The most common malnourishment is obesity unlike thirty years back. But due to the awareness of the adverse health effects of obesity many people opt for conservative methods or bariatric surgery leading to massive weight loss.
Massive weight loss is defined as more than 50% loss of the excess weight. The ideal weight is broadly taken as height in centimeters minus 100. The problems depend on the amount of weight loss, age, skin elasticity and the duration of the obesity. It is now seen more often, as bariatric surgery has become very popular.
The usual areas affected are the chest, arms, abdomen, buttocks and the thighs. In the chest, variable degrees of pseudogynecomastia in males is a devastating problem. Deflated ptotic breasts are common in females. Both groups may have rolls that may extend from the chest to back. There may be both vertical and horizontal excess.
The arms are also often affected with loose pendulous skin hanging down giving a “Bat wing” appearance. More often it continues with a lateral excess on the chest wall and is addressed together.
The trunk is usually “pear” shaped with multiple skin folds. The buttocks are deflated with ptotic hanging skin and will lack the usual aesthetic contours. There may often be a lot of excess fat in the supra buttock area causing an appearance of lack buttock contours and has to be treated by removing that fat.
The thighs also may have a lot of loose skin with multiple folds mainly in the medial side. Medial and lateral thigh have to be addressed separately. Usually the lateral thigh lift with liposuction is combined with the lower body lift. Medial thigh is dealt with later. The lower limb lymphatics, which are below the saphenous vein in the medial and anterior aspect of thigh, must be respected and avoided.
Multiple procedures may be combined safely and when there is a staged procedure, a minimum of 3 months’ gap is preferred in-between. Staging of procedures are planned keeping in mind the medical status, length of procedure, vectors of tension, surgeon experience, operative assistance and cost to the patient. The usual order which we follow is lower body lift + lateral thigh lift + Lipo back/ med thigh followed three months later by upper body lift + Brachyplasty + medial thighplasty.
Patient selection is very important to avoid complications. At least 12–18 months following bariatric surgery is mandatory. Weight must be stable for at least 3 months.
BMI <35 kg/m2 is acceptable
BMI >35 kg/m2 - increased risk of surgical complications
BMI of 25–30 kg/m2 – ideal
BMI >32 kg/m2 - limited aesthetic outcomes
We must be cautious when there is severe medical comorbidities, psychiatric co-morbidities, unrealistic expectations and in long term smokers. We must also be cautious with BMI >35 kg/m2, uncorrected coagulopathies, severe disorders, that affect wound healing and systemic medical disease.
Preoperative assessment includes complete history, physical exam, weight history, past surgical history, nutritional status and psychiatric co-morbidities. Besides routine investigations, S. Protein, Albumin, Vit B12, S. iron are done. A mammogram is usually done before breast surgery.
Degree of skin excess, distribution of fat, number and location of rolls, quality and elasticity of the remaining skin are noted. Scars from prior surgeries, rectus diastasis, ventral hernias and asymmetries are also noted.
Before surgery, patients are advised to use incentive spirometer and are advised to lie in Trendelenburg position. In the preoperative counselling, long and potential wide scars are discussed with the patients. Problems of wound breakdown and healing inadequacies are discussed.
In Upper body lift, operative planning and procedures selection is based on deformity present, patient’s expectations and acceptability of final scar placement and surgeon preference. If there is only mild amount of skin excess and good skin elasticity - liposuction alone is preferred.
In moderate to severe skin redundancy excisional procedures are done. When there is a descent of the lateral inframammary crease, transversely based excision, vertical excision or an excisional brachyplasty extended to lateral chest up to inframammary crease is done.
The problems of the arms are classified as follows:
Group 1 - moderate to firm skin and voluminous upper arm fat deposit
Group 2 - flabby skin with fat deposit
Group 3 - flaccid skin and no fat deposit
We may get away with liposuction of the arms in group1 patients but the rest require excisions and they involve long incision scar from axilla to elbow. A lot of planning goes into deciding the position of the nipple areola complex which is taken on an inferiorly based deepithelialised pedicle. Drains are placed and are removed when it is below 30 ml. Elastic compression garment are also given to the patients.
A lower body lift or belt lipectomy addresses the abdomen, buttock and the lateral thigh. It eliminates hanging panniculus and creates a waist definition. It decreases or eliminate lower back rolls. Nowadays, in some patients, a fleur de lis abdominoplasty is done where the abdomen gets better definition but the trade off is a midline vertical scar in the front of the abdomen. Medial thigh plasty may be done at a later session.
The usual complications are kept to a minimum by proper planning and doing the procedure when the body is fit. But seroma, hematomy and issues of wound healing may occur. All precautions against thrombotic events must be taken. Wide scars and contour asymmetry are also likely to occur.
Dr. Sundeep Vijayaraghavan, Clinical Professor
Centre for Plastic and Reconstructive Surgery, Hair Transplant, Composite Tissue Allotransplantation
Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala.