marking and operative techniques.9

COSMETIC

Marking and Operative Techniques

As plastic surgeons gain experience caringfor the massive weight loss patient, tech-niques continue to evolve and aestheticoutcomes continue to improve. Althoughthere is no single correct operative techniquein body contouring, there are certain funda-mental aspects that must be understood andutilized to achieve satisfactory outcomes. With-out exception, the quality and laxity of the skinin massive weight loss patients are differentfrom those in non--massive weight loss pa-tients. Regardless of how tight the skin may bepulled, over time, there will be a degree ofrelaxation. This typically contributes to scarmigration and some loss of shape or contour(Figs. 1 and 2). Some surgeons have estab-lished a clear revision policy, which they con-vey to the patient. It is prudent for the surgeonto include information about potential scarmigration in the informed consent document.If the surgeon has a clear understanding of thepatients expectations, it is easier for him orher to develop a relationship of trust, in whichthe patient can rely on the surgeon to knowwhat is safe and realistic (Table 1).

DEFLATION AND SKIN LAXITYThe excessive amount of stretching of the

skin in massive weight loss patients contributesto their overall poor skin tone and lack of elas-ticity. Yo-yo dieting also takes a huge toll onthe skin and underlying structures. The amountof weight lost and current body mass index areimportant factors to consider when evaluatingthe massive weight loss patient. After significantweight loss, there is often a deflated appearancethat is especially noticeable in the breasts, but-tocks, and faces of these patients. In almost everycase, the skin fails to retract completely andbecomes redundant, collapsing inferiorly. Inthe lower trunk, the redundant tissues of thelower abdomen and pubic area fall directly to-ward the inner thighs, often causing pain andirritation. In the upper trunk, the redundanttissues contribute to back rolls, breast ptosis,and excessive skin under the upper arms.

SCAR PLACEMENTScar placement is a critical factor in planning

surgery. Although massive weight loss patients willgenerally accept scars in any location for improvedcontour, good preoperative planning can help en-sure the best placement for scars. A woman witha masculine body type who has no waist contourmay tolerate a scar along a newly created waistline,whereas a woman with a gynecoid body type mayprefer to have those scars much lower (i.e., in thebikini area).

Location alone is not enough when planningthe position of a scar. Tissue laxity above andbelow the proposed scar, degree of tension ap-plied at closure, and the extent to which ambu-lation may pull on or affect the scar are all critical

Received for publication July 6, 2005; revised October 22,2005.Copyright 2005 by the American Society of Plastic Surgeons

DOI: 10.1097/01.prs.0000196294.33236.8a

Fig. 1. Vulvar distortion following lower body lift and thigh-plasty. Photograph courtesy of Joseph F. Capella, M.D. All rightsreserved.

Fig. 2. Scarmigration from thighplasty. Photograph courtesy ofSusan E. Downey, M.D. All rights reserved.

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to achieving an ideal end result. In addition, ifautologous augmentation is considered for eitherthe buttocks or breasts, the scar may need to berepositioned to accommodate such a procedure.Finally, it is important to evaluate prior scars andhow upcoming procedures can utilize or improvecurrent scar location.

ROLE OF LIPOSUCTIONThe role and timing of liposuction in these

patients vary among plastic surgeons. Patients witha larger body mass index may benefit from ag-gressive liposuctioning, and occasionally, liposuc-tion may be all that is necessary to produce anaesthetic result, especially in areas such as theupper arm. There continues to be debate as towhen to perform liposuction, but there is generalagreement that the degree of edema that can becaused by the procedure is an important factor tobe considered. Table 2 gives the differing schoolsof thought on the role and staging of liposuctionin the massive weight loss patient.

MARKING FUNDAMENTALSAlthough there are many opinions on how to

mark the patient before body contouring surgery,there are some fundamentals that are importantto understand (Table 3):

Allow adequate time for marking. Some sur-geons mark the day before, while others preferto mark just before the procedure(s). On av-

erage, the panelists take approximately 25 to 40minutes to mark the patient.

Be mindful of asymmetry and mark accord-ingly.

Be careful with incision lines. If you are uncer-tain about an incision line, it is better to takeout less rather than too much, which couldresult in difficulty closing or poor scarring.

Be precise with marks. Be sure to have enoughhatch marks above and below incision lines tobring the tissues back in proper alignment.

Photographing the patient after marking andon a regular basis during the postoperative periodhelps to educate the plastic surgeon, so that mark-ing techniques may be adjusted as needed. Pre-operative and postoperative photographs are alsouseful for patient education.

LOWER BODY CONTOURINGPROCEDURES

For many massive weight loss patients, theirprimary goal in seeking body contouring surgeryis some type of abdominal improvement. Evalua-tion of these patients, however, demonstrates thatmost will also need additional excisional proce-dures to achieve their desired outcome. Theseprocedures can include gluteal augmentation,mons reduction, flank excision, and a thigh lift. Thesurgeons approach to lower body contouring pro-cedures in these patients will have to factor in not

Table 1. Critical Factors in Body Contouring Proceduresin Massive Weight Loss Patients

Degree of deflation Degree of skin laxity Careful evaluation of prior scars Scar placement Role of liposuction

Table 2. Staging Liposuction in the Massive Weight Loss Patient*

Pros Cons

StagedSeparate liposuction stage Requires additional surgical stage Requires additional surgical stageLiposuction in combinationwith a lower body lift

Debulking prior to excisionAvoids edema associated with liposuction

Cost of extra surgeryAdditional recovery timeTissues may be stiffer, makinglater advancement difficult

SimultaneousLiposuction at the same time Eliminates extra surgery

Treats one area at a time, which allows thatarea to be rejuvenated in one sitting

Significant edema maycompromise results/scarPotential to compromisevascularity of flaps

*These factors are particularly important to consider in procedures involving the extremities.

Table 3. Marking: A Roadmap to Success

Allow adequate time Look for asymmetries Mobilize tissues and mark accordingly Do not overcommit; marks can and should beconfirmed during surgery

Use hatch marks to help prevent tissue rotation and torestore anatomy

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only theirphysical presentationbut also thepatientsdegree of commitment to the surgical process.

The terminology for contouring proceduresin the lower body varies among plastic surgeonsand includes panniculectomy, abdominoplasty,belt lipectomy, circumferential abdomino-plasty, and lower body lift. In general, a lowerbody lift treats the lower trunk and thighs as aunit and will elevate the proximal, anterior, andlateral thigh complex, whereas a belt lipectomyand a variety of more centrally anchored pro-cedures will create a more defined waist with lessof an impact on the thighs. The panel membersagreed that, ideally, a lower body procedureshould be the first operation performed whenapproaching body contouring in the massiveweight loss patient. Depending on the degree oftissue laxity, the amount of excess skin, and thepotential for improvement with liposuction, alower body procedure can have a positive effecton surrounding areas (i.e., lateral thighs, chest,and back). The outcome of the lower body pro-cedure will help determine the surgical goalsand steer the surgical approach for the nextphase of contouring (Fig. 3).

