Outline

Circumferential dermolipectomy has been an effective means of reducing excess skin and fat after massive weight loss, however, regions of residual midabdominal and epigastric fat frequently confer a suboptimal contour, and often mediocre cosmetic results. Liposuction in association with lower body lift surgery has been regarded with caution, for fear of ischemia or necrosis of the undermined flaps as potential dire consequences. In this study, a theoretical and technical approach that maximizes safety and aesthetics in circumferential lower body lift after massive weight loss with contouring using liposuction is described and evaluated. Twenty-four patients were treated with follow-up ranging from 6 to 40 months (mean follow-up 17 months). All patients were treated with the resection of circumferential skin and fat maintaining a low-lying transverse suture line with a prone-to-supine approach. Dorsally, liberal liposuction is performed after the instillation of lidocaine-free wetting solution above and below the resection lines. Ventrally, the upper flap is elevated widely to the umbilical horizontal. The umbilicus is circumcised, and the dissection then progresses in a narrow column above the rectus sheaths to the xiphoid. Judicious subcostal undermining is performed, maintaining an intact bilateral subcostal “perforator zone” of 4 to 6 cm. Diastasis repair and anterior sheath plication are performed, and the umbilicus is anchored to the fascia. Wetting solution is instilled, and suction-assisted lipoplasty of the entire flap, particularly in the midline and in the region of the neo-umbilicus, is performed, removing excess fat and providing discontinuous lateral flap “undermining.” There was 1 hematoma (4%) requiring re-exploration and 4 seromas (17%) treated with percutaneous aspiration. There was no infection, skin loss, or wound dehiscence. Unlike standard dermolipectomy procedures with wide undermining, the maintenance of a broad subcostal blood supply with selective direct undermining allows for liberal flap contouring with suction and the establishment of lower suture-line position. With this technique, liposuction can be safely used during lower body lift to maximize aesthetic outcomes.

Circumferential dermolipectomy (belt lipectomy or lower body lift) has been an effective means of reducing excess skin and fat after massive weight loss (MWL),1–3 however, regions of residual midabdominal, epigastric, flank, and lumbar fat frequently confer a suboptimal contour, and often a mediocre cosmetic result. Combining liposuction with lower body lift, the logical adjunctive procedure to improve the aesthetic balance of the dermolipectomy, has been regarded with caution, for fear of ischemia or necrosis of the undermined flaps and peri-incisional skin loss as potential dire consequences. Although the performance of circumferential dermolipectomy procedures in the absence of flap contouring by direct fat excision or liposuction is safe, there are clear limitations in the cosmetic results that can be achieved. Akin to any abdominoplasty procedure, the technical considerations of lower body lift demand great respect for the blood supply to the undermined flaps.

Our group and others 4–11 have reported the safe use of liposuction in abdominoplasty. Careful patient selection is of paramount importance in all studies, as is the preservation of appropriate perforators of the vascular zones of the abdominal wall. As in classic abdominoplasty procedures, the anterior abdominal flap in circumferential dermolipectomy is the most vulnerable to aberrations in blood supply, as anterior undermining and caudal flap transposition is often the most substantial of the circumferential maneuvers. Huger 12 described 3 anterior abdominal wall vascular zones based on the superior epigastric vessels (zone I), inferior epigastric and circumflex iliac vessels (zone II), and intercostal, subcostal, and lumbar perforators (zone III). In a classic abdominoplasty, wherein the remaining lateral (zone III) blood supply is dominant, the central flap is rendered “least safe” for treatment with suction lipectomy,13,14 and this applies in-kind to the circumferential lower body lift procedure. The central portion of the anterior apron flap in both circumferential dermolipectomy and anterior abdominoplasty is, of course, the region that, from an aesthetic standpoint, requires the most contouring.

To improve both aesthetics and safety in abdominoplasty procedures, a selective approach to the extent of dissection and maintenance of an increasingly rich blood supply is progressively more common.4,8,10,11 With greater respect for, and preservation of, blood supply, more liberal contouring by liposuction and ultimately enhanced aesthetics can be achieved. It is the application of this concept of vascular supply-driven selective undermining to the circumferential dermolipectomy procedure that serves as the basis for this study. We describe and evaluate a theoretical and technical approach to the lower body lift procedure that maximizes aesthetics and safety by selective undermining and contouring with liposuction.

Twenty-four patients were treated from March 2005 through June 2008 with follow-up ranging from 6 to 40 months (mean follow-up 17 months). All patients had experienced MWL by diet and exercise or by bariatric surgery, were nonsmokers, and had reached and sustained a weight-loss “plateau.” Patients were selected to include only ASA class I 15 (no medical problems) and ASA class II 15 (well-controlled thyroid disease or hypertension, with no pulmonary or cardiac disease). The data were reviewed retrospectively.

The skin is marked preoperatively in the standing position. A grid pattern is marked to facilitate closure (Fig. 1). Inferior and superior circumferential incision lines are oriented to maintain the final suture line location as low to the pubis as possible, and at or below the anterior superior iliac spines (Fig. 2). The superior incision line marking is an estimate, confirmed at final tailoring. Suction areas are marked over the midline-anterior abdomen, epigastrium, flanks, thighs, and lumbar regions as indicated by the location of adiposity.

Surgery is performed with the patient under general anesthesia in all cases using a prone-to-supine approach. Sharp dorsal belt excision is carried out with no undermining of the upper or lower flaps. The superficial fascial system (SFS) is approximated with interrupted 0-polydioxanone suture. Wetting solution consisting of 1 mL of epinephrine (1:1000) per liter of lactated ringers is infiltrated. No local anesthetic is added to the solution, removing the potential for lidocaine toxicity in these cases that are all performed under general anesthesia. Liposuction of the lumbar region and posterior flank region, incision-line, and the posterolateral thigh region are performed with 4 and 5 mm cannulas as indicated. Dorsal dermal approximation is completed over closed suction drains, and the patient is replaced to the supine position.

Continuing anteriorly with a low-transverse incision, the upper flap is elevated widely to the umbilical horizontal, and the umbilicus is then circumcised. From the level of the umbilicus, cephalad dissection then proceeds in a narrowing column in the midline to the xiphoid. The width of this “tunnel” is maintained only as wide as is required to effectively plicate the anterior rectus sheathes to the midline, while maintaining maximal blood supply from zone I and III perforators. The medial border of the rectus muscle is identified, and undermining is carried between 1 and 2 cm laterally over each anterior rectus sheath. The width of the rectus diastasis then determines the total width of the tunnel, that is, a 3 cm diastasis requires an undermining width of approximately 6 to 7 cm. A lighted retractor is helpful for this dissection, and for later long rectus plication to the xiphoid in the undermined region.

To allow for the inferior transposition of the flap, judicious lateral undermining is performed, maintaining an intact bilateral subcostal perforator zone of 4 to 6 cm. The remainder of the flap mobility is conferred by discontinuous undermining provided by suction lipectomy.

Anterior sheath plication is then performed with interrupted monofilament suture from the xiphoid to the pubis (0-polydioxanone alternating with 0-polypropylene). The umbilicus is tacked to the fascia, maintaining a short umbilical stalk, with interrupted 2-0 polydioxanone at 6- and 12 o'clock. These sutures are left untied until final apposition to the dermis of the flap.

On-Q catheters (I-Flow Corp., Lake Forrest, CA) are inserted into the dissection plane, instituting continuous administration of 0.25% bupivicaine. Temporary inset of the flap is then carried out at the SFS and dermis. Lidocaine free wetting solution is infiltrated, and liberal liposuction is then performed both below and above Scarpa's fascia using 3 and 4 mm cannulas over the entire flap and flanks, providing both discontinuous undermining and aesthetic refinements.

The upper flap is then placed on traction inferiorly, and the limits of skin and caudal flap resection are marked and excised. The location of the neo-umbilicus is then marked and incised. Sharp excision of sub-Scarpa's fat is then carried out immediately beneath and surrounding the neoumbilical site, promoting a gentle concavity in this region.

