Body contouring
Assessment of the body contouring patient
History
 weight changes/ ideal weight
 eating disorders
 obstetric history and future babies
 previous abdo surgery
 general medical, smoking
Examination
 fully undressed
 record height, weight
 circumference of pertinent body parts
 from behind- spinal curvature assymmetries, buttocks, fat rolls
 from sides and in front
 look for skin excess, skin laxity, fat distribution, abdominal scars
 pinch skin between fingers to determine fat amount and therefore suitability to
liposuction
NB
 the abdomen, hips, and subtrochanteric areas should have a pinch thickness of > 3 cm
in order for the patient to benefit from liposuction.
 areas of normally little fat like ankles and calves, need at least 2cm of fat on pinch
test to be of benefit
 -skin laxity test by lifting up the area of concern and seeing what happens to the
wrinkles (the perceived fat excess may in fat just be skin laxity)
FIG. 4A + B. Lifting skin
and subcutaneous tissues
over the hip area reduces
trochanteric fullness, lifts
the lower buttock, and
eliminates surface
irregularities by skin
tightening. Ability to lift the
skin 8–10 cm in this area
and produce the illustrated
visual changes indicates that
the patient will benefit from
an outer thigh lift.
Procedures
 Liposuction is used to correct the majority of contour problems and surgery is
seen as an adjunct. Surgery is indicated primarily for:
1. Skin laxity without significant fat deposits
2. Excessive skin laxity and cellulite, or buttock ptosis
Surgical sequence

consider postbariatric body-contouring surgery after at least 15 to 18 months or when
their weight loss has plateaued for 3 to 6 months.
1. Central body lift and suction of flanks and thighs;
2. 3 to 6 months later: medial thigh lift and brachioplasty;
3. 3 to 6 months later: breast surgery (reduction/ mastopexy), with trunk liposuction if
needed; and
4. 3 to 6 months later: facial rejuvenation.
Thigh Lifts
 2 groups of patients
1. those with classic lipodystrophy who have generous fat deposits on the
trunk, thighs, and buttocks and who are disproportionately broader in the
hips than in the rest of the body
2. those with generalized skin flaccidity in the medial and lateral thighs after
massive weight loss.
2. According to Regnault, overweight patients showing a firm adiposity are not
good candidates for surgery. The amount of tissue which can be removed safely is
relatively small and the result is poor. . . . Firm adiposity may be accepted only in
special cases, such as patients with trochanteric adiposity, where localized surgery
is performed.
3. Grazer’s classification

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


Type 1: medial thigh excess – SAL if good skin turgor, otherwise skin reduction
Type 2: saddle bag trochanteric bulge (ecto and mesomorphs) – SAL
Type 3: Saddle bag + additional bulge superiorly – SAL
Type 4: Like type 3 with deepened midgluteal depression – SAL
Type 5: Typical obesity pattern (endomorphs) – SAL or combined with reduction
Type 6: traumatic or congenital – SAL surgery
Type 7: Sagging and wrinkling due to aging – autologous fat to wrinkling and
liposuction

The pattern of deformity determines the specific technique to be used, whether
semicircular, circular, longitudinal, or a combination of these.
Many medial thigh lift techniques have been proposed over the years, but
conventional (Pitanguy) techniques are prone to wide scars that migrate outside of
swimsuit lines, vulvar distortion, and early relapse.
The fascial anchoring technique(superficial fascial system) of Lockwood’s has
reduced the frequency of these complications significantly.
His modification consists of
1. suction lipectomy in the upper inner thigh
2. excision of a crescent of redundant skin
3. anchoring of the inferior thigh flap to the deep layer of the superficial
perineal fascia (Colles’) without undermining or deepithelialization of the
flaps.