General surgical goals in lower body proce-dures include the following:

Flattening the abdomen Recreating the umbilicus

Elevating the mons Creating a waist in female patients (generally

not desired in male patients) Excision or liposuction of lower back rolls Defining the buttocks (do you need to create

projection, reshape, or reduce?) Lifting the outer/anterior thighs Improving the inner thighs (when feasible)

It is important to understand the effect theprocedure will have on adjacent areas of the body.Howwill the position of the inframammary fold beaffected? How will the procedure affect the upperback rolls and thighs? Knowing the desired out-come helps to determine how to approach themarking process, which in turn helps to define thebest technique to achieve the patients expecta-tions (Table 4).

Fig. 3. Improvement in the thighs after belt lipectomy and autologous gluteal augmentation.Photographs courtesy of Robert F. Centeno, M.D. All rights reserved.

Table 4. Lower Body Procedures: Points to Consider

Marking Scar placement Role of infiltration Liposuction of the back and/or thighs Positioning Role of buttock augmentation Mons reduction Umbilicoplasty Closure

Volume 117, Number 1S Marking and Operative Techniques

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MarkingAs with all body contouring procedures in

the massive weight loss patient, precise markingis critical for a successful outcome. The amountof excess skin may make it difficult to reliablyidentify underlying landmarks that are oftenused to achieve symmetry. Although techniquesvary, Dr. Kenkel describes one approach. Mark-ing begins with the patient slightly flexed at thewaist, which helps create the position the patientwill assume after completion of the anterior re-section. Failure to mark the patient in this po-sition may create undue tension, which can re-sult in dehiscence. The posterior aspect isusually marked first. An estimation of where thescar will lie is based on the patients anatomy aswell as the degree of laxity on the lower thorax.The upper marks tend to be convex, followingthe buttocks subunit, and are placed around thelevel of the posterior iliac crest. The degree oftissue laxity above the incision needs to be takeninto account when determining the uppermostportion of the resection. Using a pinch test, thebuttock and lateral thigh are serially mobilizedup to the superior level mark to determine theinferior incision. The majority of mobilization isgoing to come from below, with the upper in-cision being relatively fixed. The lower mark isusually in the form of a lazy S and should beconfirmed during surgery, before excision. Mea-surement is made from the midline to createaccurate vertical marks. Hatch marks are addedas useful reference points during surgery.

Some panel members believe it was easier tomark the patient anteriorly while lying flat, par-ticularly if there is a prominent pannus. Ptosis ofthe mons is addressed first. The mons is liftedvertically and the proposed incision is marked at

the level of the pubic bone, generally 4 to 7 cmabove the introitus. The anterior lateral thighskin is then mobilized up and onto the anteriorsuperior iliac spine. The incision line in thepubic area extends laterally toward the anteriorsuperior iliac spine. With an upward and inwardpull, this line is communicated laterally with the(previously marked) posterior markings. An es-timation of the cephalad incision is marked andconfirmed during surgery (Fig. 4).

Scar PlacementPosterior scars should frame the aesthetic sil-

houette of the buttock. Scar position varies depend-ing on all previously mentioned factors. In general,in autologous augmentation, the posterior scar isplaced more inferiorly, so that the tissue can bemobilized andpositionedproperly at the apexof thebuttocks. Table 5 lists general guidelines for scarplacement in lower body contouring procedures.

InfiltrationSome panel members believe that infiltration

in the posterior area results in less blood loss andan easier plane of dissection. Alternatively, infil-tration can make electrocautery more difficult,and ultimately, it may be responsible for a higherincidence of seromas in this region. Some panel-ists find that Epitome disposable electrosurgicalcautery (UtahMedical Products, Midvale, Utah) isuseful and efficient in a wet environment.

Role of Simultaneous Liposuction of the Backand/or Thighs

Surgeons can consider incorporating liposuc-tion of the back and/or thighs with a lower bodylift. This decision should be based on the patients

Fig. 4. Marking of a patient for a lower body lift. Photographs courtesy of Jeffrey M. Kenkel, M.D. All rights reserved.


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body habitus and needs, but it can be done safely.Liposuction of the lateral thighs can be an alter-native to blunt dissection, facilitating reposition-ing of the tissues. Alternatively, liposuctionmay beused to debulk a patient in a staged fashion beforethe excisional surgery.

Patient PositioningThere were some philosophical differences

among the panel members concerning the posi-tion sequence for lower body contouring proce-dures. There are those who favor prone-supinepositioning, while others prefer supine, lateral-decubitus positioning (Fig. 5).

When the prone-supine position is used, thecephalad incision is made first and carried downto the level of the deep fascia. The skin is thenundermined at this level toward the proposed in-ferior incision. Care should be taken to preservea fatty layer of tissue overlying the deep fascia.There is a lymphatic network within this tissue,and its preservation may help decrease the risk for

seroma. The lateral thigh is thenmobilized, eitherbluntly, using an instrument such as the Lock-wood elevator (Byron, Santa Barbara, Calif.), orwith liposuction. The lower marks are confirmedand then resected. Deep drains are threadedalong the posterior incision and rolled and tuckedinto the excess skin laterally. Closure begins at thesuperficial fascia. Several panel members incor-porate three-point sutures to secure the superfi-cial fascia to the deep fascia, in an effort to oblit-erate the deep space that is created. This skin isthen closed using a monofilament. Many panelistsuse a topical skin adhesive.

With this method, the lateral aspects are left asdog-ears to be taken out with the anterior resec-tion. It is important to abduct the thighs to max-imize the skin take-out laterally. Anteriorly, theresection is performed in a manner similar to anabdominoplasty, with the incisions joining theposterior resection. In general, most panel mem-bers adhere to a two-layer fascial plication.

In the supine, lateral-decubitus sequence, theabdomen is resected first and everything else isadjusted to the anterior resection. There are tworeasons for this. First, it allows for maximum con-tour of the abdomen while putting less tension onthe back, which can lead to dehiscence. Second,the lateral positioning maximizes the lateral re-section, which is often necessary to obtain the bestpossible waist and hip definition. Regardless of thetechnique used, it is important to abduct the legsto maximize the lateral take-out.

Table 5. Scar Placement in Lower Body Procedures

Posterior scars: Beginning at or near the gluteal cleft Lateral scar: At the iliac crest Groin scar: Above the inguinal ligament MonsApproximately 7 cm superior to the vulvar cleft or penisStraight across the mons

Fig. 5. (Left) Prone-supine positioning. Photograph courtesy of Jeffrey M. Kenkel, M.D. (Right) Supine, lateral-decubitus positioning.Photograph courtesy of Joseph F. Capella, M.D. All rights reserved.


