This is an excerpt from Dr. Gelfant’s book Cosmetic Plastic Surgery: A Patient Guide, which was originally published in 1997.
Despite the great advances which have been achieved since the advent of suction lipoplasty, surgeons and patients are still unable to restore skin elasticity. When weight gain and loss, age, pregnancy and disease cause skin to be loose, (or when liposuction has been done aggressively) more traditional surgical techniques are still needed to tighten skin and fit it to the underlying changed shape. It is the same when you lose several inches around the waist – clothing must be altered by “taking it in” or removing a dart. The skin, which is the fabric covering your body, must be altered by removing the excess.
There are two main categories of body contouring surgery. The first, suction assisted lipoplasty ( liposuction), involves fat removal through very small incisions. The second, is the subject of this chapter, and includes surgery such as abdominoplasty, thigh lifts, and upper arm tightening surgery. Suction lipoplasty will be covered in another chapter because it really is a very different approach to contouring.
The explosion of body contour surgery we have seen in the past three decades began with liposuction when it was brought to North America in the early 1980’s. More recently two other major factors have made body contouring surgery much more common. The first is the massive growth in the fitness industry, and paradoxically the second is the dramatic increase in obesity (what a strange culture we have).
The fitness industry, combined with nutrition and weight loss sectors, account for over $600 billion in sales by recent estimates. Walking down a commercial street in metro Vancouver it is nearly impossible not to encounter a storefront operation of a gym/workout facility, a yoga or pilates studio, or something similar; this doesn’t include the myriad of establishments selling various nutritional supplements, physiotherapists, massage therapists and fitness equipment outlets. While Vancouver may be particularly known for this, this trend is strong throughout North America.
One of the good things about practicing plastic surgery now, compared to when I first started, is that so many of my patients are now “body aware” and know a very reasonable amount of anatomy and so are very easy to educate about both what I am trying to do surgically, as well as how to rehabilitate after surgery.
With the explosive increase in obesity in North America has come a search for solutions, including basic research looking for “fat genes”, a diet industry (Dr. Bernstein’s and others) as well as much improved surgery for obesity (Lap banding and others). The surgical treatments have become successful and large numbers of patients have now been able to lose huge amounts of weight and keep it off, something that was never achievable by other methods. But a plastic surgery problem has developed in that these patients are now faced with the prospect of having huge areas of excess skin in their arms, trunks, thighs and breasts, and a whole new sector of plastic surgery, “post bariatric surgery” has developed.
The most common body contouring operation, aside from liposuction, is abdominoplasty, or the Tummy Tuck, as it is commonly referred to by lay people. Though mini- operations for the abdomen became popular after the advent of liposuction, in most patients, and especially in the post-bariatric patient, a full abdominoplasty, with the necessary longer incision, is required. In fact, my most common abdominoplasty is not a lesser variation of a traditional procedure, but often is more extensive, combining liposuction and other maneuvers with the abdominoplasty to get a superior result
Buttock and thigh lifts are done via incisions placed along the panty or Bikini line through the hip and low back region for the outer thigh and buttock, and high up the inner thigh at its junction with the groin for the inner thigh. In massive weight loss patients, an inseam incision may be needed for the inner thighs.These operations are similar in concept to the abdominoplasty, and are less commonly done, but again, with the massive increase in patients wanting skin removal surgery from Lap banding treatment, they are far more common now than when I wrote the first edition of this book. Additional procedures have been developed and evolved. These have included “upper body lifts” which remove excess skin from the underside of the breasts and around the bra strap area, and well as procedures to tighten tissues not effectively treated by the procedures I have described above. The past thirty years has truly seen an explosion of knowledge in the area of body contour surgery
History of Body Contour Surgery
Removal of a fold of skin plus the underlying fat dates back to the early part of the 20th century. In the 1960’s, the operation was refined considerably and popularized by a Brazilian surgeon, Pitanguy. He also did early thigh and buttock lifts. Many of his improvements are with us to this day. Further advances were made, particularly in incision design, by a Quebec surgeon, Paule Regnault, who also worked on innovations in breast lift and reduction surgery. However, the two most significant advances in the last quarter century have been the advent of suction lipoplasty, which allowed for treatment of the abdomen fat, with or without skin removal, and the deep layer support techniques of Dr. T. Lockwood of Kansas City. He carefully looked at the anatomy of the abdominal wall, and decided that there was merit in using the superficial fascia, a layer of thin but strong tissue, part way down in the fat layer, as the main means of support, in repairing the skin incisions during both abdominoplasties and thigh lift procedures. This layer had been known to surgeons and anatomists for many years, but most plastic surgeons never felt it had enough strength to be of significant use in repairing the abdominal wall and it was often either ignored or only loosely stitched. Since Dr. Lockwood’s major contributions in the 1990’s, there have been further major contributions from a whole host of surgeons in the past two decades.
