surgical stage,
hospitalization, increased costs and additional recovery
time. In addition, the tissues may be stiffer making the
later flap advancement more problematic.

LOWER BODY CONTOURING

Goals
The objectives of lower body contouring include
flattening of the abdomen, excision of the lower back
rolls, relocation/recreation of the umbilicus, creating a
waist line in women, reshaping/redefining the buttocks,
lifting the antero-lateral thigh and elevation and/or
reduction of the mons.
Surgical options
As the deformities after MWL are circumferential in
nature, the treatment should also be circumferential to
address the trunk as a unit.[14] Most of the MWL patients
seeking improvement of their lower body would require
a circumferential body lift along with gluteal contouring,
mons reduction, excision of the flanks and a thigh lift.
Anterior resection only, may be chosen as part of a
staged procedure or when the circumferential treatment
is not an option. Conventional thigh lift, buttock lift,
abdominoplasty etc. fall short of achieving the optimal
outcome and are often stretched to their limits in MWL
patients. Attempts to manage the patient who has
undergone bariatric surgery with abdominoplasty and
liposuction alone are likely to result in an unsatisfactory
outcome. Unsightly scars, dog-ears or flattening of the
body curves occur. Due to these limitations, various
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techniques have been described to treat post-bariatric

lower abdomen circumferentially. These include
circumferential belt lipectomy,[15,16] circumferential
torsoplasty,[17] lower body lift[18] and body lift.[19] Although
they have different names, each involves a simultaneous
abdominoplasty and a thigh and buttock lift. The main
disadvantages of circumferential procedure are that the
operating time is prolonged as the tissue resection and
the incision length are doubled, and the patient needs
to be repositioned intraoperatively. If increased surgical
time or patients medical condition poses a significant
risk, the procedure should be staged into an anterior
dermolipectomy followed by a buttock lift/gluteal
contouring and thigh lift at a later date.
Circumferential abdominal lipectomy is an extended
abdominoplasty operation without thighs and buttocks
undermining. The incision course extends into the back
and the buttock regions on both sides. This serves solely
to prevent dog ears and doesnt produce any tightening
effects on the back or buttocks. There is much scarring
with unsatisfactory result especially in the back areas.

Circumferential belt lipectomy is relatively more extensive

operation wherein excision of the excess and redundant
tissue is performed circumferentially directly at the hip,
back and anterior abdominal region.[15,16] The excised
wedge is more extensive and broader. The operation is
performed with the patient first in supine and then in
both lateral decubitus positions. Although it results in a
relatively high circumferential scar above the iliac crest,
the tightening effect at the back particularly in the waist
region is far superior compared to the circumferential
abdominal lipectomy. It creates a more defined waist and
has lesser impact on the thighs.
Lower body lift involves more extensive undermining
and aggressive resection.[18] The operation is done
with the patient in prone and then the supine position.
Discontinuous cannula undermining and adjunctive
ultrasound assisted liposuction of back, hips, sides
and epigastrium are added to provide better contours.
It stresses the importance of meticulous handling of
superficial fascial system (SFS) and approximating the
SFS with permanent sutures to maintain the soft-tissue

Figure 2: A 22-year-old female following 55 Kg weight loss after gastric bypass surgery. Figs2 A to C are preoperative pictures
of contour deformities. Figs 2 D F show preoperative markings and prior to belt lipectomy. Figs 2 G to I are early post-operative
pictures after lower body contouring

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Shrivastava et al.

contours and to maximize the scar quality over the longterm.[20-22] The dissection is done below the Scarpa fascia
resulting in resection of complete superficial soft-tissue
layer. The volume reduction thus achieved may result in
flattening of the buttocks.
In
circumferential
suprafascial
lower
truncal
dermolipectomy[23] the dissection is done above the
Scarpas fascia (dorsally as well as ventrally).The fascia
remains attached to the deep fat in the resected areas
circumferentially. The resilient fascia can be used for
repositioning and remodelling in different vectors. The
stretching of the superficial fascia system occurs in the
vertical-medial direction independently of the vector
along which the skin is stretched. Gluteal superficial
fascia system tightening in the buttocks absorbs much of
the tension. This has been referred to as gluteal SMAS
analogous to the facial SMAS in face lift surgeries. In the
area of the abdomen, strong pulling of the fascial system
achieves an additional lifting effect on the thighs and
mons pubis.
Marking [Figure 2 D-F]
Precise pre-operative marking is essential for a successful
outcome. Markings are done with the patient in standing
position. Besides marking the anterior (from xiphoid to
anterior vulvar commissure) and posterior vertical midline,
additional full length paramedian vertical reference lines
should be drawn symmetrically on either side to provide
exact orientation during surgery. Loose, redundant skin
and subcutaneous tissues fall to one side in supine/lateral
position and the orientation is further lost once the
flaps are elevated. The folds of redundant tissues make
it difficult to identify the anatomical bony landmarks
used for achieving symmetry. The ptotic tissues must
be lifted against the gravity while transverse incisions
are marked. It is recommended to do the markings with
the patient slightly flexed at the waist. This simulates
the position the patient will assume after completion of
the anterior resection. Failure to mark in this position is
likely to put undue tension on the suture lines, especially
on the dorsum which may lead to wound dehiscence
postoperatively.