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Gluteal AugmentationMany massive weight loss patients have de-

flated buttocks that look unnaturally flat and lackshape and definition. A circumferential body liftcan cause further flattening as the buttock skin israised. These patients can benefit from augmen-tation, which produces a more natural and aes-thetically pleasing shape. The panelists discussedseveral options for gluteal augmentation, includ-ing autologous augmentation, fat transfer, andimplants.

Autologous AugmentationSeveral panel members perform gluteal autol-

ogous augmentation. Drs. Leroy Young and Rob-ert Centeno describe this approach. If needed, theskin edges are infusedwith saline and epinephrineto reduce potential blood loss. The flap, which ismarked before surgery, is de-epithelialized andthe tissue to be used for autoaugmentation is dis-sected and mobilized. Dissection around the out-lined flap is beveled to the underlying musclefascia to create two dermal islands. The skin andsubcutaneous tissues overlying the gluteus maxi-musmuscle are elevated from the distal to near thegluteal crease at the inferior incision to accom-modate the flap. Pushing the flap distally duringundermining helps determine whether there issufficient mobility to allow proper positioning ofthe flap. Releasing the muscle fascia superior andlateral to the flap can increase mobility. To ensureit is properly positioned in the buttocks, the der-mal island is released and then anchored to themuscle fascia to maintain its position. Tacking thedermis to the flap and the muscle fascia can fur-ther shape the flap to produce increased projec-tion and roundness. After it has been confirmed

that the maximum projection point is positionedcorrectly, the incision is closed over the flap. Dur-ing closure, two drains are brought out anteriorlyand the superficial fascial system is closed. The der-mis is then closed with sutures and a topical skinadhesive is applied to seal the wound. Drs. Youngand Centeno report no additional complicationswith this procedure beyond what is normally seen ina circumferential body lift. It typically adds between45 and 60minutes to the procedure. Although post-operative patient follow-up continues to demon-strate success, some panelists believe this proceduremay not stand the test of time and might possiblycontribute to abnormal buttock projection (Fig. 6).

Fat TransferAutologous fat transfer can be used to en-

hance buttock shape or to improve results afterlower body procedures. Unfortunately, many pa-tients are deflated and do not have adequate do-nor sites for grafting.

ImplantsSilicone implants have been associated with

less than optimal outcomes because of palpabilityand a greater risk of infection and dehiscence.

Mons ReductionIt is usually necessary to rejuvenate the pubic

area of the massive weight loss patient. Thepanel members agreed that when excess skin ispresent, a certain amount of the mons should beremoved, in a vertical direction. Ideally, the in-cision should lie at or just above the level of thepubic bone, with the mons pubis elevated to itsproper position and then extended laterally. Itis important that the incision not be too low, asthis could interfere with the lymph drainage

Fig. 6. Gluteal autoaugmentation in 42-year-old patientwith a bodymass index of 28.5 (230-lb. weight loss). (Left) Preoperative view.(Center) Marked for surgery. (Right) Three months postoperatively. Photographs courtesy of J. Peter Rubin, M.D. All rights reserved.


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system and/or innervation. In addition, careshould be taken so that the mons is not pulledtoo high, which may result in an alteration of theposition of the clitoris and/or urethral meatus.In some cases, horizontal laxity may be present,necessitating some type of vertical take-out incombination with the above or during a separatestage. Some panel members initially address themons during a lower body procedure, and ifadditional work is needed, it is often undertakenat another stage (Fig. 7).

UmbilicoplastyRegardless of how well abdominal contouring

is performed, success is often measured by thefinal appearance and location of the umbilicus. Anabdomen that is too tight can interfere with heal-ing at the umbilicus, because the excess tensioncan contribute to the development of skin dehis-cence in this area or below it.

Although techniques vary, that is, some sur-geons prefer the Mercedes technique, some fa-vor a transverse incision while others utilize asingle vertical incision; all panel members agreethat smaller is better when it comes to theumbilicus. In addition, avoidance of a concen-tric circle diminishes the chance of the scarforming a concentric ring that contracts. Insome patients, the umbilical stalk is too long andmust be shortened, if possible. In those patientswho have had a prior umbilical or vertical mid-line hernia repair, the overall viability of theumbilicus and surrounding tissues may be ques-tionable. In this case, it may be necessary toperform a neo-umbilical reconstruction, de-layed or primarily, to achieve an aestheticallypleasing result.

ClosureThe posterior aspect is typically drained and

closure is done in several layers (Fig. 8).All panel members incorporate some type of

superficial fascial closure. There are those who be-lieve that using three-point sutures, incorporatingsuperficial fascia to the deep fascia, may help de-crease the dead space and, ultimately, the risk forseromas. It must be noted, however, that when in-corporating three-point sutures utilizing permanentsutures, the surgeon must watch for indentationsthat can be created from superficial placement.Three-point sutures can also potentially entrap sen-sory nerves, resulting in anterior pain and/or neu-romas. The skin is then closed in a manner thesurgeon is accustomed to. There is general agree-ment that topical skin adhesives or glues are useful,in that they eliminate the need for bulky dressingsand make it easier for patients to care for theirwounds at home (Figs. 9 through 11).

Fig. 7. Circumferential abdominoplastywithmons reduction. (Left) Preoperative view. (Right)Oneyear postoperatively. Photographs courtesy of Jeffrey M. Kenkel, M.D. All rights reserved.

Fig. 8. Drain placement in lower body lift procedure. Photo-graph courtesy of Jeffrey M. Kenkel, M.D. All rights reserved.


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Fig. 9. Preoperative and 7-month postoperative views after lower body lift (patient hadundergonegastric bypass 1 year earlier). Bodymass index: highest, 59; low, 32. Photographscourtesy of Joseph F. Capella, M.D. All rights reserved.


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Fig. 10. Preoperative and 5-month postoperative views of a 28-year-old woman after lower bodylift. Bodymass index: highest, 51; low, 32. Photographs courtesy of JosephF. Capella,M.D. All rightsreserved.


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Fig. 11. Preoperative and 9-month postoperative views of a 46-year-old woman after circumfer-ential body lift with buttock augmentation and a brachioplasty (patient had undergone a laparo-scopic RVBG). Recurrence of lateral laxity is demonstrated by the appearance of lateral hip fullness.Photographs courtesy of Felmont F. Eaves, III, M.D. All rights reserved.


