Update on Oblique Flankplasty: Easily Executed, Long-Lasting, Integral Component of Total Body Lift Surgery.

BACKGROUND: Twenty years ago, coordinated aesthetic surgery for laxity and lipodystrophy after massive weight loss (MWL), so-called total body lift surgery (TBL), encompassed circumferential hip hugging transverse lower body lift (LBL) with possible buttock auto-augmentation, and a transverse bra line upper body lift (UBL) with breast reshaping. Brachioplasty and vertical thighplasty were often included. Disappointing aesthetics of the posterior torso led to innovation with J-torsoplasty and oblique flankplasty. OBJECTIVES: The goal of this study was to demonstrate in a large clinical series and in a range of case presentations from 2 plastic surgeons that oblique flankplasty with lipoabdominoplasty (OFLA) optimally narrows the waist, suspends lateral buttocks and thighs, and integrates with J-torsoplasty and vertical thighplasty to tighten skin and aesthetically contour the torso and thighs with an acceptable rate of complications. METHODS: Retrospective chart review of 151 consecutive flankplasties between June 2010 and April 2023, including sex, age, BMI, associated operations, complications, and revisions was performed. Five case presentations were accompanied by limited photographs and a marking video. RESULTS: Across a broad clinical spectrum, malleable oblique flankplasty resected bulging flanks and, facilitated by neighboring liposuction and/or J-torsoplasty, consistently pulled in lax skin and anchored through cadaver-proven dense dermal adherences lax tissues to create a long-lasting skintight shapely torso and upper thighs, with only 3.3% problematic wounds. Five diverse cases showed broad applicability. CONCLUSIONS: OFLA, often with J-torsoplasty and neighboring liposuction, aesthetically recontours torso skin laxity in a variety of presentations with a low rate of complications in a high-risk population.

Interplay of Oblique Flankplasty with Vertical Medial Thighplasty.

After 25 years' experience, the authors present the senior author's current integration of lower body lift with vertical medial thighplasty. Mostly, oblique flankplasty with lipoabdominoplasty (OFLA) has replaced the traditional transverse posterior lower body lift and abdominoplasty due to improved esthetics and lower rate of complications. OFLA proceeds either immediately or as a first stage to the medially based reduction of thighs. L-vertical medial thighplasty, facilitated by excision site liposuction and scalpel assisted skin avulsion, is our preferred complimentary operation for predictable results and low rate of complications.

Quill barbed sutures in body contouring surgery: a 6-year comparison with running absorbable braided sutures.

BACKGROUND: Body contouring operations are concluded with suture closure of long incisions under tension. While an expeditious and secure repair without complications is the objective, wound closure typically consumes a substantial percentage of the operative time and too often leads to delayed wound healing and other problems. OBJECTIVES: The authors evaluate suture-line wound healing for body contouring operations with barbed suture wound closure compared with absorbable running suture closure. METHODS: In this retrospective study, wound-healing complications for a 228 consecutive-patient cohort with barbed sutures over a period of 4 years were compared with those for a prior 132 consecutive-patient cohort with absorbable running sutures over a period of 2 years. Complications were classified according to severity: grade 1 (mild), grade 2 (moderate), and grade 3 (severe). The preferred suture techniques for the closure of either thick or thin subcutaneous tissue under tension are described. The authors' clinical impressions are also presented. RESULTS: Patients whose wounds were closed with absorbable running sutures had a significantly greater incidence of complications at all severity grades of severity than did those with barbed suture closures, with the exception of grade 3 (severe) complications in thighplasty. Logistical regression was <1, and the confidence interval was also <1, in support of these results. CONCLUSIONS: Proper barbed suture selection and 2-layer technique led to a statistically significant lower rate of wound-healing complications as compared with prior experience with traditional running braided absorbable sutures. Other benefits were more rapid speed of closure, adequate security of the wound closure, and increased surgeon satisfaction. LEVEL OF EVIDENCE: 3.

Contemporary Management of Gynecomastia.

Contemporary management of gynecomastia includes transareolar excision of gland, disruption of inframammary fold, ultrasonic-assisted lipoplasty with muscular definition, bipolar radiofrequency tightening, pedicled NAC mastopexy with boomerang pattern excision and J torsoplasty, NAC grafts with hockey stick excision pattern, and pectoralis muscle lipoaugmentation. Therapeutic options are arranged across a modified Simon classification. The aesthetic goal is near total glandular reduction, with proper position and shape of the nipple areolar complexes, and masculinity with skin adherence reflecting musculoskeleton. Clinical cases demonstrate these multiple approaches, successes, and pitfalls. Complications relate to delayed healing caused by excessive closure tension or inadequate or inappropriate treatment.