Posterior markings are done first. The upper incision lines

on either side follow the buttocks subunit in a gentle
convexity at the level of the posterior iliac crest. From
either side, the lines dip slightly towards the midline,
angled towards the gluteal furrow, in a shallow V. This
Indian J Plast Surg Supplement 2008 Vol 41

provides an optical accentuation of the buttock form.

The degree of tissue laxity above the incision also needs
to be considered when determining the uppermost
point of excision. To determine the lower incision line, the
buttock and the lateral thigh are serially mobilized up to
the superior level mark using the pinch test. The upper
incision shall remain relatively fixed with maximum
mobilization coming from below. The lower incision is
marked in the form of a lazy S. Hatch marks are also
added to act as useful reference points during surgery
as well as to helping proper alignment of the flaps at the
time of closure.
Anterior marking is begun by vertically lifting the mons
with one hand and drawing the horizontal incision within
the pubic hairline, about 5-7 cm above the upper vulvar
commissure (or base of the penis) with the other hand.
Tissues in the inguinal region are next lifted superomedially. The incision line from the pubic tubercle (the
lateral edge of the pubic hair) ascends obliquely superolaterally towards the anterior superior iliac spine to join
with the previously marked posterior lower incision
line on both the sides. The pinch test is once again
done serially to determine the superior incision line
for anterior resection, in much the same manner as in
abdominoplasty. This level may go above the umbilicus.
Position and technique
Some surgeons prefer to operate with the patient in
prone to supine position, while others favour supine to
lateral decubitus position. The patient is circumferentially
prepped with the povidone iodine from shoulders to
the ankles in the standing position. The patient is then
draped with a sterile half sheet and asked to lie on a
sterilely draped operating table. Sterile stockings and
sterile sequential compression devices are placed. A
Foleys catheter is placed following general anaesthesia.
The large excess of tissues can get compressed and lead
to necroses. In prone position in particular, pressure
necrosis can form around the periorbital region and
the breasts. Arms also need to be sufficiently padded to
prevent neuropraxia. The entire team must bear these
considerations in mind while positioning the patient.

When prone to supine position is used, full thickness

cephalad incision is made first through the skin and
subcutaneous fat down to the level of the deep fascia.
Undermining is done at this level towards the marked
inferior incision taking care to maintain a fatty layer of
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tissue overlying the deep fascia. This helps in preserving

the lymphatic network and reduces the risk for seroma
formation. The lateral thigh is mobilized either bluntly or
with liposuction cannula. The flap thus raised is pulled
up to confirm the lower incision markings and resection
is accomplished. Suction drains are placed and closure
is done in three layers. Three point sutures are taken to
secure the superficial to the deep fascia to obliterate the
dead space. Number 1 polyglactin is used to approximate
the superficial fascial system and deep dermis while
number 0 polyglactin is placed at the level of dermis.
Because of the wound length, 3-0 running poliglecaprone
is used for subcuticular closure thus obviating the need
for suture removal. This layered closure minimizes the
tension along the suture lines during the early months of
scar maturation. Many surgeons in addition use topical
skin adhesive for final cuticular approximation.
After closure, the lateral aspects on either side are left
with big dog ears. These will need to be taken out with
the anterior resection. The patient is turned supine
and the anterior resection is accomplished similar
to an abdominoplasty with the incisions joining the
posterior incisions. While taking out the skin laterally,
the thigh should be abducted to maximize the excision.
Throughout the procedure the subcutaneous tissues are
divided and the flaps are elevated with cautery set to a
high level. The anterior abdominal wall flap is elevated
to the level of the umbilicus which is preserved as usual.
Superior to the umbilicus, the dissection is kept over the
rectus abdominis muscles to the level of the xiphoid. The
anterior abdominal wall flap is divided in the midline to
the level of the umbilicus to facilitate exposure of the
xiphoid region.
In patients who have had a lap-band procedure, the
ports are often secured in the paramedian position in
the anterior abdominal wall fascia. It may get buried
and rendered inaccessible with routine plication. At
this stage, the port should be moved to the subcostal
position. Plication is then performed making sure that
the port tube has not got entrapped in any suture. After
the plication is complete the port should be secured to
the fascia in the subcostal position. The two layer fascial
plication is done with Number 1 polypropylene suture.
Haemostasis is secured and layered closure is done
over suction drains brought out through mons pubis.
Following extubation, the patient is transferred to either
ICU or ward in a beach chair position.
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In the supine to lateral decubitus position, the anterior