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UPPER BODY PROCEDURESAn evaluation of the upper trunk should in-

clude the breasts, lateral chest, and upper back.For procedures in the upper body, the panelmem-bers emphasized the need to perform lower bodysurgery first, as these procedures affect the degreeof work required for good aesthetic outcomes inthe upper body. In selected patients, liposuctioncan be an important first step for upper- and mid-back rolls (Fig. 12).

The surgical goals in upper body proceduresare as follows: To reshape/augment breast parenchyma to re-

store projection and fullness To achieve appropriate nipple-areola complex

position and size To recreate/reposition the inframammary fold To reduce the skin envelope To eliminate prominent axillary skin rolls To elimination mid- and upper-back rolls

Excessive skin in the arms can affect the typeof procedure that will be performed on both theanterior and posterior upper chest. The upperarm, lateral chest, and breasts are intimatelyrelated, and in general, all require contouringfor adequate rejuvenation of this area. The sur-geonmay elect to address the upper torso (arms,back, and breasts) all in one stage or in severalstages, treating either the breasts or arms firstand completing the remaining area in a subse-quent surgery. The final staging sequence is pa-tient- and physician-specific.

Breast ReshapingBreast deformity in these patients is much

greater and more technically challenging than innonmassive weight loss patients. Beyond the typ-ical breast changes of glandular tissue loss andptosis, there tends to be more asymmetrical vol-ume loss in the massive weight loss breast, and

Fig. 12. Views of upper and mid back rolls. Photographs courtesy of Joseph F. Capella, M.D. Allrights reserved.

Fig. 13. (Left) Implant descent. (Right) Twelve months after augmentation-mastopexy. Photo-graphs courtesy of Jeffrey M. Kenkel, M.D. All rights reserved.


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there is more of a deflated and flat appearanceof the breast. Skin laxity is very apparent, andthe degree of excess skin can be significant.Most of these patients have grade III ptosis. Inaddition, they often present with prominentaxillary skin or a fatty roll that usually contin-ues well into the back.

The panel members have different ap-proaches and techniques for shaping and con-touring the breast in the female massive weightloss patient. Some elect to perform a mastopexy/augmentation in one stage, while others prefer toperform a mastopexy alone, utilizing a number ofdifferent techniques to reshape the remaining

Fig.14. Preoperativeand1-yearpostoperativeviewsfollowingmodifiedshortscarperi-areolarinferiorpedicle reduction (SPAIR). Photographs courtesy of JeffreyM. Kenkel, M.D. All rights reserved.


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breast parenchyma. If more fullness or a largerbreast size is desired, augmentation can be per-formed concomitantly or at a later date. The panelmembers believe that combining mastopexy andaugmentation in one procedure requires experi-ence and a degree of expertise. Implant positioncan be difficult to control, and descent is common(Fig. 13). Furthermore, augmentation in combi-nation with significant transposition of the nipple-areola complex decreases vascularity and in-creases the risk for healing problems. Patientsshould be informed that secondary proceduresare frequently needed to optimize results.

Preservation of the nipple is another criticalfactor in breast surgery. The panel members havedifferent approaches to mastopexy in the massiveweight loss patient, but regardless of technique, allagreed that the ultimate goal is to preserve bloodsupply and sensation. Their skin resection tech-niques also differ; an inverted-T can often takecare of excessive skin, while others prefer a mod-ified T- or L-shaped incision. Although short-scarvertical incisions are options for traditional pa-

tients and are sometimes used in massive weightloss patients, most panelmembers believe that thistechnique would not adequately correct the de-gree of skin deformities that are present in themassive weight loss breast. Regardless of the tech-nique utilized, it is universally accepted that goodaesthetic results include the following qualities(Figs. 14 and 15 and Table 6):

Elimination of the horizontal and vertical excess Recreation of the inframammary fold in its

correct position Adequate symmetry and nipple position Good projection with superior fullness Good lateral curvature of the breastSymmetry and Positioning of the Nipple-AreolaComplex

Many patients will present with some degree ofasymmetry. In most cases, symmetry can beachieved with careful attention to initial markingas well as constant checking during surgery. Al-though it is not likely in these patients, if signifi-

Fig.15. (Left)Stage1:mastopexybyasuperomedialpedicletechnique(2yearspostoperatively).(Right)Stage2:abdominal recontouring.PhotographscourtesyofFelmontF.Eaves, III,M.D.All rights reserved.

Table 6. Mastopexy, Augmentation, and Reduction:Points to Consider

Scar placement Symmetry Proper position of the nipple-areola complex Projection Medial fullness Chest wall diameter

Table 7. The Breast in Male Massive Weight LossPatients: Points to Consider

Body mass index: before weight loss and current Degree of nipple-areola complex ptosis Amount of breast projection Amount of hypertrophy Amount of excessive skin Loss of inframammary fold definition


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cant asymmetry is noted, it may be necessary toaugment one breast or reduce the other to achievean aesthetic result. It is important to sit the patientup to get an adequate view of projection, nipplealignment, and medial breast curve from a varietyof positions. Small adjustments to nipple place-ment can easily be made during the procedure.

Projection, Medial Fullness, and DurabilityThe panel members believe it prudent to re-

shape the breast using as much of the availablebreast parenchyma as feasible. Their techniquesvary, but they believe that suspending the breast

tissue to the chest wall with sutures is helpful inshaping the breast. Good pillar closure helps sup-port the breast and its new shape. Relying on skinsupport to maintain shape in this or any patientgroup results in a loss of shape over time.

There was some discussion about using prod-ucts such as Surgisis (Cook Biotech Inc., WestLafayette, Ind.), AlloDerm (LifeCell Corporation,Branchburg, N.J.), andmesh. Not all panelists hadexperience with these products, but those that didbelieve they provide strength and support to theunderlying tissues. With regard to implants, therewere differing opinions about subglandular versussubmuscular placement. The preferences of thepatient and physician seem to dictate implant po-sition in these patients

Male Breast ConsiderationsNearly all morbidly obese men have some de-

gree of breast hypertrophy, which is a result ofboth glandular and fatty tissue. Fatty tissue nor-mally accumulates along the chest, flanks, andupper back inmen. After weight loss, there is a lossof definition of the inframammary fold, lateralchest wall bulkiness, excessive skin, breast ptosis,and, in some cases, excessive breast projection. Itis important to consider the nipple-areola com-plex when evaluating the breast of the male mas-sive weight loss patient. The nipple-areola com-plex is normally approximately 20 cm from thesternal notch and at the fourth intercostal space.These numbers are merely guidelines, and goodjudgment must be used when determining final

Fig.16. Thepatientsprimaryconcern isprojection.Photographcourtesy of Joseph F. Capella, M.D. All rights reserved.

Fig. 17. The patients primary concerns are projection and ptosis.Thenipple-areola complex isbelowthe inframammary fold. Photo-graph courtesy of Joseph F. Capella, M.D. All rights reserved.