The neo-umbilicus is then “anchored” to the dermis under mild tension with the tying of the preplaced sutures. Two closed suction drains are inserted, and final tailoring and inset of the flap are carried out in the SFS and dermal planes. Compressive binders are never used.

Twenty-four circumferential dermolipectomy procedures were performed in 24 patients; 9 achieved MWL by nonsurgical means only, and 15 underwent bariatric surgery (bypass or band). Of these, 12 were performed laparascopically, and 3 were open incisional procedures. There were 18 women and 6 men. Total liposuction aspirate volumes ranged from 850 to 3100 mL (mean 1790); estimated anterior flap suction volumes ranged from 400 mL to approximately 1200 mL.

Minor complications included 4 seromas (17%), successfully treated with percutaneous aspiration, and 2 scar irregularities (8%) that required revision under local anesthesia. There were no infections, and no cases of flap ischemia, skin loss, or open wound. There was one hematoma (4%) that required a return to the operating room. There were no deep vein thromboses or other major complications.

With the dramatic rise in the number of patients seeking correction of the sequellae of MWL over the past decade, plastic surgeons have been compelled to rethink the classic mores and tenets of their approaches to body contouring. After MWL by nonsurgical measures or by bariatric surgery, the very real functional concerns of intertriginous irritation, cellulitis, panniculitis, and other impairments due to skin excess are counterbalanced by the psychosocial impact of bodies that are no longer obese, but are far from the aesthetic ideals for which these individuals strive.

Body contouring after MWL has evolved from “amputative” procedures, such as panniculectomy, to more thoughtful “body lift” procedures; the name itself implies a restoration of form and cosmesis that transcends simple removal of excess skin and fat. Indeed, with a variety of circumferential dermolipectomy procedures,2,3,16–23 some more pleasing torso contouring results have been achieved. Often, however, as the fuller, more voluminous, circumferentially larger upper flap is transposed to the slimmer, narrower lower incision line, considerable cosmetic and technical limitations remain. After MWL and more standard dermolipectomy procedures without liposuction, there is almost invariably residual localized epigastric adiposity, potential step-transitions at the suture line, suboptimal periumbilical contour, often with a “pasted-on” appearance of the neo-umbilicus, and flank and other regional excess. This begs the question: is the achievement of improved aesthetics by additional flap contouring with direct fat excision or liposuction appropriate and safe?

We have previously explored improvements in aesthetics and safety in abdominoplasty with broad subcostal perforator preservation to the anterior flap and liberal use of liposuction,4 and in this study have further extended the theory and technique to the MWL and circumferential dermolipectomy group. The keys to advances in both abdominoplasty aesthetics and safety when combined with liposuction have been careful patient selection and careful and selective undermining of the abdominoplasty flap.4–11

It is our current practice to have postbariatric surgery and nonsurgical MWL patients be at a sustained plateau for a minimum of 6 months before surgery. All patients selected are also healthy ASA class I or II,15 and nonsmokers.

The technical considerations that maximize flap vascularity, and consequently safety, are selective direct midline undermining of the anterior flap, with discontinuous lateral undermining, which preserves an abundant zone III (lateral) perforator network and a number of zone I (superior epigastric) perforators. To gain access to the fascial midline for plication of rectus diastasis, by necessity some zone I perforators are interrupted, although with judicious exposure of only the medial aspects of the anterior rectus sheaths bilaterally above the umbilicus, some zone I epigastric vessels are maintained. Furthermore, the flank and lumbar components of the circumferential lower body lift procedure are by nature limited-undermining maneuvers; hence, perfusion of the dorsal skin margins is rarely in question. With minimal interruption of the Zone III perforators, the lateral and posterior dermolipectomy does not adversely impact the anterior abdominal blood supply.