abdominal resection is done first. The umbilicus inset
is completed, drains placed and complete closure done
(as above), up to the lateral border. A large dog ear on
both sides is temporarily closed with staples and the
patient is turned to left lateral decubitus position with
waist flexed to approximately 30o and knees to 45o. The
entire hip roll region is removed and the dog ear excised
after undermining the lateral thighs. Once again, the legs
should be kept abducted to maximize the lateral takeout. Similar procedure is then done on the other side
with patient in right lateral decubitus position.
Post-operative care
Patient is restricted to the bed for first 24h. Thrombosis
prophylaxis is given using low molecular weight heparin.
Assisted ambulation is encouraged from Day 2. Sequential
compression devices and Foleys catheter are removed
if the patient is ambulating well. Hb%, PCV, serum
electrolytes and blood sugar are monitored. PCA (patient
controlled analgesia) pump is given, if available. Broad
spectrum antibiotics and anti-inflammatory analgesics are
continued for five days. Drains with output of less than
30 ml in past 24h are removed after five days. However,
all drains should be removed by five weeks regardless of
the output. Before discharge, the patient is fitted with
compression garments to be worn for six-eight weeks.
Gluteal contouring
Significant adipose tissue loss in buttocks results in
ptosis and decreased projection leading to varying
degrees of platypygia. In addition to the skin laxity
and the volume loss, relaxation of the superficial
fascial apron contributes to gluteal ptosis. Aggressive
lifting performed to improve the contours of the
thighs and lower back in circumferential body lifts can
further exacerbate platypygia which results in further
flattening. Gluteal aesthetics in a MWL patient can be
enhanced with autologous tissue augmentation, large
volume autologous fat transfer or alloplastic implants.
Adjunctive techniques such as resection and tightening
of SFS (gluteal SMAS), posterior thigh lift, infragluteal
diamond lift can refine the results.
Autologous gluteal augmentation (AGA)
Gluteal auto augmentation can be accomplished using
either bilateral de-epithelialised island AGA flaps,
a moustache AGA flap[24] or superior gluteal artery
perforator flaps.[25] The flaps are designed and moulded
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Shrivastava et al.

using autologous skin and fat that would otherwise be

discarded in the posterior portion of lower body lift.
Island AGA flaps are outlined as two separate islands, one
on each buttock and de-epithelialised. The dissection is
bevelled down through the SFS and the gluteal fascia to
create two dermal islands. Muscle fascia is released on
the superior and lateral aspects of the flap to increase
the mobility of the islands. After confirming the position
of the maximum projection point, the body-lift inferior
skin flap is advanced over the island AGA flaps. The
dead space may be reduced by placing sutures between
the overlying body-lift flap and the island AGA flaps. The
SFS is sutured, drains placed and the closure is done
in layers. Although reasonable results are obtained, the
amount of volume that is produced is insufficient to
overcome the gluteal flatness in most MWL patients.
Moreover, the point of maximum projection is higher
than ideal.
Moustache AGA flap design is the modification of the
island AGA flaps with placement of the central bridge
of tissue and lateral flap extensions or handlebars. It
is a partial island and partial transposition flap. The
moustache handle bars are elevated from the fascia and
rotated inferomedially. This recruits additional tissue for
augmentation and lowers the point of maximum gluteal
projection to the level of mons pubis. Additionally flap
is imbricated to itself laterally to prevent trochanteric
fullness. Moustache flap is indicated when a reasonable
augmentation is desired especially for female patients.
Superior gluteal artery perforator flap for gluteal auto
augmentation is a large oval-shaped de-epithelialised
flap based on the previously dopplered SGA perforators,
dissected from lateral to the medial aspect till the lateral
perforator is encountered approximately 9 cm from
midline. The flaps are rotated inferomedially, placed in
a previously created gluteal pocket and tacked to the
gluteal fascia. The closure is done in the same way as for
the island AGA flaps.
Autologous fat transfer
Large volume autologous fat transfer can be used in
select patients as an adjunctive mode to enhance the
buttock shape. Its efficacy as a primary modality in MWL
patients is contested vigorously in literature. Many MWL
patients do not have adequate donor sites for fat harvest.
Nonetheless, it is clinically effective and can play a vital
role in body contouring.
Indian J Plast Surg Supplement 2008 Vol 41

Alloplastic implant augmentation

MWL patients do not have sufficient pad of fat to cover
the implant, and their skin is thin which makes them
susceptible to implant visibility, palpability, migration and
extrusion. Moreover, the implant designs have limitations
to be used as primary modality for gluteal augmentation
in pronounced platypygia.
Monsplasty
The mons is almost always ptotic and may exhibit both
horizontal and vertical excess. It may be partially or
totally hidden under the overhanging anterior abdominal
wall pannus. Mons should be rejuvenated as a part of the
abdominoplasty / body lift procedure. The vertical mons
excess can be excised by placing the lower transverse
incision for body lift 2 cm below the pubic hairline (about
5-7 cm above the superior vulvar commissure-at the level
of the pubic bone). Too low incision would interfere with
the lymph drainage and innervation. Vertical, wedge
excision may be incorporated to reduce the mons width.
The ptotic mons tissue should always be resuspended to
the superficial fascia of the abdominal flap. Care should
be taken not to pull the mons too high, lest it may alter
the position of the clitoris and / or urethral meatus. Mons
reduction surgery can be scheduled at a later stage also
along with other additional procedures.
Umbilicoplasty
The final appearance and location of the umbilicus on
the anterior abdominal wall is often viewed by patients
as an important measure of success. Smaller umbilicus is
aesthetically more pleasing than the larger umbilicus. Many
techniques have been described to preserve or recreate
the aesthetic appearance of umbilicus. Several incisions
(horizontal crescent shaped, inverted V incision, single
vertical incision etc.) have been employed with the aim
of making an opening of sufficient size and achieve some
superior hooding. Concentric circles should be avoided
as these rings exhibit contraction later distorting the
shape. It results in an abnormally small umbilicus which
is not only unnatural but presents hygienic problems
also. In patients who have had umbilical hernia repair or
vertical midline hernia repair done earlier, viability of the
umbilicus becomes doubtful. In such cases, neo-umbilicus
reconstruction needs to be performed either primarily or
at a later date to achieve a pleasing outcome.