Fig.18. Viewof a28-year-oldmanweighing240 lbs (after a200-lb. weight loss) 6 months after body lift and liposuction of thechest. Photograph courtesy of Joseph F. Capella, M.D. All rightsreserved.


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nipple-areola complex position. As a general rule,the male nipple-areola complex is closer to theinframammary fold and just lateral to the breastmeridian (Table 7).

As in all cases of body contouring with massiveweight loss patients, it is important to understandwhat concerns the patient. Issues that must beaddressed in this patient group include breast hy-pertrophy, projection, excess skin, and ptosis(Figs. 16 and 17). When discussing body contour-ing of the upper trunk in men, it is critical that thepatient have a realistic understanding of the scarsthat may be required to achieve the desired out-come. It is helpful to have pictures on hand todemonstrate examples of what the patient cananticipate immediately postoperatively as well as 1and 2 years postoperatively.

Male Breast TechniquesThere was overall agreement among the panel

members it is preferable to perform a body lift, orsome type of lower trunk procedure, on a malepatient before upper trunk contouring. Lowerbody procedures often combined with liposuctionto the chest and flanks may diminish projectionand tighten the chest sufficiently so that furthersurgery is unnecessary (Fig. 18). In cases of mildptosis, additional liposuction can be performed,with resection of a more vertically oriented ellipseof excess tissue along the flank and axilla. Thisavoids the more visible anterior chest scar, but thesurgeonmust be careful to avoid lateral retractionof the nipple-areola complex. In a patient withskin redundancy only, an inverted-T mastopexy(Figs. 19 and 20) can have a positive effect byeliminating the excess skin and providing more

control over the position of the nipple-areola com-plex. This procedure positions scars along the an-terior chest, which most patients find acceptable.

In some cases, the inframammary fold is fairlywell defined, but the nipple-areola complex lies

Fig. 19. Illustration of inverted-T mastopexy with extension to-ward the flank. This approach offers control of the nipple-areolacomplex, but the anterior chest scars are more obvious. Illustra-tion courtesy of Joseph F. Capella, M.D. All rights reserved.

Fig. 20. Same patient as shown in Figure 18, (left) preoperatively and (right) 13 months after in-verted-T mastopexy. Photographs courtesy of Joseph F. Capella, M.D. All rights reserved


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well below it. In these situations, an inverted-Tmastopexymay lead to an excessively long pedicle,which can create the potential for inadequate cir-culation or bulkiness of the central chest. This typeof patient is best managed by direct excision of theexcess tissue at the level of the inframammary fold,with a free graft of the nipple-areola complex (Fig.21). Scars can be more prominent with this pro-cedure, but patients are usually pleased with apositive aesthetic outcome and are less concernedabout scars. The vertical scar is eliminated usingthis technique. As with other massive weight lossbody contouring procedures, patients must un-derstand that visible scars are necessary for im-proved appearance in clothing. Regardless of thetechnique, the critical components of male chestrejuvenation include proper placement of the nip-ple-areola complex and reconstruction of the in-framammary fold, particularly laterally.

Lateral Chest and Back TechniquesThe panel members approach the lateral chest

and back in a number of ways. Some prefer a trans-verse excisionacross theback,while others chose thelateral chest wall excision approach.Once the breastprocedure is completed, patients typically have ex-

cess skin laterally that is then accounted for duringthe lateral chestwall excision.Panelmembers almostalways perform the lateral chest wall excision imme-diately after thebreast procedure. It shouldbenotedthat either approach could affect the vascularity ofthe abdominal wall flap; therefore, lateral chest wallexcision should not be performed with a lower bodylift (Table 8).

Transverse ExcisionWhen incorporating a transverse back excision,

it is helpful to mark the outline of the patientsbrassiere along the back. This will help guide theplacement of the incision. With the patients armsup, the intended line of closure is marked (betweenthe upper and lower outline of the brassiere), ex-tending to the lateral chest wall. As the tissue ispulled down, anchor points are marked. The pointsare measured from the intended line of closure toensure symmetry, and the anchor points are con-nected (Fig. 22). A pinch test is used to estimate howmuch skin to excise. The lower incision line is con-firmed at the time of surgery.

The initial incision is made along the supe-rior anchor line and taken down to the deepfascia. The flap is undermined down to the lower

Fig. 21. (Left) Preoperative view of a 26-year-old male patient with an initial weight of 433 lbs., after a 160-lb weight loss. (Center) Abilateral flankplastyandmastopexywitha freenipplegraftwereperformed. (Right) Twentymonthspostoperatively. Photographsandillustration courtesy of Joseph F. Capella, M.D. All rights reserved.

Table 8. Transverse versus Lateral Excision

Pros Cons

Transverse excision More directAvoids lateral scar (potentially less visible)

Requires two positions when combined with armand/or breast procedures

T scar in some casesWider scar

Lateral excision Flows from arm to breast More visible scarBetter scar Indirect pull on target areaOne position


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estimated incision line. At the midline hatchmark, a towel clamp is attached to the superioranchor line and the skin is pulled underneaththe elevated flaps to the point where the surgeondetermines the skin will be rejoined. A mark ismade and the flap is cut to that point. The skinis joined together with a clamp, and the processcontinues to the lateral chest wall, with cuts madedown each vertical hatch mark. The surgeon con-

firms the proposed inferior incision before commit-ting to excision. Dog-ears created along the lateralchest wall are worked medially and incorporatedinto final closure during the breast portion of theprocedure.

Lateral Chest Wall ExcisionThe inframammary fold is marked, and a

nice gradual transition line is drawn from thelateral inframammary fold up to the axilla. Thisarea is then pinched in a superior medial di-rection to estimate the amount of skin to beresected. The posterior back skin is quite thickand is less mobile than the more anterior breastskin. The center of the posterior incision oftenextends even more posteriorly along the chest,to help accommodate and maximize resectionin the mid-back region, where most patientshave back rolls. This results in a longer limbposteriorly that needs to be distributed evenlyalong the anterior incision. Hatch marks arecritical to help ensure proper alignment andvectoring of tension (Fig. 23).

The anterior incision is made first and carrieddown to the level of the chest wall. Posterior dis-section is then performed to the posterior mark,which is reconfirmed so that safe closure can beachieved. The tissue is then resected. The lateralextent of the breast surgery transitions nicely intothe lateral chest wall excision (Fig. 24).

ARMSPatient education,while always vital, is extremely

important whendiscussing body contouring optionsfor the upper arms. The degree of the deformity canbe quite variable, and good outcomesmust take intoaccount the laxity of the skin and the degree of

Fig. 22. Preoperativemarkings for a transverse excision. The redarea indicates the extent of excision, based on preoperativemarkings. The intended line of closure is indicated in black. Pho-tograph courtesy of J. Peter Rubin,M.D. and drawing courtesy ofHolly Smith. All rights reserved.

