Background: Extreme weight loss has a lot of positive medical benefits for the obese patient, from cardiovascular health to an overall lifestyle improvement. The one negative effect from a generalized ‘body deflation’ from the weight loss is the discovery of loose and hanging skin that is seemingly everywhere. While it can occur anywhere from the neck to the ankles, it is always seen in both men and women around the waistline.

While extreme weight loss definitely causes a dramatic change in one”s waistline, one will almost certainly not look like the picture that is often illustrated as seen here. Rather, the negative waistline effects from extreme weight loss can include an overhanging abdominal pannus and hip and buttock sagging. Like the effects of wax dripping off a candle, the skin slides off the upper trunk down over the waistline and into the thighs. Reversal of these effects requires a circumferential approach that removes excess tissue and lifts and tightens around it. This procedure is known as a body lift.

The body lift has become well known as a bariatric plastic surgery technique over the past decade. While it has become popular as a result of the influx of patients from surging numbers of people who have had bariatric surgery, it is actually a much older procedure that dates back decades and is known as a belt lipectomy. The trade-off of a circumferential scar is a small price to pay for the dramatic effects of the procedure.

Case Study: This 42 year-old female had lost 125 lbs after gastric bypass surgery one year previously. Her weight has been stable for the past four months and she had been on a regimented diet and regular exercise program. Her laboratory studies showed stable electrolytes and nutritional levels. She was bothered by an abdominal pannus, bulging hips and hanging buttocks.

Markings for a body lift procedure included the design for a frontal tummy tuck with arced excision patterns carried across the hips and across the midline of the back using a pinch technique to see what could be safely removed. Under general anesthesia, the tummy tuck portion was carried out in the supine position. Then switching to alternating right and left side positions, the hip and back excisions were performed and closed. A total of three drains were placed prior to the skin closures. Her long circumferential skin incisions were closed with barbed sutures. All incisions were taped and a circumferential binder was placed. She was sent home as an outpatient after recovering from anesthesia.

She had a surprising low level of pain after surgery. Her drains were removed two weeks after surgery. She returned to full activity, including exercise, but six weeks after the body lift surgery.

The circumferential body lift is a very effective procedure for the extreme weight loss patient. It often is the foundation of all the body contouring options and is always the first procedure done and may be the only one that is ever done for some patients. Whether the back portion of the body lift is needed depends on how much loose skin exists over the hips and buttocks and its scar trade-off must be carefully weighed compared to the sagging tissue problem. If it is not done, then the patient is having an extended tummy tuck and not a body lift.

Case Highlights:

1) Generalized sagging of the body commonly occurs after extreme weight loss, either from bariatric surgery or diet and exercise-induced..

2) A body lift treats the excess sagging tissues by a waistline circumferential excision.

3) A body lift is a combination tummy tuck, hip lift and upper buttock lift done in a 360 degree horizontal orientation.

Dr. Barry Eppley

Indianapolis, Indiana

Unlike many plastic surgery procedures that are performed in outpatient centers (e.g., breast augmentation, facelifts etc), body contouring is more extensive and invasive surgery. Some bariatric surgery patients also have associated medical conditions which may lead to increased complications form surgery or anesthesia. The question then becomes as to the safety of extensive body contouring procedures in an outpatient setting.

In the April 2012 issue of Aesthetic Surgery Journal, a study was published entitled ‘Outpatient-Based Massive Weight Loss Body Contouring: A Review of 260 Consecutive Cases’. These patients came from a single plastic surgeon in private practice in the state of Washington. Over a six year period (2004 – 2011), 260 patients (93% women) who underwent a total of 544 body contouring procedures was evaluated. The average age of the patients was 42 years with an average weight loss of 130 lbs. The most common procedures performed were a lower body lift, liposuction and armlifts. Nearly 60% underwent more than one procedure with an average operating time of over 5 hours. (330 minutes) Nearly 90% of the patients went directly home after leaving the recovery room.

The most common complications were wound separation (17%) followed by seroma (5%) and urinary retention. (4%) There was one case each of the need for blood transfusion and a pulmonary embolism. No instances of infection, death or need for inpatient hospitalization occurred.

This study is impressive as 260 consecutive cases of any procedure is significant, let alone complex body contouring procedures. It demonstrates that good patient selection with an experienced plastic surgeon and anesthesiologist in an accredited surgery center can produce exceptional outcomes with a very low rate of complications. The lack of DVT and pulmonary embolism complications, albeit one patient, is noteworthy given the length of the surgeries and their extensive nature. Only one infection and such a low rate of seroma formation is also noteworthy given the hundreds of patients treated.

Wound complications are the norm in any form of body contouring whether it be the arms, breasts or lower body. I tell my patients to expect minor wound healing issues that will not be completely healed until six to eight weeks after surgery. It is never a question of if but where and how significant is the wound opening area.

This study clearly shows that many bariatric plastic surgery procedures can be safely performed as outpatient procedures. Combination procedures, which may take up to four to six hours of surgery, can be done and still send the patient home without increased risks of DVT or PE complications.

Dr. Barry Eppley
Indianapolis, Indiana

Currently, men make up a minority of patients presenting for body contouring surgery after weight loss.  However, their numbers are increasing and they have several different body concerns that women. One of these is that of the chest area. The skin sag and the presence of excess fat under the nipple creates a relatively new type of problem. Some call this chest problem gynecomastia but that is inaccurate. It is really pseudogynecomastia as it has more skin and less actual fat.

 Most male chest deformities after weight loss require dealing with the extra skin. Some patients may need liposuction only but this is not common in my experience. When a male patient is motivated to undergo chest reconstruction, they almost always have a significant problem.  It usually requires removal of skin and then what to do with the the sagging and often stretched out nipple. The skin part is relatively easy. The overhanging skin (that which sags below the lower chest crease) is horizontally removed with the goal of making the chest flat and keeping the final scar low enough so that it hopefully lies in the natural skin crease at the lower end of the chest muscle.

The more difficult choice is how to manage the sagging nipple. Choosing a new location is based on standard measurements but how to get there is another. The nipple can be removed and replaced like a skin graft or the nipple can be moved while attached to some underlying breast tissue. (similar to how it is done in a female breast reduction) Both methods are reasonable but they have slightly different outcomes. Free nipple grafting gives one the flexibility to place it anywhere on the chest but the nipple will not have sensation and make look a little artificial and stuck-on. (plus there is no  guarantee it will survive and it may lose some color after it is healed. ) Pedicled nipple grafts are harder to perform and are more limited in where they can be placed. But they usually look more natural and have better color. In some cases, the amount of sagging chest skin dictates which nipple technique can be used. But in others, it is a matter of the patient’s choice and their level of concern about the look of the nipple. In many cases, like in severe gynecomastia, the nipple-areolar transposition technique is best with inframammary fold excision.

For male extreme weight loss patients, the chest deformity is right up there in concern just behind the abdominal and waistline areas. Men are most interested in how their chest looks in clothes and want a relatively flat appearance in shirts.

Dr. Barry Eppley

Indianapolis, Indiana