124 – Belt Lipectomy / Lower Truncal Contouring, Al Aly, MD, FACS

Belt Lipectomy/LowerTruncal ContouringAl Aly, MD, FACSProfessor of Plastic SurgeryDirector of AestheticsUniversity of California Irvine

Ethicon ConsultantInvestment in InsorbAngiotechRoyalty from QMP for bookAllergan Consultant

Willstress key principlesrather thanspecific details

Factors That Affect RESULTS Weight or BMI at presentation Fat deposition pattern Quality of skin-fat envelope

Patients will lose weightand stabilize at aparticular level, which willvary from patient topatient

The Skin-Fat Envelope Thickness Pliability Translation of pull

If all treated the sameResults are inferiorBasic Principle

IMPORTANTMWLP haveCIRCUMFERENTIALlower truncal excessBasic Principle

Why Circumferential Excision? Tension & dynamics Tailoring physics Severe vertical excess Obese psychology

What Do ExcisionalProcedures Accomplish? Eliminate excess skin & fat Create distant contour

Treatment Options Abdominoplasty “T” or “fleur de lis”lipectomy Circumferential lipectomy

Abdominoplasty Ideally treats Mild excess belly fat Excess belly skin Belly laxity

AbdominoplastyThe design of theoperation has atendency to eitheraccentuate outerfullness or create it

Abdominoplasty Will not treat: Sides/waist Outer thighs Back Buttocks

It is important to understandthe dynamics of lowertruncal contouring

Tension is bad for scaringbutTension is essential forcontour

Surgical improvement=Tension above and belowthe closure

A circumferential procedure=aggressive as you need tobe

MWLP Circumferential Excess Differentially greater anteriorly Often vertical excess is severe To Tx appropriately – huge verticalexcision

T Shaped PanniculectomyEven when done well,incomplete and ofteninadequate effect on thesides & back is seen

“Stigmata of Obesity”

If you don’t address “ObesityStigmata”?Failure

Rehabilitation of thelower trunk in themassive weight losspatient most oftenrequires circumferentialtreatment

Body Lifts Are NotAll The SameBasic Principle

Approaches to The TrunkLower Body LiftBelt Lipectomy

Surgical Approaches to The Trunk Each philosophy has its pros andcons Each has its proper place in thearmamentarium of the plasticsurgeon Not exclusive of each other

Lower Body Lift Lower wedge-lateral & posterior Onto buttocks proper Final scar below the widest aspect ofthe pelvic rim-below underwear Eliminates zones of adherence

Lower Body Lift Pros Superior thigh reduction &elevation Reduces need for medial thigh lifts Scar below underwear

The “Sun Dress Effect”

Lower Body LiftLoss of adherence zonesScar below pelvic rimTenting across waistBlunting

Belt Lipectomy Zones of adherence are maintainedfor support The incisions are overall in a higherposition – natural junction ofbuttocks & back

Cinching at waist level creates adepression above the buttocks

Belt Lipectomy Pros Creation of a waist Better definition of buttocks Contour control at the level ofthe scar Better overall truncal contour

Belt Lipectomy Cons Thighs not lifted laterally as well Scars maybe outside of underwear line Medial thighs often need a vertical scar Overall thighs are not as well treated bybelt alone

Workup This is a BIG operation A “major life event” Extensive preoperativeworkup

ElectrolytesAlbuminAlkalinePhospataseALT (SGPT)AST (SGOTBUNCalciumCBC w/Differential CholesterolCreatinineFerritinGlucoseMagnesiumTotal ProteinPT/PTTVitamin B12CopperThiamine

Criteria For Surgery Medically healthy Psychiatric stability Non-smoker Reduced intra-abdominalcontent Stable weight for ~3 to 6 months

Malnurtition is common inpost bariatric surgerypatients, especiallyduodenal switch patients.Check their labs early

If BMI > 35, > 100%complication

Philosophy THE MONEY IS ANTERIOR Aggressive side excisions Adjust back to anterior &lateral resections