UPPER BODY CONTOURING

The regions included in the evaluation of upper body are
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Body contouring, massive weight loss

the breasts, lateral chest, arms, upper and mid back. The
plastic surgeon must remember that the circumferential
lower body lift operation exerts a significant positive
impact on breasts, flanks and upper back. It reduces the
magnitude of the upper body contouring procedures
required or may occasionally even eliminate their need.
However, in women it can also result in significant
downwards migration of the inframammary folds.
Precisely for this reason, it is recommended not to
perform the breast contouring surgery before or even
with a body lift operation.
The upper arms, lateral chest and the breasts are
intimately related and all need contouring usually in one
stage for adequate rejuvenation of the area. The location
and direction of lateral inframammary crease in both
women and men is assessed. If the patient has a normal
upward sweeping lateral inframammary crease, he / she
would present with breast and upper arm deformities
that are independent of each other and can be treated
by independent breast reconstruction and brachioplasty
procedures. However, if lateral crease position is lower,
the breast, arm and lateral chest deformities may be
treated simultaneously. Thorax then is treated as a unit.
However, the staging sequence is surgeon and patientspecific.
The goals to be achieved are to restore projection and
fullness of breast parenchyma with appropriate NAC size
and position, to reposition / recreate the inframammary
fold, to eliminate axillary skin rolls, mid and upper back
rolls, and to reshape the arms by excising loose, hanging
and redundant folds of excess skin and fat.
Breast reshaping
In MWL patients, loss of breast parenchyma and glandular
tissue results in marked breast volume deflation with
flattening, while loss of skin tone and elasticity leads to
severe ptosis. The nipple position is more medialised
and the volume loss may be asymmetric. Additionally,
axillary skin rolls and lateral breast rolls blur the borders
between the lateral breast and the chest wall. The lateral
breast rolls often continue posteriorly as upper back
rolls. There is descent of lateral inframammary crease to
varying degrees. In view of these extensive deformities,
traditional mastopexy procedures are often inadequate
in a MWL breast.

Some surgeons elect to perform an augmentationmastopexy in single stage, while majority prefer to perform
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mastopexy alone first followed by augmentation at a later

date if a larger size is desired. Combining augmentation
and mastopexy with transposition of NAC reduces
vascularity of the flaps and may compromise healing.
Moreover, the implant position is difficult to control, and
malposition with descent are common complications.
The submuscular / subglandular placement of the implant
is dictated as per the preference of the surgeon and the
patient. Smaller implants are preferable as the heavier
implants might contribute to the risk of recurrent ptosis
and scar-widening. The combined procedure requires
experience and expertise, and secondary procedures are
often needed to optimize the outcomes.
Regardless of the technique used for skin resection,
aesthetic result should achieve bilateral symmetry, good
projection, superior fullness, correctly positioned NAC,
with well defined lateral curvature and inframammary
fold. The normal inframammary fold has a semicircular
shape, with its lateral aspect rising superiorly as the
lateral chest wall is approached. It may be necessary
to augment one breast and reduce the other to obtain
symmetry. It is vital to make the patient sit up during the
surgery to review various landmarks to obtain adequate
symmetry.
For patients with severe ptosis and flattening of the
breast shape, auto augmentation mastopexy has been
described using a lateral deepithelialised dermal/breast
parenchymal flap.[26] This selectively adds tissue to the
breast mound, simultaneously eliminating the lateral skin
roll deficiency. The central breast tissue is suspended to
the rib periosteum to achieve superior pole fullness and
long lasting results. Suspension of breast parenchyma
to pectoral fascia has also been used.[27,28] However,
recurrence of ptosis is less likely with suspension to rib
periosteum. The only drawbacks of this technique are the
need for intraoperative tailoring and the lengthy scars.
Autoaugmentation mastopexy in MWL breast has also
been reported with cephalic rotation advancement
of deepithelialised extended superomedial pedicle,
incorporating the lower pole of the breast.[29] Glandular
shaping is done through plication and the pedicle is
suspended as needed to fill the upper pole. This provides
an internal sling, narrows the wide breast and redefines the
inframammary fold. Good pillar closure helps support the
breast and its new shape. Intercostal artery perforator flap
from the lateral chest has also been used for autologous
Indian J Plast Surg Supplement 2008 Vol 41

