Aesthetic Plastic Surgery 3:357-368, 1979 Aesthetic :plastic urgery

Torsoplasty*

Mario Gonz~ilez-Ulloa, M.D., F.A.C.S. , F . I .C.S. , A.R.C.M., F . I .A.P.S.

Dalinde Medical Center, Mexico City, Mexico

Abstract. Torsoplas ty is a series of operations performed on the torso, from the arms to the thighs, to correct deformities caused by obesity, weight re- duction, obstetrical remissness, or congenital problems. The results have been highly satisfactory and the complications minimal.

Key words: Torsoplas ty - - Obesity - - Tissue aging

The simple fact that the procedure described in this report can be performed opens new paths of possibilities for the surgeon in the management of the soft tissues of the human body.

Torsoplas ty is an operation designed to be carried out as a single surgical procedure (total torsoplasty) when time is highly important to the patient and the patient 's general health is satisfactory. The surgical environment must be adequate, and auxiliary teams must be available. Otherwise, sectional torso- p las ty- - tha t is, one or more in tervent ions--can be performed.

Fig. 1.

*Presented at the Sixth Meeting of the I.P.R.S.-I.S.A.P.S. in Rio de Janerio, May 1979 Address reprint requests to Mario Gonzfilez-Ulloa, M.D., Tuxpan 16 10 Piso, Dalinde Medical Center, Mexico 7DF Mexico

0364-216X/79/0003-0357 $02.40 �9 1979 Springer-Verlag New York Inc.

358 M. Gonz~ilez-Ulloa

Total torsoplasty entirely reshapes the human torso, restoring normal ten- sion to the skin and placing the tissues in an antigravitational position. The Greek term from which the word t o r s o derives means "wand" or "s tem"; the torso is that portion of the body that extends from the upper part of the arms to the upper part of the thighs.

Torsoplasty includes 1) brachioplasty of various degrees, depending on the deformity; 2) mammoplasty, with either diminution or augmentation of volume and correction of the breast's shape; 3) abdominoplasty in its various modali- ties; 4) gluteoplasty, for either diminution or increase in volume and correction of ptosis; 5) cruroplasty, in its various aspects of improving the thigh or in diminishing the volume of the trocanteric region; and 6) lumboplasty in cases of deforming adiposity in this region (fig. 1).

Torsoplasty may be sectional when only one or more of these procedures are carried out, without comprising the entire torso. The most frequent indications are for sectional torsoplasty, and total torsoplasty is reserved for severe dis- figurements of the torso.

To perform this series of operations, it is indispensable that there be an ade- quate surgical environment and that auxiliary teams are available to ensure that the patient is maintained in proper condition.

Total torsoplasty might be indicated in the patient who, as a result of a sud- den change in personal situation, find that their physical appearance is inade- quate for social, economic, political status and the time element is of utmost importance.

Methods

The tracing for an incision for torsoplasty, made prior to the operation, is circu- lar (Fig. 2A). For the correction of the posterior lateral and anterior portion of the thigh, including the removal of a large epitrocanteric pad, infragluteal pro- longation of the incision allows for the introduction of the gluteal prosthesis if gluteal hypotrophy is present (Fig. 2B and 2C).

Fig. 2

Torsoplasty 359

Fig. 3

Fig. 4

After the tracing is completed (Fig. 3A), the operation (Fig. 3B) starts with the circular section of the umbilicus, leaving an adequate amount of adipose tissue cover around the umbilical tube.

The large abdominal incision is now made (Fig. 4A), and wide undermining is carried out upward to the xiphoid process (Fig. 4B, left). The aponeurosis of the rectal muscle is sutured with stainless steel wire, No. 0 (Fig. 4B, right).

In five patients in our series we have corrected mammary hypotrophy through the same abdominal incision (Fig. 5A). Undermining upward over the aponeurosis of the pectoral muscle and inserting the prosthesis saves surgical time and avoids another scar. The prosthesis is fixed with a U stitch tied over a sponge and button (Fig. 5B). For a better result, the table is set in jacknife position during sectioning and suturing.

Strong downward traction is exerted on the abdominal flap. The medial part is sectioned until the lower flap is reached. The flap is pushed by an assistant.

360 M. Gonz~ilez-Ulloa

Fig. 5

Fig. 6

Here a pilot suture is placed (Fig. 6A). The excess tissue is then resected from the abdominal wall (Fig. 6B).

An incision is continued vertically downward into the upper part of the thigh (Fig. 7A), reaching the crural aponeurosis. Tunnel undermining is done to sepa- rate adipose tissue from the aponeurosis in the thigh (Fig. 7B). We justified the incision in this case because rhytidectomy of the peripheral thigh was needed. In other cases, the epitrocanteric adipose tissue is resected as a thick layer, without skin incision.