Fig. 23. Preoperativemarking of lateral chest wall excision and brachioplasty. Photographs cour-tesy of Jeffrey M. Kenkel, M.D. All rights reserved.


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deflation. Rarely is liposuction alone sufficient toprovide a reasonable aesthetic result. Most patientsrequire a brachioplasty to achieve the desired out-come. Patients must understand that these scars arelonger and visible and may stay thick and heavy fora prolonged period of time. Photographs are im-perative when discussing brachioplasty outcomes.Patients must be willing to accept the scar trade-offto have amore aesthetically pleasing shape and con-tour (Fig. 25).

In the massive weight loss patient, excess skingenerally presents around the arms and is notlimited to the area between the elbow and theaxilla. It can cross the axilla to the lateral chest walland is often accompanied by lateral breast rolls.This flow across different parts of the body makesit nearly impossible to consider one area withoutassessing the resulting effect on other regions.Short scars cannot address distal skin laxity andhave limited utility in the massive weight loss pa-tient. Most often, the incision has to extend ontothe lateral chest wall proximally and to the level ofthe elbow distally (Table 9).

LiposuctionThe ideal candidate for a brachioplasty has

highly deflated arms. Those with residual fat

around the arms may benefit from liposuction(Figs. 26 and 27). The panelists differ on whetherthey performed liposuction concurrently or at anearlier stage, but all agreed that edema in the armscan be more problematic than that in the thighs.Those panelists who perform liposuction at thesame time as the brachioplasty suggest the following,with each arm operated on separately: Wettingsolution (1-1 ratio) 5 minutes LiposuctionResect Close

It is thought that this approach can help min-imize the edema associated with liposuction

PositioningThere are several ways to position arms during

surgery. Most commonly, the arms are abducted at90degrees andmaintainedonarmboards.Recently,some have found that suspending the arms abovethe head allows unimpeded movement of arm skinand a more significant improvement in skin resec-tion. In addition, the arms are elevated, which helpsfacilitate lymph drainage. When the arms are sus-pended, care should be taken to ensure that thereis no stress on the brachial plexus, by securing theforearms (Fig. 28).

Fig. 24. Preoperative and 6-month postoperative views of patient shown in Figure 23. Photo-graphs courtesy of Jeffrey M. Kenkel, M.D. All rights reserved.


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Technical ConsiderationsThe panel members use a variety of incision

techniques. Although the more traditional T-typeincision can be utilized, some panel members findthat in very large arms, it is difficult to remove theskin redundancy in the axilla, due to the excessiveamount of skin between the anterior and posteriorfolds, without scars that are too visible. Experiencehas led to the development of a number of differentresection techniques for the arms of the massiveweight loss patient (Fig. 29).

Traditional ExcisionThe incision begins anteriorly and is carried

down through the superficial fascia to the levelof the deep fascia. The dissection begins prox-imally and continues until undermining isachieved at the level of the posterior mark. It isvery important to note that as one approachesthe transition between the middle and distalthirds of the arm, more fat should be main-tained on the deep fascia and care should betaken to identify the medial antebrachial cuta-neous nerve as it exits the deep fascia, often withthe basilic vein (Fig. 30).

Once dissection reaches the predeterminedposterior limit, hemostasis is confirmed and adrain is placed. At each hatch mark, the poste-rior mark is confirmed and an incision is made.The points are approximated using staples. Thetissue between the hatch marks is then sequen-tially excised, and the wound is closed with sta-ples as each intervening segment is removed.After the excision is completed, the staples areremoved and the final wound closure is accom-plished with either long-lasting absorbable su-tures or permanent sutures for superficial fascia

and absorbable monofilament in the dermis. Ifthe excision crosses the axilla, a Z-plasty shouldbe performed to prevent scar retraction andaxillary banding.

Double Ellipse ExcisionThis technique incorporates two ellipses, one

inside the other, for marking. The outer ellipse isguided by the anatomic landmarks that can bepalpated. The inner ellipse is an adjustment forclosure and accounts for skin thickness. For mark-ing, the level of the axillary crease is found andpinched just beneath themusclemass in the axilla.This process is followed down the arm; marksshould be made at each point both anteriorly andposteriorly. The chest wall proximal to the axillarycrease is also pinched and marked. If a thoracicrejuvenation will be performed at the same time,themarks can extendmuch further onto the chestwall. Distally, the marks can cross the elbow ifnecessary. The dots are connected anteriorly andposteriorly to complete the marking for the outerellipse. The tissues are then pinched along everydot. The distance between the fingers at each ofthese points is estimated and the inner ellipse isdrawn, cheating in, approximately half the dis-tance of the estimated pinch at each point. Cross-hatch marks are drawn across the ellipses and acentral line is then drawn from the armpit to theend of the ellipse (Fig. 31).

In the operating room, a sequential resec-tion and closure technique is used. Excisionstarts from the most distal aspect to the firsthatch mark. The tissues are then reapproxi-mated up to that point. This can be accom-plished with either temporary staples or a per-manent multilayer closure using sutures. Theprocess is then repeated to the next hatch mark.This sequential technique limits the amount ofedema that can develop in tissues left open forextended periods of time. Once the chest wall iscrossed, edema becomes less of an issue and theentire remaining resection can be completed atone time (Figs. 32 through 34).

Fig. 25. Three-month postoperative view of brachioplasty scar.These scars areoftenmoreprominentand take longer tomature.Photograph courtesy of J. Peter Rubin, M.D. All rights reserved.

Table 9. Arms: Points to Consider

Addressing the lateral chest/breast Liposuction when? Positioning Technical considerations Edema Scar placement Prolonged recovery Potential complications


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EdemaAvoiding peripheral intravenous lines in the

upper extremities will help reduce edema in thearms. Patients must also be fully informed as tolimitations in elbow flexion and the importance ofkeeping the arms elevated during the postoperativephaseafterbrachioplasty.Overextensionandfailure toelevate can contribute to both acute and long-termedema (Table 10).

Scar PlacementAlthough massive weight loss patients are gen-

erally tolerant of scarring, brachioplasty scars canbe wide, raised, and visible in short-sleeved cloth-ing. It is critical to discuss this preoperatively toavoid patient dissatisfaction.Many surgeons locatethe scars in the bicipital groove, but others prefera more posterior location. Regardless of location,the scar should be placed to minimize visibility

Fig. 27. Patient with a body mass index of 32 and heavy adiposity on the arms underwent lipo-suction (500 cc per arm) and resection. Photographs courtesy of J. Peter Rubin, M.D. All rightsreserved.

