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PRS- April 2008 Abdominotorso Contouring

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PRS- April 2008 Abdominotorso Contouring SPECIAL TOPIC Treating the Abdominotorso Region of the Massive Weight Loss Patient: An Algorithmic Approach Steven G. Wallach, M.D. Summary: There has been tremendous growth in the number of patients seek- New York, N.Y. ing body contouring procedures after massive weight loss. Most patients desire improvement of the abdominotorso region first. After massive weight loss, there is enormous variability of body proportions, and therefore there have been many surgical options proposed based on the quality of the skin, subcutaneous fat component, and location of the lax tissue. Each area needs to be assessed to see whether there is a significant lower abdominal component, an upper midline abdominal component, or contributions from the buttocks and flanks. An algorithm for treatment is presented to simplify the decision-making process. Patient examples are also shown to demonstrate the usefulness of the algorithm. (Plast. Reconstr. Surg. 121: 1431, 2008.) s a result of the increasing popularity of anatomical regions based on this rating system, bariatric surgery, plastic surgeons are treat- but details regarding the different treatment plans Aing greater numbers of massive weight loss were not elucidated. patients. These patients typically lose more than It is rare for a massive weight loss patient to 100 pounds and have significant skin laxity with undergo just a full abdominoplasty; treatment of varying amounts of subcutaneous tissue excess. the flanks and buttocks has become common. Commonly, the abdominotorso region is treated Therefore, many patients require a more involved first; it often gives patients the most grief. The procedure such as a circumferential abdomino- overhanging pannus may predispose this region to plasty or even one that uses a fleur-de-lis approach. rashes and can make it difficult for patients to wear It stands to reason that a new system is necessary properly fitted clothing. to classify and treat this subset of abdominotorso Several authors have proposed systems that have contour patients. In a fashion similar to the ap- become useful tools for classifying and treating pa- proach for arm contouring described by Appelt et tients desiring abdominal contour surgery.1–3 How- al.,5 the author has developed an algorithm for ever, these systems do not adequately classify the treatment and classification of the abdominotorso massive weight loss patients who are now seeking region specifically for the massive weight loss pa- treatment. tient. Included are descriptions of the procedures Recently, a classification of contour deformi- and patient examples illustrating the usefulness of ties after bariatric weight loss was described by the algorithm (Fig. 1). Song et al.4 The system involved evaluating 10 different anatomical regions commonly treated PREOPERATIVE EVALUATION after massive weight loss. A table was used to il- A discussion with the patient is performed re- lustrate preferred treatment plans for different garding their surgical goals, the various surgical treatment options, and the impact that their med- From the Department of Plastic and Reconstructive Surgery, ical conditions can have on the surgical outcome. Albert Einstein College of Medicine; Lenox Hill Hospital; Surgery is usually delayed until the weight loss has and Manhattan Eye, Ear, and Throat Hospital. Received for publication September 8, 2006; accepted De- cember 20, 2006. Presented in part at Advances in Aesthetic Plastic Surgery: Disclosure: The author has no commercial associ- The Cutting Edge VI Symposium, in New York, New York, ations or financial disclosures that would pose or November 12 through 16, 2006. create a conflict of interest with information pre- Copyright ©2008 by the American Society of Plastic Surgeons sented in this article. DOI: 10.1097/01.prs.0000302463.55208.bf www.PRSJournal.com 1431 Plastic and Reconstructive Surgery • April 2008 Fig. 1. Algorithm for treatment and classification of the abdominotorso region after massive weight loss. plateaued; for a bariatric surgery patient, this is full abdominoplasty. The laxity and quality of the usually after at least a 100-pound weight loss or skin are evaluated in a vertical dimension in the longer than 1 year after the gastric procedure. supraumbilical region as well. Using the vertical up- Sometimes, surgery is performed sooner for a pa- per abdominal midline as a reference point, a ver- tient who requires a panniculectomy to assist in tical pinch is performed pinching tissue from each the management of other conditions. side of the midline to evaluate the upper abdominal The patient is first examined in supine posi- midline excess and laxity. If a vertical pinch improves tion and evaluated for hernias and the extent of the upper abdominal waistline and can eliminate rectus diastasis. A patient that has had an open supraumbilical fullness, the possibility of performing abdominal procedure has an increased risk of her- a