Aly et al 3,17,24 elegantly likened the torso to a “lampshade,” describing a cone of concentric and widening circumferences as it progresses from thorax to pelvis; the more craniad the upper circumferential incision is made, the less the discrepancy with the lower incision line, and the less horizontal excess remains (obviating the need for a fleur-de-lis approach in most cases). Blunt-cannula liposuction has been shown by Teimourian et al 25–27 to preserve a network of blood vessels between skin and underlying tissues. We have found that with liberal liposuction of the superior flap, the fatty turgor is decompressed, allowing for more flap mobility and more relaxed caudad transposition. The resulting increased laxity in the flap results in the ability to position the final transverse suture line further inferiorly under minimal or no tension in the suprapubic region. Furthermore, the discontinuous cannula undermining and fatty fullness reduction maneuvers with liposuction can be further accentuated by anchoring the flap under moderate tension with the umbilical inset (where blood supply is rich), further minimizing tension on the caudal suture line.

In contrast to high lateral tension approaches to circumferential dermolipectomy,16 with laterally arching scars curving well above the bilateral anterior superior iliac spines, we favor incision lines that reside considerably lower. Previously felt to compromise a more pleasing midabdominal silhouette or “hour-glass” contour that can be more predictably defined by a higher-riding incision line, the waistline in a low-incision circumferential dermolipectomy can indeed be accentuated in the presence of a lower-lying incision; diastasis repair and fascial plication combined with liposuction can effectively restore the waistline.

In the absence of flap contouring, the neoumbilicus of the more conventional dermolipectomy procedures can appear flat or pasted on. With the present technique of flap contouring, when the location of the neo-umbilicus on the upper flap is ascertained, direct defatting below Scarpa's fascia, combined with additional neoumbilical liposuction, results in a more pleasing periumbilical concavity. Anchoring the flap at this location to the fascia and to the cranial and caudal aspect of the umbilicus completes the inset.

No lidocaine is used in the wetting solution to reduce any potential for lidocaine toxicity. Bupivicaine 0.25% administered continuously through the On-Q catheters provides sufficient local postoperative analgesia. Total aspirate volumes by suction-assisted lipoplasty ranged from 850 to 3100 mL (mean 1790), which included the anterior flap and additional regional suction including flanks, back, and thighs; the estimated flap and bilateral subcostal region suction volumes ranged from 400 mL to approximately 1200 mL. The suction-assisted lipoplasty is performed with 3 and 4 mm Accelerator III cannulas (Byron Medical, Inc., Tucson, AZ), which are used “openings-down,” particularly when suctioning in the plane between Scarpa's fascia and dermis.

We never use a compressive binder immediately after surgery, as all efforts to maximize perfusion of the flap are undertaken. Occasionally, external compression is used after one and a half to 2 weeks in selected cases. All patients are admitted for observation for at least one night, with an indwelling bladder catheter, antiembolic compression boots, and continuous pulse oximetry. Patients are mobilized on the evening after surgery. No heparin, enoxaparin, or other anticoagulant medications are used. There were no cases of deep vein thrombosis or pulmonary embolism in our patients.

We have found this technique to be applicable to the gamut of widely varying morphologic presentations after MWL. Mild skin and fat excess (Fig. 3), moderate laxity and excess (Fig. 4), and more severe excess with both vertical and horizontal redundancy (Figs. 5, 6) can be addressed safely with the combination of liposuction contouring and circumferential lower body lift. In this series, 3 cases involved patients who had previously undergone open bypass procedures with a vertical midline incision (Fig. 7). Each case was treated with circumferential transverse excisions, limited direct central undermining, and liberal liposuction with no fleur-de-lis component. We feel that the fleur-de-lis approach should be reserved for patients with severe horizontal supraumbilical excess only, as the caudad mobilization of the smaller upper torso “cone” circumference is most often possible with the techniques described herein.

Unlike standard abdominoplasty and dermolipectomy procedures, characterized by wide undermining, the maintenance of a broad subcostal blood supply with selective direct midline undermining allows for liberal liposuction of the flap, the establishment of lower suture-line position, and enhanced abdominal contour. With this technique, liposuction can be safely used with lower body lift to maximize aesthetic outcomes.

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Key Words: lower body lift; circumferential dermolipectomy; belt lipectomy; abdominoplasty; liposuction; plastic surgery after massive weight loss; body contouring after bariatric surgery