Markings The essence of the procedure Adjustable guidelines forsurgery Vary according to anatomy &desires

Markings Photograph them Look at them prior tosurgery Compare them to yourresults

A major goal of marking=Controlling Scar Position

Controlling scar position isbased on:“Simulating tissuedynamics at closure”Basic Principle

The final position of a scar,in an excisional procedure,is based on the“tissue mobility”on either side of the woundBasic Principle

Low Tissue Mobility=Zones of Adherence

The Mons is “V” ShapedBasic Principle

Approach to Mons Eliminate vertical – 1 st procedure Avoid central midline excisions Defat if needed Let lymphatics reconstitute Tx horizontal excess last

Superior marks anteriorlyare passivethey simply fit into the inferiormarksas in a puzzle

Our Back Markings Confusing to understand Create an initial inferior line “purelyas a reference” Create superior mark based on pinch But superior line is final “determiner”of scar position

Markings Make vertical marks equidistantfrom anterior & posteriormidlines to help align the closure In large BMI patients the lowercircumference is always larger,thus there will be a discrepancy

Controlling Scar Position Anteriorly – inferior mark Posteriorly – superiormark

Technique Two surgeons General anesthesia Epidural

Position Sequence Evolution Prone/Supine Lateral/Lateral/Supine Supine/Lateral/Lateral

Flap Elevation Thin- traditional butminimal Thick flap- some form oflipoabdominoplasty

“If the flap is thick, layit in a depression”Basic Principle

Philosophy on Buttocks Autoaugmentation Buttocks implants-not ideal Fat injections

Autoaugmentation Often augments the wrong level Not apparent on the table Position of scar is compromised Proper scar position can lead,sometimes, to optical illusion ofaugmentation

Autoaugmentation Possible and real complications Wrong position Fat necrosis Infection/sepsis Skin necrosis Resistant seromas Uncontrolled pain

Postoperative Care Walk the day of surgery Patient is to walk bent forone week Patients will stay 2-4 daysin the hospital assumingno complications

Postoperative Course 4-6 weeks to recover Final results at 1 year +

Goals of Surgery Flat abdomen Elevate mons if needed Create a waist if needed Eliminate lower back rolls Define buttocks Lift outer & ? Inner thighs

Massive Weight LossGenerally, resultscorrelate with thepatient’s BMI atsurgeryBasic Principle

Expected ResultsHigh BMI

Expected ResultsIntermediate BMI

Horizontal Upper AbdominalScars Obvious vascular issues Consider time and position Options Use as inferior of flap Use as vertical limb Limited supra-umb. dissection &evaluate-cut upper line first

Expected ResultsNear ideal BMI

Indications forCircumferential Procedures MWLP Overweight - BMI = 26-29 Ideal weight patients Over-liposuctioned lowertrunk

Overweight Patients Usually – 26 to 29 No weight loss Unable to lose weight Circumferential issues

Normal weight patientsthat want especiallyexcellent contour

Over liposuctionedlower trunk

CAUTION!!!you improve contournotquality of skinBasic Principle

Complications

Complications Seromas (30%) Wound healing problems (20%) Psychiatric Difficulties (8.6%) Infections (4.3%) Tissue Necrosis (4.3%) Pulmonary Emboli (2.9%) DVT (1.4%)

Complications arecommon after beltlipectomy surgery;with seromas being thepredominantcomplication

A high BMI is associatedwith an increased risk ofcomplicationsBasic Principle

Both the surgeon and thepatient need to be aware thatbelt lipectomy is an extensiveprocedure with a fairly highcomplication rate

Usual Sequence Belt lipectomy w/ or w/oliposuction of thighs Upper body work Thigh reduction Face

Combination Surgery Generally like to do belt alone Never (?) upper and lowertogether Thighs always after belt

Transfusions Infrequent in our series But common in practices thatcombine many procedures Probably related to theamount of surgery done inone sitting

Thank You