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.

Enhancing Masculine Features After Massive Weight Loss.

BACKGROUND: Whereas body contouring surgery after massive weight loss in women emphasizes sculptured adipose and broader lower torso, little attention has been devoted to accentuating the male physique. OBJECTIVE: To determine if boomerang excision pattern correction of gynecomastia with J torsoplasty combined with an abdominoplasty with oblique excisions directly over bulging flanks provide effective and safe optimizing of muscle visibility and upper torso dominance. METHODS: A description of comprehensive body contouring through an abdominoplasty and a series of obliquely oriented ellipses of the male torso is followed by review of 19 consecutive patients. RESULTS: Seventeen patients were performed in a single stage. Nine of the last ten cases included J torsoplasty and oblique excision extensions over the flanks. Of the 17 patients responding to a ten-question survey, 15 were satisfied with chest improvement. One of the first eight patients with a transverse lower body lift was satisfied with the flank bulges. All of the last eight cases with direct oblique flank excisions were satisfied with their lower body. Five patients (26 %), having a total of 74 operative procedures, had significant complications of chest hematoma, persistent hip and buttock seromas, superior NAC edge necrosis, and distal necrosis of the fleur de lis abdominoplasty. One boomerang correction underwent minor revisions. One transverse lower body lift underwent major revision. No complications occurred in the last ten patients, having oblique flank excisions instead of transverse lower body lifts. CONCLUSION: Comprehensive excisional body contouring surgery of a central high tension abdominoplasty with a series of obliquely oriented ellipses throughout the torso appears to provide low risk improved body contour for the muscular male. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Enhancing Masculine Features After Massive Weight Loss.

BACKGROUND: Whereas body contouring surgery after massive weight loss in women emphasizes sculptured adipose and broader lower torso, little attention has been devoted to accentuating the male physique. OBJECTIVE: To determine if boomerang excision pattern correction of gynecomastia with J torsoplasty combined with an abdominoplasty with oblique excisions directly over bulging flanks provide effective and safe optimizing of muscle visibility and upper torso dominance. METHODS: A description of comprehensive body contouring through an abdominoplasty and a series of obliquely oriented ellipses of the male torso is followed by review of 19 consecutive patients. RESULTS: Seventeen patients were performed in a single stage. Nine of the last ten cases included J torsoplasty and oblique excision extensions over the flanks. Of the 17 patients responding to a ten-question survey, 15 were satisfied with chest improvement. One of the first eight patients with a transverse lower body lift was satisfied with the flank bulges. All of the last eight cases with direct oblique flank excisions were satisfied with their lower body. Five patients (26 %), having a total of 74 operative procedures, had significant complications of chest hematoma, persistent hip and buttock seromas, superior NAC edge necrosis, and distal necrosis of the fleur de lis abdominoplasty. One boomerang correction underwent minor revisions. One transverse lower body lift underwent major revision. No complications occurred in the last ten patients, having oblique flank excisions instead of transverse lower body lifts. CONCLUSION: Comprehensive excisional body contouring surgery of a central high tension abdominoplasty with a series of obliquely oriented ellipses throughout the torso appears to provide low risk improved body contour for the muscular male. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

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.

Malar augmentation with a polymethylmethacrylate-enhanced filler: assessment of a 12-month open-label pilot study.

BACKGROUND: Most filler procedures in the United States are performed with hyaluronic acid (HA) derivatives. Artefill (Suneva Medical, Inc, San Diego, California), the only polymethylmethacrylate (PMMA)-enhanced dermal filler approved by the US Food and Drug Administration (FDA), has been well tolerated by patients for treatment of nasolabial folds and has a safety profile similar to other approved fillers. OBJECTIVES: The authors investigate the safety and efficacy of Artefill for malar augmentation. METHODS: This prospective, multisite, open-label study included a total of 24 patients with age-related lipoatrophy. Only patients with mild to moderate lipoatrophy were considered candidates for treatment. Artefill was injected in the supraperiosteal layer of the malar region, at a maximum volume of 6 mL (3 mL/side). Touch-up injections were performed at weeks 4 and 6, up to a maximum total volume of 8.8 mL. Standardized assessments of results were made at 2, 6, and 12 months. Outcome measures included the Global Aesthetic Improvement Scale (GAIS), change in malar lipoatrophy grade, and patient satisfaction. Standardized photographs of each patient were collected. RESULTS: Average patient age was 48 ± 5 years. Average volume of injections was 5.55 ± 1.87 mL. Based on both the patient- and physician-rated GAIS, 95.8% of study participants were reported as being "improved" or "very much improved." The change in malar lipoatrophy grade was significantly improved from baseline to 1 year by 0.96 ± 0.98 (P < .0003). Patients also reported high levels of satisfaction, with 87.5% being "satisfied" or "very satisfied." There were no reported adverse safety events in the study. CONCLUSIONS: Artefill demonstrated improvement in malar atrophy with a high level of patient satisfaction and an excellent safety profile. The absence of any adverse events in our study patients was notable, and we believe this is a result of the uniform nature of the PMMA particles in the Artefill and the strict and sterile manner in which this PMMA dermal filler is produced.

Treatment of overweight patients by radiofrequency-assisted liposuction (RFAL) for aesthetic reshaping and skin tightening.

BACKGROUND: Patients with massive volume or skin laxity typically are not ideal candidates for liposuction treatment due to the excess amounts of loose skin after the procedure. The feasibility, safety, and efficacy of a novel radiofrequency device (BodyTite system) for radiofrequency-assisted liposuction (RFAL) were prospectively evaluated with overweight and weight loss patients. METHODS: In this study, 17 women with an average aspirated volume of 1,759 ml in the arms, abdomen, or thighs were treated. The treatment technique is described with the resulting weight, circumferential, and contraction measurements collected at a follow-up assessment after 6 and 12 weeks. Three-dimensional scanning was used to document volume changes in selected cases. Patient satisfaction also was recorded. Body contour and area tightening results were evident for all the patients, with high posttreatment satisfaction. Skin contraction was significant at 6 weeks and continued past 12 weeks of follow-up evaluation. RESULTS: On the average, after 12 weeks, patients had lost 6.2% of their original abdominal circumference, 4.4% of their original thigh circumference, and 9.2% of their original arm circumference. The mean vertical contraction was 7.9% for the abdomen, 3.6% for the thighs, and 2.4% for the arms. The maximum results showed a circumference loss of 16.5% for the abdomen, 11.4% for the thighs, and 17.7% for the arms. The maximum vertical contraction was 15.7% for the abdomen, 7.4% for the thighs, and 3.3% for the arms. The average follow-up period was 13.3 months (range, 3-26 months). CONCLUSION: The RFAL approach is a viable means of energy-assisted liposuction for overweight and massive weight loss patients. Significant volumes of fat can be removed safely and effectively with improved contour and clinically significant skin tightening.

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.