After both the abdominal and crural flaps have been freed, reciprocal traction is performed to pull the skin and adipose tissue of the thigh upward while the abdominal tissues are pulled downward. At this stage, one can measure the amount of skin and adipose that must be resected (Fig. 8A and B).

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Fig. 7

Fig. S

Excess tissue is excised from the external aspect of the thigh (Fig. 9A), the segment is resected (Fig. 9B), and pilot fixation sutures are placed to distribute the skin evenly (Fig. 9C).

The stretching of the skin after pilot suturing of the thigh and lower part of abdomen is quite remarkable (Fig. 10A). The opposite side is similarly cor- rected. The next step is to transpose the umbilicus at the same level at which it emerges from the muscular portion of the abdomen. This is carried out through asingle vertical incision 2.5 cm long. When the umbilicus has been fixed in situ, the abdomen appears stretched and youthful and the abdominal concavity will become obvious.

When the areas that have undergone surgery are explored to determine the degree of stretching, the laxness of the skin of the gluteal region will be clearly noticeable (Fig. 10B and 11). To stretch this area, a prosthesis of adequate volume will be placed after the patient is turned to the ventral decubitus position.

362 M. Gonz~ilez-Ulloa

Fig. 9

Fig. 10

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Fig. 11

While the patient is still in the dorsal decubitus position, the operation is continued in the brachial region. An axis is marked from beneath the edges of the pectoralis major muscle to the channel in between the medial epicondyle and the troclear of the humerus. The amount of tissue to be removed can be appreciated clinically (Fig. 12A). The incision is always started in the posterior border of this area. Dissection is carefully done toward both sides of the in- cision, over the brachial aponeurosis (Fig. 12B). After this wide undermining, the flaps are opposed. It can be appreciated (Fig. 12C) how the clinical evalua- tion of the amount to be removed is actually far less than can be accomplished by surgery.

Suturing is done in two layers--catgut 3-0 for the subcutaneous tissue and 5-0 Dermalon for the skin (Fig. 13A). Pilot sutures are placed to distribute the skin. For the excess tissue located exactly on the elbow (Fig. 13B), in which the skin is almost always plicated and callous in the elderly patient, resection is done with the arm flexed to avoid producing an ischemic flap. The skin is then care- fully sutured with 5-0 Dermalon (Fig. 14A and B).

The patient is now turned to the ventral decubitus position. The excess skin of the subgluteal fold and the site for the prosthesis implant are marked. Both apex and main axes are marked (Fig. 15A). The excess skin of the gluteal fold is now resected (Fig. 15B). Dissection is carried out at the muscular level, under- neath the aponeurosis, so that the Dacron patches of the prosthesis remain adhered and allow reciprocal motion of the prosthesis in concert with the glu- teal muscle. Undermining is done with scissors and then with the hands to make sure that the strong adherence between the adipose tissue and the coccyx are freed (Fig. 16A and B). The prosthesis has been specially designed* in several sizes: Ultramacro (640 cc), Macro (405 cc), Medium (280 cc), Micro (200 cc), Minimicro (160 cc), and Ultramicro (120 cc). Their volumetric design is shown in Figures 17A and B.

*Dow-Corning-

364 M. Gonzfilez-Ulloa

Torsoplasty 365

Fig. 14

Fig. 15

M. Gonzalez-Ulloa

MACRO GLUTEAL PROSTHESIS 405 c.c. I

.5 .5

2]m,,

2 . i cm Fig. 17

After being soaked in saline solution, the prosthesis is introduced into the site in which it will be placed (Fig. 18A). It is fixed with a transfixion suture that goes through the ear of the prosthesis. The needle is drawn at the points marked at both poles and is then passed through small sponges and tied over buttons to keep the prosthesis immobile for a period of 8-10 days. The immedi- ate volume replacing the empty space can be readily seen in Figure 18B. Su- tures are done with 3-0 catgut for the adipose tissue and 5-0 Dermalon for the skin.

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The preoperative aspect of the buttocks (Fig. 19A) is flat, lax, and sad, whereas the postoperative appearance is full, firm, and strong (Fig. 19B). A close-up (Fig. 19C) show the site of the implant as well as the final suturing of the gluteoplasty and the corrected exterior part of the thigh.

The correction of the ptotic breast is performed in the usual manner: We use a modified Passot-Dufourmentel technique, which gives a good result with a quite inconspicuous scar, good volume, and good position of the nipples.

368 M. Gonz,~lez-Ulloa

Results and Comment

Torsoplasty has produced highly pleasing results for both the surgeon and the patient. The satisfactory contour created by the operation has helped to im- prove the outlook and attitude of the patient.

The operation requires about 6-8 hours to perform, and the period of con- valescence is approximately 15-20 days, with continuing observation for the possible development of keloids in the otherwise very fine scars.

Complications from the operation have been limited, consisting of minimal fusion of adipose in two patients.

When there is less urgency for the operation, sectional torsoplasty is more frequently performed.