Fig. 26. Patientwith abodymass index of 23 and little adiposity on the armsunderwent resectionwith no liposuction. Photographs courtesy of J. Peter Rubin, M.D. All rights reserved.


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during activities of normal daily living and to max-imize tissue resection.

Brachioplasty scars fade and soften more slowlythan scars in other anatomical areas. Frequent com-munication during all phases of wound healing iscritical to properly manage patient expectations(Figs. 35 through 37).

Potential ComplicationsComplications following brachioplasty in-

clude superficial dehiscence where the scarcrosses the axilla, seroma, and lymphocele (Figs.38 and 39). The rates of infection and bleedingare low, partly due to the tightness of the arm

from the wound closure. Tightness can producenerve compression, so it is important to monitorthe degree of tightness and inquire about numb-ness. Many of the panel members use gabapen-tin (Neurontin; Pfizer, New York, N.Y.) for sur-gically related peripheral nerve pain, whenindicated. Doses range from 100 to 300 mg threetimes as day.

THIGHSThe panel agreed that in the massive weight

loss population, the thighs are one of the moredifficult areas to contour. Redundant soft tissueis characterized by poor skin tone and laxity. Itcollapses inferiorly in the anterior thigh andinferior medially in the medial thigh. Lowerbody lift procedures often have a beneficial ef-fect on the thighs, especially the lateral thighand the proximal anterior thigh. Because of thispotential positive benefit, the panel membersprefer to leave final thigh shaping until the re-sult of the circumferential body lift is stable(Table 11).

Horizontal versus Vertical ResectionThe traditional Lockwood horizontal excision

(Fig. 40, above) does not address the excess cir-cumferential tissue found in most massive weightloss patients. As panel members have gained ex-perience, new surgical techniques have emergedthat are proving to be very effective in providing

Fig. 28. Suspension of the arms above the head. Photograph courtesy of JeffreyM. Kenkel,M.D. All rights reserved

Fig. 29. Markings for lateral flank excision with brachioplasty.Photograph courtesy of Jeffrey M. Kenkel, M.D. All rights re-served.


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shape and contour for the entire thigh. When ahorizontal excision alone is insufficient to achievethe desired outcome, panelists are incorporatinga vertical excision (Fig. 40, center). The advantageof this approach is the better shaping gained fromthe circumferential pull (Fig. 40).

There are two general philosophies with re-gard to the medial thigh lift in the massiveweight loss patient. One still relies on a verticalvector in addition to the horizontal vector,whereas the other eliminates the vertical pulland limits the groin incision to correction of adog-ear. The latter technique diminishes ten-sion along the groin, decreasing the incidenceof vulvar distortion and widening of the scar.The primary disadvantage of a vertical incisionis the longitudinal scar, which is difficult to hide.Because of this, patients must fully understandthe ramifications of this procedure. Preopera-tive and postoperative photographs become es-pecially important in the educational processwhen discussing thigh procedures with the mas-sive weight loss patient (Fig. 41).

Marking for Horizontal and Vertical ResectionWhen both horizontal and vertical excisions

are incorporated, patients should be in a supineposition with thighs flexed and knees abducted.While in abduction, the excess skin in the proxi-malmedial thigh can be estimated by determiningthe most distal point along the medial thigh thatcan be advanced toward the groin crease and allowfor safe closure. A wedge- or crescent-shaped pat-tern of excess skin is then marked for resection.

If a vertical component is being incorpo-rated, a line is drawn from the adductor longus

tendon distally along the thigh and curved an-teriorly toward the patella. This marks the futurelocation of the vertical scar. Pinching the skinboth anteriorly and posteriorly, the surgeon es-timates the amount of skin to be excised at var-ious points along the medial thigh, and a markis made at each location. These marks are thenconnected, delineating the tissue to be resectedvertically. Transverse hatch marks are drawnacross the first two lines that serve as referencepoints for final closure. The patient should thenstand so that the vertical markings can be ex-amined for symmetry and to verify that they arenot visible from either side or along the but-tocks. This helps position the scar in the leastperceptible location.

Fig. 30. Medial antebrachial cutaneous nerve. Photographcourtesy of Jeffrey M. Kenkel, M.D. All rights reserved.

Fig. 31. The double ellipse incision. Photograph courtesy ofAl S. Aly, M.D. All rights reserved.


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Marking for the Vertical Excision TechniqueIn a J-type or short groin scar incision, the

proposed incision is marked approximately two tothree fingerbreadths behind the adductor longustendon and extends distally to the medial femoralcondyle (Fig. 42). An estimation is made bothanteriorly and posteriorly, mobilizing the tissuesand tapering down toward the area of the knee.The scar may extend down to and below the knee,if necessary. The anterior groin incision is notdetermined until the vertical resection is com-plete, and serves as a method to remove the excessor redundant skin from the proximal thigh mo-bilization. It should be noted that this area mustbe approached with caution; a superficial plane ofdissection is required to preserve the underlyinglymphatics.

Role of LiposuctionMost of the panel members agreed that lipo-

suction is important when contouring the thighs.In addition to removing fat, liposuction can allowfor more tissue mobility. Since problematic swell-ing can result from liposuction of the thighs, somepanel members prefer a staged approach, per-forming liposuction during an earlier procedure.A modest amount of liposuction (knee) can safelybe performed concomitantly with excisional sur-gery.

Positioning of the LegsThe panel members approach positioning of

the patient for thigh procedures in a variety ofways. While some prefer a prone/supine position,others favor a lithotomy position. Still others limit

the position to supine only. All agreed that theposition chosen should allowmobility of the thighand provide the surgeon with comfortable accessto the operative area (Fig. 43 and Table 12).

Crescent-Type Approach (vertical and horizon-tal incisions)

The depth of dissection superior to the ad-ductor magnus muscle should extend to thesuperficial or subcutaneous fat to avoid injury tothe lymphatic system. Posterior to this muscle,

Fig. 32. Arm ready for serial excision. Photograph courtesy ofAl S. Aly, M.D. All rights reserved.

Fig. 33. Sequential resection closure technique. Photographcourtesy of Al S. Aly, M.D. All rights reserved.

Fig.34. Z-plasty. PhotographcourtesyofAl S.Aly,M.D.All rightsreserved.

Table 10. Causes of Edema

Surgery Wetting solution Flexion at elbow Intravenous lines


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the dissection along the perineal crease shouldbe at the level of the underlying muscle fascia.At that point, Colles fascia should be visible inthe crease, and distal undermining of 4 to 5 cmalong the thigh perineal crease is completed.The caudal incision is confirmed, and the cres-cent-shaped tissue is then excised. Skin edgesare approximated using towel clips, which arethen used to approximate vertical markings.