Shrivastava et al.

augmentation mastopexy in a MWL breast.[30]

Male breast rejuvenation
After MWL, due to excess skin and inelasticity, there is
varying degree of breast ptosis along with the lateral
rolls on either side. There is loss of definition of inframammary crease and, in some cases, excessive breast
projection due to hypertrophy. The critical components
of male breast rejuvenation are reduction in the bulk
and projection, proper positioning of the nipple-areola
complex and restoration of the natural appearing
inframammary crease. In males, the NAC lies immediately
lateral to the breast meridian and is closer to the inframammary crease. It is vital to explain to the patient the
placement and extent of the scars in order to achieve the
desired result.

It should be remembered that lower body lift operation

in combination with liposuction often results in sufficient
tightening of the flank and chest obviating the need for
further surgery for upper torso. Additional liposuction
may be needed in cases of mild residual ptosis. The
excess tissues along the axilla and the lateral chest may
be resected by designing a vertically oriented ellipse
laterally in order to avoid more visible scars on the anterior
chest. Care should be taken to avoid displacement of the
NAC complex laterally. In severe ptosis, an invertedT
mastopexy with extension towards the flank gives good
results. Bilateral flankplasty with direct excision of the
excess hanging tissues at the level of inframammary
crease is an alternative. However, in this procedure, a
free nipple graft would be needed and it would result in
a long scar along the anterior chest.
Lateral thoracic excisions
The lateral chest wall excision should be performed
immediately after the breast procedure is completed.
Wearing a brassiere makes the redundancy more evident,
with the excess skin and fat bulging over the top. These
rolls can be removed either by transverse excision or by
using lateral excision approach. Both approaches could
affect the vascularity of the abdominal flaps; hence the
lateral thoracic excisions should not be combined with
the lower body lift operation.
Transverse excision
While planning the transverse back excision, pinch
technique is used sequentially to ascertain and mark
the extent of the resection. It is helpful to mark the
Indian J Plast Surg Supplement 2008 Vol 41

outline of the patients brassiere along the back. This

helps to place the intended line of closure between the
upper and the lower outline of the brassiere. Crosshatch
marks are made across the excision markings to achieve
proper alignment during closure. The superior extent
of the upper back rolls is incised first down to the level
of the muscle fascia. The inferiorly based skin-fat flap
is elevated to the proposed inferior level of resection.
With the flap elevated superiorly, while the shoulder is
pushed inferiorly, the flap is pulled in the pants over
vests fashion and the excess is tailored to the superior
line of excision. Closure is done in two layers over the
suction drains brought out laterally on either side. The
lateral breast and upper back rolls thus are eliminated
while the lateral inframammary crease also gets elevated
to its proper position.
Lateral chest wall excision
Most of the horizontal thoracic excess can be addressed
by an elliptical excision extending vertically from the
axilla to the inframammary crease, either independently
or as a part of an extended brachioplasty. The lateral
thoracic excision can even be extended down along the
lateral abdominal wall to address the horizontal excess
of the abdominal wall as well as the back laxity. However,
the patient will then have a long scar laterally [Figure 1
O and R].

The technique basically is a wedge excision of the

loose tissue. As it does not include undermining, if the
markings are properly done, there is little chance of any
skin loss. The markings are done with the patient in
standing position. The lateral extent of the breast and
the inframammary fold is marked as the lowest point of
the proposed excision. The excess skin is pinched in the
superomedial direction to determine the excess and the
elliptical excision is marked. The posterior skin is less
mobile as compared to the anterior breast skin. The
centre of the posterior incision can be extended more
posteriorly to maximize the resection in the mid-back
region. However, this would result in a longer posterior
limb which would need to be adjusted during closure. The
final scar would lie well hidden under the arm when it is
at rest. They are particularly helpful when the posterior
flap needs to pulled superomedially to correct the lateral
inframammary fold descent.
The anterior incision is made first down to the deep
fascia and the flap is raised till the posterior incision
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Body contouring, massive weight loss