Management of upper abdominal laxity after massive weight loss: reverse abdominoplasty and inframammary fold reconstruction.

BACKGROUND: Central to body contouring after weight loss surgery is treatment of the abdominal region, often through a circumferential abdominoplasty. This procedure, however, neglects the laxity of the lower thoracic/upper abdominal region. A reverse abdominoplasty with reconstruction of a new inframammary fold (IMF) corrects this deformity through removal of excess skin along the IMF. Since 2002, we have performed 88 reverse abdominoplasty procedures within the context of a single or staged total-body lift (TBL). METHODS: A retrospective chart review of 129 TBL cases indicated that 88 patients had a combined or staged reverse abdominoplasty and circumferential abdominoplasty. Complication rates were noted as localized or generalized. RESULTS: Fifty-three of our patients had combined reverse abdominoplasty and circumferential abdominoplasty and 35 had the reverse abdominoplasty during a second stage. The complication rates for both groups were about 5% per patient per procedure with differences that were not statistically significant. Also, the revision rates for reverse abdominoplasty and circumferential abdominoplasty were similar for both groups, indicating patient satisfaction with the procedures. CONCLUSION: In selected patients, effective treatment of the abdominal region demands correction of both the upper and lower abdominal laxity and contour. This can be performed safely, effectively, and reliably by a reverse abdominoplasty with IMF reconstruction independently or simultaneously with circumferential abdominoplasty.

Enhanced recovery after body-contouring surgery: reducing surgical complication rates by optimizing nutrition.

BACKGROUND: Currently, many body-contouring patients are overweight or obese or recently have sustained massive weight loss. Often these patients need multiple surgical procedures with extensive incisions. The need for optimal healing in all these patient populations is, however, hampered by their existing nutritional deficiencies. METHODS: Based on the authors' previous work (Agha-Mohammadi and Hurwitz Plast Reconstr Surg 122:604-618, 2008; Agha-Mohammadi and Hurwitz Plast Reconstr Surg 122:1901-1914, 2008), three clinical studies were initiated. The first study examined the preoperative nutritional parameters of 90 body-contouring patients. Of the 48 postbariatric patients, 38% had low prealbumin (<20 mg/dl), 33% had vitamin A deficiency, 32.6% had low hemoglobin (<12 g/dl), 16.3% had iron deficiency, 9.5% had vitamin B12 deficiency, and 12% had hyperhomocystinemia. Among the 42 nonbariatric patients, only 10% had low prealbumin and 11.5% had vitamin A deficiency. Other deficiencies were less remarkable. The second study evaluated the effect of a surgical nutritional supplement on the prealbumin, vitamin A, vitamin B12, and folate levels of 13 decubitus ulcer patients. The data indicated an increase in all the measured parameters, particularly a prealbumin increase of about 0.8 mg/dl per day. The third study investigated complications experienced by 131 body-contouring patients. The patients were divided into postbariatric and nonbariatric groups, then stratified according to their body mass index (BMI). The rates of minor and major complications in obese nonbariatric and postbariatric patients (receiving the nutritional supplement) were comparable with those of normal-weight nonbariatric patients. CONCLUSION: Obese nonbariatric and postbariatric patients are at nutritional risk for many primary ingredients of wound healing and immune system competency. Appropriate nutritional supplementation is an effective means for correcting these nutritional parameters and can significantly reduce surgical complications associated with obesity and bariatric surgery.

L-brachioplasty: an adaptable technique for moderate to severe excess skin and fat of the arms.