Lockwood Lower Body Lift 1 (1993)
Preferred where patient has had previous abdominoplasty and a moderate to severe
medial thigh problem.
Operation
-prep, drape, infiltrate, liposuck as req'd
Preoperative marking for combined inner and
outer thigh lift. Reference line (line of final
closure) is thick black line. Thin black lines
represent the expected upper and lower
resection lines. Where the reference line and
resection lines overlap, resection lines are
white. Short vertical lines outline the bathing
suit. Long vertical marks drawn at the anterior
and posterior midlines and the left and right
midaxillary lines to aid in symmetry of
closure. A: Frontal view. The lower transverse
pubic line is 5–7 cm from the anterior vulvar
commissure when the skin is put on moderate
upward stretch. The upper transverse line in
the hypogastrium is the expected superior
limit of resection. B: Note the Burow’s
triangle excision at lower mid line to help
reduce discrepancy between lengths of upper
and lower lines. C: Most of skin resection will
be below the reference line. D: Reference line
and upper resection line are identical in the
groin. The line of excision and the reference
line end anterior to the buttocks fold so that
subcutaneous
fascia
to,
scar isfat
notand
visible
fromdown
behind.
-incision is carried through the superficial layer of
but not through, the deep subcutaneous layer of fat and fascia (Fig. 21). The deep
subcutaneous layer is characterized by a darker, more orange fat and a looser, lamellar
arrangement of fascial elements
FIG. 21. Incising the superior limit of
resection to the deep layer of superficial fascia
over buttock and flank. The depth of the
incision over the anterolateral abdomen is to
the filmy innominate fascia just superficial to
external oblique fascia. Although drawing
shows medial thighs together, thighs should
be held in abduction in order to reduce lateral
skin tension (see Fig. 22).
-Once the level of dissection is established, a flap is undermined in a caudal direction
extending over the buttocks area, the iliac area, and the groin and anterior thigh.
Dissection proceeds at least as far as the planned line of inferior resection. Over the
lateral thigh, undermining may extend beyond the area of the greater trochanter.
-the deep layer is several centimeters thick in the posterolateral area, but is rudimentary
in the anterolateral area, and, for practical purposes, is absent over the external oblique
fascia.
-The flap is pulled in a cephalic direction, and a decision is made regarding how much of
the flap should be excised
FIG. 22. Flap is pulled in a superior
direction, divided into segments, and held
in place with penetrating towel clips while
skin and subcutaneous tissues are excised.
Usually the entire amount of the premarked area is removed. Additional flap mobility can
be obtained by dissecting over the lower buttock and upper thigh distal to the greater
trochanter, but as the extent of flap undermining increases, so does the incidence of
postoperative seroma formation.
-closure in layers
-patient should then be turned to the right lateral decubitus position and the left side is
treated in an identical fashion.symmetrical resection, tension etc
-next the medial thigh lift is done
FIG. 23. Patient positioning for medial thigh lift
and excision of pubic-hypogastric skin segment.
The knees are shoulder-width apart, and the hips
are flexed 30 degrees.
-prep, drape, infusion
- groin incision is begun along the groin crease marking (most cephalic portion of
specimen to be excised) and is carried up to the symphysis pubis and then laterally to join
the lateral excision. In the groin, the depth of incision is to the fascia lata in the region
between the ischial tuberosity and the symphysis pubis. The depth of incision becomes
more superficial through the fat over the femoral triangle in order to leave lymphatics
intact. As the incision proceeds laterally, its depth is to the innominate fascia just
superficial to the external oblique aponeurosis
FIG. 24. Dissection of the
medial thigh and groin
flap. Note the exposure of
the muscle fascia in the
area between the ischial
tuberosity and the
symphysis pubis. The flap
over femoral triangle is
thinner, preserving
lymphatics and the
external pudendal vessels.
-Undermining of the flap is carried out in a caudal direction at the previously described
levels of dissection. With the thighs slightly abducted and the knees flexed at 30 degrees,
the skin flap of the upper medial thigh and groin area is put under moderate tension and
excised.
-closure- superficial fascial systemClosure in the groin is accomplished by suturing the
superficial fascial system of the flap to the Colles fascia along the pubic ramus between
the ischium and pubis.
FIG. 25. Deep sutures in the Colles fascia at
the upper wound edge and in the superficial
fascial system (SFS) at the lower wound edge.
Sutures over the femoral triangle are in SFS at
both the upper and the lower wound edges.
All sutures are placed before tying.
-The deep sutures take all tension off the skin closure and prevent downward migration of
the scar and eversion or distortion of the labia majora.
Lockwood Lower Body Lift 2(1995)
Medial Thigh Lift (Lockwood)
Skin design (Green = liposuction)
Combined with anchoring to Colles fascia
Aftercare
- 2–3 nights in the hospital. They are maintained in a thighs-abducted position with
pillows between the knees and gradually ambulated starting the morning after
surgery.
-
Although the patient may be unable to sit comfortably for approximately one week,
voiding and bowel movements can be performed in a semi-standing position. Return
to sedentary work activities is usually not until two weeks after surgery and sports are
prohibited for six weeks.
Complications
As for abdominoplasty but include specifically
1. wound complications – medial thigh lifts highest of all the body contouring
procedures (30-35%)
2. seroma – going too deep with groin excision
3. scar migration out of swimsuit lines
4. vulval distortion
5. contour irregularities
Brachioplasty