This results in a wedge-shaped excision patternthat is always larger at the proximal end andthen tapers toward the knee. One of the mostimportant elements in good closure duringthigh procedures is to create low tension at thethigh perineal junction; excess tension can re-sult in dehiscence and/or vulvar distortion. Ab-ducting the thighs during the procedure helpsensure that this is accomplished.

Fig. 35. (Left) Preoperativemarkings for brachioplasty. (Right) Postoperative results. Photographs courtesy of Al S. Aly, M.D. All rightsreserved

Fig. 36. Before and after brachioplasty. Photographs courtesy of Felmont F. Eaves, III, M.D. All rights reserved

Fig. 37. Time will improve arm scars. Photographs courtesy of J. Peter Rubin, M.D. All rights reserved.


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Vertical Excision TechniqueIf liposuction is required around the knee, it

should be performed first. Either a smallamount of local anesthetic with epinephrine ora very small amount of infiltration fluid can beinfused along the incision. The anterior incisionis made first and deepens through the superfi-cial fascia toward the deep fascia. Dissection isbegun more proximally so that the saphenousvein can be identified and carefully dissectedand preserved. Failure to preserve the saphe-nous vein can result in significant prolongationof edema. Dissection proceeds posteriorly deepto the superficial fascia to the predeterminedposterior mark. After confirmation of the tissueto be excised, hemostasis is ensured and drainsare placed. The serial hatch marks are used toapproximate the tissue, and the intervening seg-ments are removed, closing the wound distally toproximally. The proximal redundant skin isthen removed along the groin anteriorly, andthe underlying fatty tissue and lymphatics arepreserved. Closure is performed in three layersusing stronger, longer-lasting sutures for the su-perficial fascia and absorbable monofilamentfor the dermis. Not all panel members use drainsin thigh procedures, but those that do bringthem out through the groin area; this providesbetter patient comfort and drain monitoring.Usually, complications following thigh proce-dures are minor. Paying careful attention to the

depth of dissection and limiting the degree ofundermining can help avoid skin necrosis,wound dehiscence, and long-term edema.

THE FACEIn the massive weight loss patient, the face is

usually the last region to be addressed. Volumeloss is a normal part of facial aging, and this pro-cess becomes even more profound as these pa-tients shedweight, producing a gaunt appearance.

Fig. 38. Wound separation. Photograph courtesy of J. Peter Ru-bin, M.D. All rights reserved.

Fig. 39. Seroma/lymphocele. Photograph courtesy of J. PeterRubin, M.D. All rights reserved.

Table 11. Thigh Procedures: Points to Consider

Horizontal versus vertical resection Markingscar placement Role of liposuction Positioning of the legs Technical considerations

Table 12. Thigh Procedures: Technical Considerations

Dissectionminimal undermining Caution at the femoral triangle Close as you go

Table 13. Goals in Facial Rejuvenation in the MassiveWeight Loss Patient

Restore facial contour/shape Restore neck contour Lift and fill


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Areas of concern include excessive facial fat atro-phy, neck lipodystrophy, redundant skin/superfi-cial musculoaponeurotic system, and loss of facialshape/elasticity (Table 13 and Fig. 44).

When counseling the massive weight loss pa-tient, it is important to help them understand thatbecause of the excessive skin laxity, secondary pro-cedures are often required (Fig. 45).

TechniqueRhytidectomy in the massive weight loss pa-

tient most commonly requires a multiplanertechnique to adequately address both volumedeficiency and skin laxity. The details of thesetechniques are beyond the scope of this supple-ment, but will be addressed in future publica-tions.

KEY POINTS: SUMMARYThe following are key points in marking and

operative techniques (Table 14):

Patient safety is first and foremost. Communication with massive weight loss pa-

tients is critical to ensure that they understandboth the short- and longer-term aesthetic re-sults of body contouring surgery. They mustunderstand that recurrent laxity is not neces-sarily failure of the operation but rather anexpected outcome.

Adequate time needs to be set aside for mark-ing the patient, either the day before or themorning of surgery. These marks are the road-map to success in body contouring.

There is no one way to approach body con-touring in the massive weight loss patient,but certain fundamentals must be embraced.These include understanding the role of li-posuction, scar placement, and the degree ofexcision that is safe and will contribute to apositive result.

A lower body procedure will typically have apositive effect on the thighs, back, and, attimes, the position of the inframammary fold.It seems prudent, then, to perform lower bodyprocedure first, so that the adjacent areasachieve maximum benefit before additionalprocedures are performed.

There are differing opinions as to whether amastopexy should be performed at the sametime as augmentation in the massive weightloss patient. There may be a benefit to per-forming a mastopexy with repositioning of theexisting breast parenchyma in one stage, and

Fig. 40. (Above) The traditional Lockwood technique. (Center)Horizontal and vertical vectors. (Below) Vertical vector only. Pho-tographscourtesyof JeffreyM.Kenkel,M.D. Illustrationscourtesyof Holly Smith. All rights reserved.


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then assessing the need for augmentation at alater time.

The thighs and arms can be difficult areas totreat. Patients must be willing to accept scarsthat are more visible to obtain a more aesthet-ically pleasing shape and/or contour.

The specific closure methods and materialsused by the panel members differed, but allagreed that diligent closure of multiple layersis critical to ensure an optimal outcome. Theuse of a topical skin adhesive is common andprovides significant postoperative benefits tothe patient.

SUMMARYTraditionally, plastic surgeons train dili-

gently to perfect techniques that work for themand their patients. The massive weight loss pa-tient, however, presents unique challenges. Tra-ditional approaches do not adequately addresstheir needs. Individual considerations must betaken into account, and a balance must beachieved between excisional surgery and vol-ume augmentation.

Fig. 41. Thigh resection can result in scars that can extend below the knee. Photographs courtesy of J. Peter Rubin, M.D. All rightsreserved.

Fig. 42. Marking of patient for medial thigh lift with a vertical excision. Photographs courtesy of JeffreyM. Kenkel,M.D. All rights reserved.

Table 14. Marking and Operative Techniques: SummaryPoints

Communication Understanding the fundamentals Marking the roadmap to success Lower body liftplan procedures to benefit adjacentbody areas

Mastopexy-augmentationunderstand the pros and cons Thighschanging concepts Armsscars are slow to mature


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Fig. 43. Positioning of the thighs using spreader bars. Photograph courtesy of Jeffrey M.Kenkel, M.D. All rights reserved.

Fig. 44. Vectors of facial rejuvenation. Illustration courtesy ofRod J. Rohrich, M.D. All rights reserved.


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Fig. 45. Preoperative and 2-month postoperative views after neck andface lift. Photographs courtesy of Jeffrey M. Kenkel, M.D. All rights re-served.


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marking and operative techniques.9

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