The L-brachioplasty is an L-shaped pattern of excision with the long limb from the elbow to the axilla and the short limb extending at right angles through the axilla and along the lateral chest. The width of the excisions through the arm, axilla and chest is based on preoperative assessment through anatomical point locations followed by pinch and gathering maneuvers. The following modifications have improved aesthetics and reduced complications: 1) improved geometric design, 2) anchor fixation of the posterior V-shaped advancement flap to the deltopectoral fascia, 3) excision site liposuction (ESL), and 4) and barbed suture closure. The free hand markings are followed by measuring equal anterior and posterior incision distances. The subcutaneous fat within the excision site is completely suctioned. After the perimeter is incised, the skin resection begins full thickness from the chest and through the axilla and then the skin only through proximal to distal arm skin. An anchor suture advances the posterior triangular flap to the deltopectoral fascia. A long-lasting absorbable barbed suture is passed through as a running horizontal mattress, starting from the center of the wound. A second continuous rapidly absorbing barbed intradermal suture completes the closure. Over the past 30 arms, only one seroma was aspirated on one occasion. There have been no lymphoceles. Appreciable swelling is over within a month. Incision dehiscence was limited to less than one centimeter in five patients. Tip necrosis of the V advancement flap occurred in three arms, leaving small wounds in the axilla to heal secondarily. Minor secondary skin reduction is rare. There were no contractures across the axilla. The women appreciated the reduced hair and axillary hollow. In most cases the skin laxity was corrected and the contour from the arm across the axilla to the lateral chest was excellent. No patient expressed regret over their scar.

Noninvasive Abdominoplasty.

Noninvasive and minimally invasive treatments are increasingly supplanting, or complimenting, abdominoplasty. For optimal delivery of patient care and to maintain a dominant share of the body-contouring market, plastic surgeons need to embrace these new technologies. High capital purchases, costly disposables, maintenance fees, lack of experience, conflicting anecdotal reports, energy-related complications, marketing hyperbole, and rapid obsolescence are formidable barriers to this adoption. Receptive plastic surgeons may be best served by accepting brief short-term retrospective reports by reputable innovative body contouring surgeons who present a succinct and clinically supported message.

Reshaping the Oversized Waist through Oblique Flankplasty with Lipoabdominoplasty.

BACKGROUND: Designed in response to the failure of circumferential lower body lifts to deepen waists, oblique flankplasty with lipoabdominoplasty aesthetically reshapes not only the waist, but also the hips, buttocks, and upper lateral thighs with minimal morbidity. METHODS: The oblique flankplasty with lipoabdominoplasty technique was standardized, with 5 of 56 cases presented. Operative records on the lower torso from March of 2000 to January of 2018 yielded 30 initial oblique flankplasty with lipoabdominoplasty cases and hundreds of lower body lifts. A subset of randomly selected lower body lift and flank liposuction operations yielded 91 cases. Through SurveyMonkey, the authors and 16 unbiased observers graded flank and global deformity using the Pittsburgh Rating and novel posterior trunk aesthetics scales. RESULTS: The oblique flankplasty with lipoabdominoplasty deepened and smoothly transitioned waists. Medial rotation of the lateral buttocks over the posterior iliac spine retained lateral fullness and established hip prominence. Central buttock laxity was corrected without intergluteal cleft lengthening. The immediate result persisted, satisfying high patient expectations. There were three minor complications and three nonexcisional revisions, with no unscheduled hospital admissions. The mean flank deformity for all cases was 1.93 was by chi-square analysis, which was significantly more than 0.88 for postoperative deformity (p < 0.001). Subgroup analysis of each procedure group showed a significant reduction in deformity. Comparing flankplasty with lower body lift, oblique flankplasty with lipoabdominoplasty had slightly greater flank deformity and far greater reduction in deformity and overall aesthetic improvement. CONCLUSIONS: For grade 2 and 3 flank deformities, oblique flankplasty with lipoabdominoplasty provides a tighter skinned lower torso with gender-appropriate curvatures, including a deeper and more smoothly transitioned waist than lower body lift, leading to uniform patient satisfaction. There was minimal secondary deformity or complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A clinical review of total body lift surgery.