vertical midline incision is discussed. The thresh- nia formation.6,7 A massive weight loss patient may old for using this additional incision is lowered if the have an excess subcutaneous fat component, patient has a preexisting paramedian or midline which can make palpation of a hernia difficult. vertical scar. Therefore, the hernia can remain occult until the The patient is then examined for mons pubis time of surgery. ptosis.8 This is marked in accordance with Baroudi’s The patient is then examined in the standing description, leaving a 5- to 7-cm length from the position. The abdominal region is evaluated for skin vulvar commissure to the top of the mons pubis.9 laxity and the extent of the subcutaneous fat com- The patient is evaluated in a right lateral, left ponent. Often, the patient will have striae, poor skin lateral, and posterior standing position using the elasticity, and recalcitrant rashes not amenable to horizontal pinch test to evaluate the impact the conservative treatment. A pinch test is performed in pinch has on lateral and anterior thigh laxity and a horizontal fashion to evaluate the amount of tissue buttock ptosis10 (Table 1). that can be excised. The horizontal pinch is per- The preoperative examination is essential be- formed on the lower transverse abdominal tissue cause there is tremendous variability of skin qual- that would be excised commonly during a routine ity, amount of the subcutaneous fat, and distribu- 1432 Volume 121, Number 4 • Contouring after Massive Weight Loss Table 1. Massive Weight Loss Abdominotorso Classification System Type Fat Vertical Abdomen Laxity (girth) Flank/Buttock Component Treatment I Variable Minimal Minimal Full abdominoplasty II Variable Moderate to severe Moderate to severe Fleur-de-lis abdominoplasty III Variable Minimal to moderate Moderate to severe Circumferential abdominoplasty IV Variable Severe Moderate to severe Fleur-de-lis circumferential abdominoplasty V Severe Moderate to severe Moderate to severe Panniculectomy tion of tissue laxity in these patients. Furthermore, is undermined and the redundant tissue is re- it is during this period when the risks, benefits, sected in the vertical midline to decrease the over- and alternatives of all procedure options can be all girth. The redundant transverse component discussed thoroughly with the patient. is then resected once the vertical component is reconciled.17–21 The key to the closure is minimal CLASSIFICATION SYSTEM tension. This patient is not flexed more than 20 to Type I: Full Abdominoplasty 30 degrees to remove the excess tissue. The post- This patient has moderate abdominal skin lax- surgical care is similar to that used for the type I ity with variable amounts of subcutaneous fat. The patient; however, I find that the drains stay in for vertical skin and subcutaneous component con- several days longer (Fig. 3). tributing to the abdominal girth is minimal. The laxity in the upper abdomen can be treated by superior elevation and excision in a transverse Type III: Circumferential Abdominoplasty fashion along the lower abdomen as performed This procedure is indicated for a patient with for non–massive weight loss patients. The flanks moderate to severe skin laxity of the abdominal and buttocks are not significantly lax and are not skin with a significant flank/buttock component. treated. Repair of the rectus diastasis is performed. The patient may have minimal to moderate excess This patient has fairly good skin elasticity that in the supraumbilical component that can be contributes to the resiliency of the tissues, pre- treated by undermining alone and excising along cluding the need for a more involved procedure. the lower transverse abdomen.10,22–26 In addition, the I have found this more commonly in the younger patient requires resection of the flank/buttock com- massive weight loss patient or in those patients ponent to treat the laxity. After anesthetic induction, who have had less than a 100-pound weight loss. the patient is placed prone and the buttocks and However, in general, this massive weight loss pa- flanks are treated first. The excess tissue is resected tient is not common. Traditional abdominoplasty and closed without tension or significant undermin- procedures have been described elsewhere.11–16 Two closed suction drains are placed in the mons ing. The patient is then placed supine and the ab- pubis region through separate stab incisions. They dominal component is treated. The patient is flexed are removed once the total fluid is less than 30 5 to 10 degrees for final excision and closure of the cc/24-hour period, usually within 1 week. The lower transverse abdomen. The postsurgical care is patient is encouraged to ambulate the first night similar to that described earlier, with the exception of surgery and is to wear an abdominal binder for that four closed suction drains are placed. Two drain 3 to 6 weeks (Fig. 2). the buttock and flank region and two drain the ab- dominal region. These drains will often be kept in Type II: Fleur-de-Lis Abdominoplasty for 2 to 3 weeks (Fig.
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