mark is reached. The excess tissue is resected after

the confirming that a safe tension-free closure can
be accomplished. If required, the posterior incision
marking can be adjusted during surgery. A lateral chest
wall excision can not only elevate the inframammary
fold, it can simultaneously reposition the lateral aspect
of the breast. The breast may appear rejuvenated
without any direct surgical intervention. The lateral
chest wall excess has also been used for a modest autoaugmentation of the breast, which may be preferable by
some to prosthesis.
Brachioplasty
In MWL patients, excess sagging skin and fat generally
presents around the arms in between the axilla and the
elbow. The deformity occasionally extends distally onto
the forearm, but invariably crosses from the arm to the
axilla at the posterior axillary fold and onto the chest
and the lateral breast. This distribution makes it nearly
impossible to address one region without assessing its
resultant effect on the adjacent areas. Liposuction alone
is rarely sufficient to provide the aesthetic result. It
needs to be decided after clinical examination whether
to directly perform a resection or to first deflate the
significantly over-inflated arms by initial liposuction
prior to performing an excisional procedure 6 months
later. Most patients would require a brachioplasty to
achieve the desired results. Brachioplasty removes the
excess upper arm skin and fat for aesthetic reshaping.
Often the incisions are extended onto the lateral chest
wall proximally and to the level of the elbow distally.
The brachioplasty scars can be wide, long and often stay
thick for many months. The short scar techniques are
inadequate for correction of the deformities of the arms
in a MWL patient.[31-33]
Traditional excision
Excision by traditional T-type incisions is usually not
sufficient to adequately remove the excess from the axilla
without making the scars that are too visible. Incisions
for the elliptical excision are made with the patient sitting
with arms abducted to 900. The anterior incision is made
first up to the deep fascia and the flap is undermined till
the posterior mark is reached. The medial antebrachial
cutaneous nerve and the basilic vein should be carefully
preserved in the distal half. After the excision is complete
the wound is closed in layers over the suction drain. A
Z-plasty should be incorporated if the excision crosses
the axilla to prevent scar contracture and banding across
the axilla.
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Double- ellipse marking and segmental resectionclosure technique.[34]

Two ellipses are marked in this technique, one inside the
other. The axillary crease level is identified and marked
by abducting and adducting the patients arm. Starting
from the axillary crease, with the arm abducted to 900,
the pinch technique is used to make the anterior and
the posterior marks at each point along the upper arm.
Joining these points anteriorly and posteriorly makes
the outer ellipse. If the thoracic rejuvenation is to be
performed simultaneously, the markings are continued
onto the lateral chest wall along the posterior axillary
fold dictated by the amount of excess. Distally the marks
can cross the elbow if necessary. Excision along the outer
ellipse would probably result in an inability to close the
defect due to failure to account for the gap because of the
fat in between the pinching fingers. Thus, an adjustment
is made along each point along the entire upper arm.
The inner ellipse is thus marked adjusted to the first
ellipse based on the thickness of the pinch. For example
if the distance between the pinching fingers is 2 cm, then
the new ellipse marks are moved in 1 cm on each side.
This adjustment need not be made onto the chest wall
as the tissues can be suitably undermined on the chest.
Crosshatch marks are made and a central line is drawn
from the axilla to the end of the ellipse.

A sequential segmental-resection-closure technique is used

to eliminate the possibility of being unable to close the
arm because of intraoperative edema developing in the
tissues left open for extended periods of time. Excision
is started along the inner ellipse from the most distal
aspect. The dissection plane is just above the muscle
fascia. Once the first cross hatch mark is reached, the
area of resection is temporarily closed with staples. This
prevents the development of the significant oedema in
that segment. The process is then repeated to the next
cross hatch mark. A Z-plasty is performed at axillary
crease level. The closure is done in two layers over the
suction drain. Extremity should be kept elevated with
elbow flexed to minimize oedema formation in the
immediate postop period. Complications include wound
dehiscence, infection, haematoma, seroma, lymphocele,
sensory loss, neuroma and nerve compression (usually in
ulnar nerve distribution). Compression garments should
be advised only after two weeks.
L brachioplasty
The L brachioplasty involves a continuous excision of
excess skin from the arm through the axilla and onto the
Indian J Plast Surg Supplement 2008 Vol 41

Shrivastava et al.

chest in the form of the inverted L.[35] The L represents

the shape of the excision, with the long limb along the
medial axis of the upper arm, the short limb meeting
at a right angle across the axilla along the mid lateral
chest. The short limb scar of the L is hidden behind the
anterior axillary fold. An inferiorly based triangular flap
of the proximal posterior upper arm is advanced across
the axilla towards the deltopectoral groove. This elevates
the ptotic posterior axillary fold with tapering of the arm
skin toward the axilla.

MEDIAL THIGHPLASTY
Although major advances have been made in upper
extremity and upper and lower truncal contouring, the
thigh area continues to remain the most difficult and
troublesome region to contour in MWL patients. It is
recommended to perform thighplasty six months after
the body lift operation. Lower body lift procedures have
beneficial effect on the lateral thigh and on the proximal
anterior thigh. The improvement in the thighs often
reduces the extent of the thigh reduction surgery.
Anatomical considerations
The skin-fat envelope of the thigh drapes over the
underlying musculoskeletal core. It is less tightly
adherent medially than antero-laterally. The entire thigh
skin-fat envelope descends inferiorly in MWL patients.
Although there is certain degree of vertical excess, most
of the excess is horizontal in these thighs. As the medial
adherence is not strong, the tissues in this area descend
the maximum giving the impression that it is vertical
rather than horizontal excess. There occurs medial
vertical descent of the horizontal excess.