Who Is A Suitable Patient?
The usual patient presenting for abdominoplasty has had previous pregnancies, and has usually decided not to have any more children. (Future pregnancies will tend to re-stretch the skin and may cause recurrence of the shape the patient feels is unsatisfactory). She may or may not have had Caesarean sections, or other abdominal surgery. The low gynecologic and Caesarean scar (called a Pfannenstiel incision by gynecologists) often is adherent to the underlying muscle, and above the incision, the non-adherent abdominal skin and fat often droop, and fold over the site of the incision. In some cases, with skin lying against skin, there may be so much problem with moisture causing skin irritation, that the medical insurance will pay for a procedure to reduce the overhanging skin, but a formal, cosmetic abdominoplasty will usually require patient payment.
The vertical abdominal muscles (the recti, or rectus abdominis) have often been stretched, and they may be separated down the midline, giving bulging of the central abdomen, and in more severe cases, there may even be a hernia of the belly button (umbilicus). In a hernia, not only does the abdomen bulge, but some of the contents of the abdominal cavity (internal organs, fat, etc.) may bulge through a weak part of the abdominal wall. Other old surgical scars may further distort the shape of the abdomen.
Occasionally, I also have male patients who want abdominoplasty surgery. Men often carry most of their trunk fat inside the abdominal cavity, rather than under the skin, and abdominoplasty is somewhat less effective at reducing and recontouring in men. Yet, they will usually have a reasonable and satisfying result.
In patients with less dramatic changes, a modified, (or rarely “mini-“) abdominoplasty may be effective. In this procedure, there is less excess skin and a significant amount of fat, so the major procedure is liposuction with the addition of a smaller skin tightening procedure. At one time, about three quarters of my patients seemed to fall into this category; the reverse is now true. This is because I feel I must do a full abdominoplasty in most of my patients to give them the result they have envisaged for themselves; a lesser operation leaves them somewhat disappointed.
Patients for buttock and thigh lift may initially come to their consultation requesting liposuction, complaining of unsightly fat and “cellulite” but, because of laxity of the skin and deep tissues, should be told that the results of suction alone may be quite disappointing. While suction offers an operation with little in the way of post-op scars, it will result in further loose skin and likely significant contour irregularities. For this reason a lift procedure is more appropriate., Despite the significant scar these operations, will result in a much restored appearance to the thigh and buttock. Some of these patients will have had suction done in the past and wish to have something further done. The situation is similar to patients who have had only suction done in the neck and have residual neck skin and muscle redundancy for which the only treatment is a face and necklift.
Patients less commonly, but still with some frequency, come asking for the contour of their arms to be improved. “Brachioplasty” is quite commonly done in combination with a breast lift and upper body lift, for massive weight losss patients, after Lap banding or losing weight on their own.
Breast lifts, with or without using implants or fat grafting to increase breast volume, are often part of the overall plan in dealing with patients who have multiple body contour issues.