BACKGROUND: Until 2001, body contouring surgery after massive weight loss was uncoordinated, with few patients achieving compete rehabilitation. OBJECTIVE: The authors report a 5-year, retrospective, 75-case clinical review to determine the effectiveness, reliability, and safety of single and multistage total body lift (TBL) surgery. METHODS: Between January 2001 and June 2006, 59 single-stage, 15 two-stage, and 1 three-stage TBL surgeries were performed, involving a total of 605 separate procedures. Outcomes and complications were compared among all TBL patients and a contemporaneous published series. RESULTS: Three representative cases are described. Overall, in patients under 55 years of age with a body mass index of less than 30, there was no significant difference in the choice of procedure (ie, single-stage TBL [95% confidence interval, 1.236-2.302] or multiple-stage TBL [95% confidence interval, 1.687-4.892]; P = .1882). Although there was no significant association between major complications and the number of procedures performed in this cohort of patients, there were increased wound healing problems following multiple-stage TBL (P > .5). Single-stage TBL surgery averaged 8.4 hours. Two-stage surgery took 7.4 hours for the first stage and 4.6 hours for the second stage, for a total of 11 hours. Banked blood transfusions for single-stage surgery were 1.5 per single-stage case and 0.78 per multi-stage case. Seventy-six percent of the patients experienced complications, mostly related to wound healing. All preoperative and postoperative Pittsburgh rating grades improved. CONCLUSIONS: TBL is customized for individuals who desire a comprehensive approach to improvement of their loose skin. The rate of complications was high and comparable to other published series. There was no difference between the complications of the single-and two-stage patients. While there was an observable reduction in deformity and a high rate of satisfactory aesthetic outcomes, this high number of complications indicates a need to improve clinical performance.

Biomechanical properties of the superficial fascial system.

BACKGROUND: Surgical repair of the superficial fascial system (SFS) has been claimed to both increase wound strength and enhance surgical outcome through anchoring of deeper tissues. OBJECTIVE: The authors assessed the biomechanical properties of the SFS to determine whether repair of the SFS layer improved early and long-term postoperative wound strength. METHODS: Four complementary studies were conducted to study the dermis and SFS junctional architecture and connective tissue content: gross dissection using a dehydrating agent (Pen-Fix; Richard-Allan Scientific, Kalamazoo, MI), a histologic study with hemotoxylin and eosin staining, soft tissue radiography, and immunofluorescence staining. Freshly excised human abdominal and lower back/buttock tissues underwent a midline incision, followed by repair using dermal sutures only (DRM), dermal sutures plus SFS sutures (DRM/SFS) or repair of the SFS only (SFS). Fresh swine abdominal tissues were similarly excised and repaired. Biomechanical tests were undertaken to compare the ex vivo human and swine tissues. Three types of closure-dermal sutures only (DRM), dermal sutures plus permanent 0-braided nylon suture in the SFS (DRM/SFS/N), and dermal sutures plus absorbable 0-vicryl suture in the SFS (DRM/SFS/V) were also tested in an in vivo swine model. RESULTS: Immunofluorescence studies showed collagen and elastin content and ratios to be comparable in the dermis and SFS. In ex vivo studies of human abdominal and back tissues, cyclic creep did not vary significantly among the different types of repair. DRM/SFS repair had a significantly higher failure load than dermal repair alone in both human abdominal and back tissues. In the in vivo swine study, normal tissue had a significantly higher failure load than all repair groups. The wounds where SFS had been repaired in addition to dermis exhibited an increased tensile strength and, among these, the wounds closed with SFS repair with a nonabsorbable suture exhibited greater tensile strength compared to absorbable suture repair. However, no statistically significant difference was noted, due to the small sample size. CONCLUSIONS: We have determined, using an ex vivo model, that repair of the SFS layer in addition to dermis repair significantly increases the initial biomechanical strength of wound repair. This has the potential to decrease early wound dehiscence. In our in vivo model, the use of a nonabsorbable suture to approximate the SFS demonstrated a trend toward increased long-term wound strength. We believe our studies provide scientific data documenting that SFS is a key contributory strength layer in the early postoperative period, and is likely to be a strength layer even in the later stages of wound healing.

Body Contouring Surgery in the Massive Weight Loss Patient.

Plastic surgeons subspecializing in body contouring are meeting the challenge of postbariatric surgery massive weight loss patients. With an appreciation of the magnitude of the surface deformity, and altered metabolism, nutrition, and psychological makeup of these patients, innovative plastic surgeons have forged an organized approach to preparation, operative technique, and postoperative care. Patients at greatest risk for complications are identified, appraised, and either their condition improved or they are counselled to reduce expectations. Beyond the removal of excess skin and adipose tissue, advanced gender-specific techniques have improved aesthetics.

Medial thighplasty.

The L thighplasty, designed to correct thigh laxity in patients with massive weight loss, is distinguished by single-stage integration into the lower body operation, presurgical marking of a unique excision design, and efficient use of prone and supine operative positions. It may be limited to an upper thigh crescent excision or extended with a wide band for distal deformity.