Abdominoplasty After Massive Weight Loss

Abstract

Body contouring surgery has experienced a true resurgence with the popularization of surgical treatment for morbid obesity. In recent years, a new and growing population of patients with extremely challenging deformities has been visiting plastic surgery clinics, demanding a new approach to techniques in search of better results. Some procedures that had been practically abandoned with the advent of liposuction are now returning because of the devastating nature of these deformities. The main concept to be incorporated by plastic surgeons in abdominal approaches to post-bariatric patients is to avoid isolated evaluation and intervention in the abdomen without considering associated deformities in the lower body. Each patient has a different reality and even specific genetic characteristics, but the general and circumferential character of the physiopathology and biodynamic deformities will always influence body contouring as a whole. Even when isolated intervention is chosen by the medical team, this decision must result from full knowledge of the overall contouring situation.

Preoperative planning is fundamental in this process and must be based on the complete physical exam, with vigorous palpation of tissues and simulation of probable correction vectors as well as the patient’s opinion. All of this careful surgical planning becomes evident in surgical site marking, which should be done carefully and calmly, preferably the night before surgery to avoid stress and mistakes resulting from marking in the operating room before anesthesia. Photographic and video records of both the physical examination and site marking provide essential support for retrospective assessments of the results obtained.

Some details of the surgical technique may also make the difference in caring for this type of patient. Although tissue resection can be extensive in the lower body, there is no need for larger detachments of remaining flaps. This means that the mobility of the covering resulting from the reorganization of the superficial fascia system permits large tissue advances, when correction vectors are found, safely and with circulatory viability. This abdominal approach without detachment was originally proposed by Avelar (Rev Bras Cir 88/89(1/6):3–20, 1999; Aesthet Surg J 22(1):16–25, 2002) and is naturally applicable in the post-bariatric patient since weight loss provokes the reduction of subcutaneous tissue and makes flap mobilization easier, with less risky maneuvers.

Technique

Anterior Transverse Approach – This technique is used for abdominoplasty in conventional patients, but is rarely recommended in the post-bariatric population. Although this approach is efficient in patients with deformities resulting from multiple pregnancies and is restricted to the anterior aspect of the abdomen, the anterior transverse approach tends to be insufficient for treating more general loose and circumferential tissue.

Circumferential Approach – The objective of this procedure is to expand the anterior transverse resection of the lower abdomen to the flanks and lower dorsum, removing an actual belt of loose tissue in order to remove remaining tissue and also lift the anterior and lateral base of the thighs, as well as the gluteal region.

Combined Anterior Approach – Also known as “anchor” or “fleur de lis” abdominoplasty, this technique combines longitudinal resection with the anterior transverse approach specifically to correct the horizontal excess abdominal tissue which is normally present in post-bariatric patients.

Combined Circumferential Approach – This technique also combines anterior longitudinal resection with the circumferential approach specifically to correct horizontal excess abdominal tissue which is typically present in the post-bariatric population.