Superficial lymphatic structures and the great saphenous

vein and its branches require special attention while
performing medial thigh lift. The lymphatics of the leg
are primarily concentrated medially and lie deeper than
the saphenous vein until they coalesce in the femoral
triangle. Injury to the lymphatics here can lead to
disabling lower limb oedema which is usually permanent.
In patients with significant varicose vein problems, the
saphenous vein may also be excised along with medial
skin resection.
Patient presentation
The extent and type of the deformity in the thigh of MWL
patients is extremely variable. Some male patients never
deposit much fat in the thighs and thus lower body lift
Indian J Plast Surg Supplement 2008 Vol 41

alone may achieve the acceptable thigh contours. Others

may present with loose circumferential skin-fat envelope.
These patients should undergo an excisional procedure
only after a lower body lift to lift the lateral, posterior
and upper-anterior thigh. However, most female MWL
patients demonstrate a minimally deflated thigh despite
an overall excellent weight loss. These patients should
undergo concomitant liposuction of the thighs with
the lower body lift, in preparation for a thigh reduction
procedure to be performed six months later. In a nutshell,
in order to attain acceptable contours, the thighs should
be deflated either by massive weight loss process, or
surgically by liposuction before the final excisional
procedure.
Preoperative evaluation
The extent and location of the horizontal and vertical
soft tissue excess should be assessed. It is vital to rule out
the pre-existing lymphoedema and deep vein thrombosis.
Any evidence of lymphoedema or significant venous
problems should be considered as contraindications for
thighplasty. If horizontal excision is being incorporated,
it is important to evaluate the degree of the traction
transmitted across the perineal junction to the labia
majora. The lateral traction thus exerted on the labia
majora with subsequent exposure of the labia minora has
often lead to medico legal actions against the surgeons.
Marking and techniques
In MWL patient, the skin laxity can be quite severe and
often extends down to and even below the knee. The
traditional medial thigh lift techniques are marred by the
problems of inferior wound migration, lateral traction
deformity of vulva/ labia majora, widening of the scars
and early recurrence of ptosis.[36] The Lockwoods classic
horizontal resection and fascial anchoring technique for
medial thigh lift designed to prevent labial spreading
and migration of the perineal scar allows a more stable
long-term result.[37,38] This technique has its vector of
pull vertically toward the groin. However, the horizontal
laxity seen in most MWL patients cannot be completely
addressed with the classic vertical pull. Moreover, it
also cannot address the middle and distal third of the
thigh.

Rejuvenation of the medial thigh requires removal of

the fat as well as excision and redraping of the entire
medial thigh skin. The technique of vertical medial thigh
lift incorporates the excision of the vertically oriented
wedge of the excess skin located on the medial aspect of
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Body contouring, massive weight loss

the thigh. It uses both an anterior and posterior horizontal

vector while totally eliminating the vertical vector/pull, to
accomplish thigh contouring. The horizontal incision in
the groin is limited to the correction of the dog-ear and
does not contribute to the actual lift of the medial thigh.
There is no need to anchor the thigh flaps to the Colles
fascia. The vertical excision closes the thigh as a cylinder.
The tension of wound closure gets distributed from the
groin to the knee along the medial thigh. Moreover, the
vertical wedge is situated posterior enough so that if a
horizontal component is needed to eliminate vertical
excess, it would not cause labial distortion. The placement
of excision also minimizes the possibility of injury to
lymphatic structures reducing the risk of lymphoedema.
Markings are done with the patient in lithotomy position
to mark the perineal crease. The tissue is pinched at various
points along the perineal crease. The point at which the
pinch has minimal traction on the labia is marked. This
would be the top of the ellipse to be excised. Now with
the patient standing with knees 12 inches apart a vertical
line is drawn on the medial aspect of thigh starting at
the point previously made at the perineal crease. This
line will be the centre of the ellipse to be excised. The
double ellipse technique of marking is used to delineate
the wedge to be excised. With the patient in lithotomy
position, the wedge is liposuctioned to completely
deflate the area. The resection is then performed using
the segmental resection closure technique and the wound
is closed in layers over the suction drain. The dog-ear at
the superior end is removed by extending the incision
transversely, posteriorly along the infragluteal crease.

FACE AND NECK

The face and the neck in a MWL patient are usually
tackled at the end. Due to sudden and massive weight loss
following bariatric surgery, the volume loss often gives
the face an emaciated and gaunt appearance. Excessive
facial fat atrophy coupled with redundant skin and SMAS
leads to loss of facial contours and elasticity. The goal in
facial rejuvenation in MWL patient is to restore the facial
and neck contours. Multiplaner rhytidectomy addresses
both volume and skin laxity. Secondary procedures are
often performed to correct the residual deformities.

POTENTIAL COMPLICATIONS
Considering the overall medical status of a post-bariatric
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surgery MWL patient who has rapidly lost massive

amount of weight, nutritional deficiencies, anaemia,
co-morbid conditions, and the extent of prolonged
surgeries performed in various stages to achieve body
contouring, relatively high incidence of complications
is not unjustified. The complication rates increase with
BMI. General complications include wound dehiscence,
seroma, infection, delayed healing, lymphocele /
lymphorrhea, suture extrusion, asymmetry, thrombosis,
nerve compressions, neuroma, sensory and/or motor
loss and scarring. Complications specific to particular
procedures that require special attention have been
described in the techniques above.
Theincidenceofcomplicationscanbereducedbyappropriate
management of co-morbid conditions before, during
and after surgery, correction of anaemia and nutritional
deficiencies, selection of the most suitable procedure for
individual patients, precise markings, meticulous surgery,
absolute hemostasis, three point sutures to obliterate the
dead space, meticulous multi-layered closure over drains,
properly instituted postoperative care, supervised nursing
and regular follow-up.
Detailed planning of each stage and discussion with
the patient, informed consent, and sound education
of the patient, relatives and the nursing care team also
contribute a lot to the overall success.
Wound dehiscence immediately after surgery is secondary
to inappropriate movement by the patient and/or staff and
is most often seen in the lower back. Patients should be
fully alert and awake prior to initiation of any movements.
Seromas may lead to delayed dehiscence and can result
in chronic wounds with delay in healing. They are treated
by serial aspirations, injections with a sclerosing agent
(Povidone iodine, dicloxacillin) or exteriorizing the
seroma cavity by making a small opening through the
scar into the cavity, placing a Penrose drain and leaving it
in place till the cavity fills itself and stops draining. Fibrin
tissue sealants have been used to decrease the size and
frequency of seromas.[39] Reports have also been published
suggesting the role of ultrasonically activated Harmonic
scalpel in the reduction of seromas in circumferential
body lift procedures.[40]
Two issues that often lead to litigations are vulval
distortion/ labial distraction after thighplasty, and
brachioplasty closure. They have already been discussed
under the respective sections above.
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Shrivastava et al.

SAFETY CONSIDERATIONS
The number of patients undergoing body contouring
surgery following MWL has increased substantially in
the past decade. Patient safety should be the topmost
priority of the body-contouring surgeon simultaneously
striving to achieve the desired aesthetic outcome.
Comprehensive informed consents separate for each
contouring procedure are mandatory.
Medical status
Special attention should be paid to the current
medical status of the patient and the accompanying
co-morbid conditions like diabetes, hypertension etc.
Weight stabilization must be ensured considering the
co-morbidities and complexity of various diseases
affecting the MWL patients, complete lab investigations,
psychiatric evaluation, cardio-pulmonary clearance,
PAC by experienced anaesthesiology team should be
a routine. Smoking habit should be documented and
should be strongly discouraged. Anaemia and nutritional
deficiencies should be suitably corrected preoperatively.
Patients should be informed about the possibility of
intraoperative blood transfusions.
Anesthesia concerns
MWL patients are difficult to intubate and may require
fibreoptic intubation and neck lines. Many suffer from
gastro oesophageal reflux and obstructive sleep apnoeas.
These patients have increased risk of aspiration.
Continuous monitoring must continue in post-op period.
Large percentage of exposed skin for prolonged periods
can lead to hypothermia. Use of warming air blankets, prewarmed IV fluids, warming devices etc is recommended.
Positioning during surgery
Patients frequently require supine, prone and lateral
decubitus positions during surgery. This carries risk for
neural and vascular compressions. Possible complications
include vertebral artery occlusion, vision loss and nerve
damage. Liberal use of soft pillows, gel mattresses and
foam padding at nerve and bone prominences help
prevent neuropraxia and skin necrosis. Regions to be
cared for include occiput, orbit sockets, ears, cervical
spine, shoulder blades, breast and nipples, sacrum, iliac
crest and knees.
Infection control
Consequent to nutritional deficiencies, diabetes, anaemia,
impaired immune state and underlying bacterial and
Indian J Plast Surg Supplement 2008 Vol 41

fungal skin infections, proper antibiotic prophylaxis for

infection control is mandatory. For longer, multistage
procedures, the risk of infections increases further.
Topical broad spectrum soaps should be prescribed for
twice daily bath for three days preoperatively. Injectable
antibiotic should be administered one hour before
surgery, during surgery and for at least 24h post surgery.
Additionally, clipping of hairs rather than shaving reduces
the chances of minor cuts and thorough scrubbing with
4% chlorhexidine gluconate solution helps disinfect the
skin.
DVT and pulmonary embolism prophylaxis
The risk of thrombosis in MWL patients undergoing body
contouring is high because of extended operation time,
the size of the wound area and the potential fat trauma.
Contributing risk factors are use of oral contraceptives,
pregnancy, advanced age, recent surgery, coagulopathies
and prolonged immobilization. Thrombosis prophylaxis
should include use of intra-operative compression
treatment of lower legs, low molecular weight heparin,
circulation promoting measures such as infusions of 2-3
litres of RL for dilution of circulating blood, postoperative
beach chair position, early mobilization etc. Intermittent
compression pumps may also be used as an alternative to
compression stockings.

CONCLUSIONS
The number of bariatric surgery procedures is on the
increase in India. In the near future we are going to see
large number of MWL patients who will require multiple
body contouring procedures. The plastic surgery
community in India has to prepare itself to effectively
deal with these patients.

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Indian J Plast Surg Supplement 2008 Vol 41