We often use a “team approach” with the massive weight loss patient, combining procedures under one anaesthetic more safely by having two plastic surgeons working simultaneously so as to complete extensive surgery in a much shorter time and reducing the number of times a patient needs to undergo surgery and go through recovery. Thus, Breast lift is often combined with a brachioplasty, thigh lifts with abdominoplasty as a lower body lift, perhaps even with other procedures. I usually prefer to limit surgery time to less than six hours, and these extensive operations usually involve an overnight stay in the surgery centre.
Technical Details Of Body Contour Surgery:
The goal of these procedures is to achieve a youthful contour to the abdomen and flanks, or to the buttocks and thighs, the upper arm, or whatever anatomical zone is being treated.
The aim is re-create this appearance of youth both at rest and with activity. Because photographs are taken with patients in static, or unmoving poses, a result from liposuction which looks good with the flash lighting and stationary pose of medical photography, maybe actually not so great in real life. Dimpling and irregularities of the skin may be quite mild in a young patient who has not had children and good skin tone. In an older patient or one who has less tone after weight loss, pregnancy or illness, there may substantial skin tone reduction.
So, an operation which removes excess skin, tightens the underlying muscles and repairs a hernia if it is present, and positions the incision along a line which can lie concealed within the lines of a bathing suit may be a huge move towards success. In a tummy tuck, the belly button is separated from the surrounding skin, and usually all the skin and fat below the level of the belly button can be removed so that the skin around the belly button is brought to the level of the pubis, and skin from higher up is tightened and brought down to the belly button level when the operation is completed. The belly button is brought out through a new hole at an appropriate level and stitched to the surrounding skin. With experience, the surgeon can usually create an abdominal contour which is not only tighter, but natural looking as well.
In a brachioplasty, patients request treatment for redundant skin and fat in the arms. This is particularly a problem after weight loss, but may be a concern with increasing age and fat accumulation combined with a familial tendency to such shape. The challenge here is to place the incision in a location which is stable and does not migrate into a prominent position as healing occurs. Brachioplasty is often coupled with breast lift surgery, and sometimes also with upper body lifts as described above.
Risks and Possible Complications:
Abdominoplasty, and the related body contouring operations, all share similar risks and possible complications. Like all surgical procedures, bleeding or infection can occur, although both are unusual. If they do occur, they may require surgical treatment, hospitalization, or may be managed with lesser measures in some cases. Infection, when diagnosed early and not severe, may respond to antibiotics by mouth, for example.
Because a space exists between the muscles of the abdominal wall and the overlying skin and fat, fluid can accumulate during the early healing phase, until these layers re-unite. For this reason, we use a drain, a soft tube with multiple holes which is placed between the skin and the muscle and exits to a small plastic bottle and removes the fluid (serum) which your body produces during the healing phase. This is removed at five to seven days after surgery. Occasionally, serum will continue to accumulate and collect, forming a seroma, which is like a lake of serum under the surface. This sometimes requires removal, either with a needle or with a new placement of a drain, but this is only a temporary problem, and usually resolves gradually.
However, problems with poor or delayed healing of the incision can occur, leaving areas with widened scars after crust formation. This is a much greater risk in smokers, so avoidance of smoking is essential.
Formation of blood clots in the legs (thrombophlebitis), with possible passage of a clot to the lung can occur with any of these procedures. While rare, this is potentially a very serious problem. At one time, abdominoplasty patients were routinely kept on bed rest for several days after surgery; today, patients are routinely up and walking within a day or so after surgery. Early mobilization has always been felt to be one of the best preventive measures against thrombophlebitis, and we believe it to be of value in body contour surgery. However there is evidence now in favour of chemoprophylaxis, giving blood thinners around the time of surgery. This has been done for many years both for orthopedic procedures such as major hip and knee surgery, and for other major surgery. Now, we are advised to do this for for major cosmetic body contouring procedures. My routine in the past five years has been to give blood thinners for ten days after surgery, beginning the day after surgery.
Major body contour surgery has become commonly performed plastic surgery, and offers an increasingly wider series of procedures for patients with a variety of body contour deformities, whether after pregnancy, or after major weight loss.
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