Goal of brachioplasty is to eliminate tissue redundancy and reduce circumference of the
arm.
Lockwood believes upper arm flabbiness is the direct result of
1) loosening of the connections of the arm superficial fascial system to the axillary
fascia
2) relaxation of the axillary fascia itself, with age, weight fluctuations, and
gravitational pull
resulting in significant ptosis of the posteromedial arm. He proposes reanchoring of the
posteromedial arm soft tissues to axillary fascia
Teimourian(1998) classifies upper arm deformities into four groups:
1) Minimal to moderate fat and minimal skin laxity – treat with liposuction.
2) Generalized fat with moderate skin laxity - liposuction but may require excisional
techniques.
3) Generalized obesity with extensive skin laxity - These patients benefit from a
combination of circumferential liposuction and skin resection.
4) Minimal subcutaneous fat and extensive skin laxity - These patients are best
treated with excisional techniques.
To hide the scars, most recommend direct elliptical excision of the redundant tissue and
place the incision medially along a line 2cm distal to the axillary crease(with or without
z-plasties) to the medial epicondyle.
Lockwood incision
Line A=Line B+Line C
Complications
1. highly visible scars
2. persistent vascular congestion,
3. edema and lymphedema from excessive skin
4. resection
5. wound necrosis -tension on closure,
6. cutaneousnerve injury from a dissection that strayed below
7. the superficial fascia.
References
A "bicycle-handlebar" type of incision for primary and secondary abdominoplasty.
Aesthetic Plast Surg 1995 Jul-Aug;19(4):307-20
Baroudi R
The authors register a revision of the literature regarding the types of low transversal
pubic incisions used in abdominoplasty. Since 1987, the traditional open W-type incision
changed to a new type called the bicycle handlebar. In this procedure, the pubic segment
remains in a lower line at the level of the pubic hair, while the lateral limbs are in a high
position. The anterior superior iliac spine is used as reference. Different types of
procedures where the umbilical skin hole reaches the pubic incision are described and
illustrated. This procedure is also used in secondary abdominoplasty. In all cases, the
incision's new position should remain hidden under a bathing suit.
Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for
liposuction.
J Dermatol Surg Oncol 1990 Mar;16(3):248-63
Klein JA
The tumescent technique for local anesthesia permits regional local anesthesia of the skin
and subcutaneous tissues by direct infiltration. The tumescent technique uses large
volumes of a dilute anesthetic solution to produce swelling and firmness of targeted
areas. This investigation examines the absorption pharmacokinetics of dilute solutions of
lidocaine (0.1% or 0.05%) and epinephrine (1:1,000,000) in physiologic saline following
infiltration into subcutaneous fat of liposuction surgery patients. Plasma lidocaine
concentrations were measured repeatedly over more than 24 hours following the
infiltration. Peak plasma lidocaine levels occurred 12-14 hours after beginning the
infiltration. Clinical local anesthesia is apparent for up to 18 hours, obviating the need for
postoperative analgesia. Dilution of lidocaine diminishes and delays the peak plasma
lidocaine concentrations, thereby reducing potential toxicity. Liposuction reduces the
total amount of lidocaine absorbed systemically, but does not dramatically reduce peak
plasma lidocaine levels. A safe upper limit for lidocaine dosage using the tumescent
technique is estimated to be 35 mg/kg. Infiltrating a large volume of dilute epinephrine
assures diffusion throughout the entire targeted area while avoiding tachycardia and
hypertension. The associated vasoconstriction is so complete that there is virtually no
blood loss with liposuction. The tumescent technique can be used with general anesthesia
or IV sedation. However, with appropriate instrumentation and surgical method, the
tumescent technique permits liposuction of large volumes of fat totally by local
anesthesia, without IV sedation or narcotic analgesia.
High-lateral-tension abdominoplasty with superficial fascial system suspension [see
comments]
Plast Reconstr Surg 1995 Sep;96(3):603-15
Lockwood T
Modern abdominoplasty techniques were developed in the 1960s. The advent of
liposuction has reduced the need for classic abdominoplasty and allowed more aesthetic
sculpting of the entire trunk. However, the combination of significant truncal liposuction
and classic abdominoplasty is not recommended due to the increased risk of
complications. Although the surgical principles of classic abdominoplasty certainly have
stood the test of time, they are based on two theoretical assumptions that may be proved
to be inaccurate. The first assumption is that wide direct undermining to costal margins is
essential for abdominal flap advancement. In fact, discontinuous undermining allows
effective loosening of the abdominal flap while preserving vascular perforators. The
second inaccurate assumption is that with aging and weight fluctuations (including
pregnancy), abdominal skin relaxation occurs primarily in the vertical direction from the
xiphoid to the pubis. This is true in the lower abdomen, but in most patients a strong
superficial fascial system adherence to the linea alba in the epigastrium limits vertical
descent. Epigastric laxity frequently results from a progressive horizontal loosening due
to relaxation of the tissue along the lateral trunk. Experience with the lower-body lift
procedure has shown that significant lateral truncal skin resection results in epigastric
tightening. In these patients, the ideal abdominoplasty pattern would resect as much or
more laterally than centrally, leading to more natural abdominal contours. Fifty patients
who underwent high-lateral-tension abdominoplasty with and without significant truncal
liposuction and other aesthetic procedures were followed for 4 to 16 months. The primary
indication for surgery was moderate to severe laxity of abdominal skin and muscle with
or without truncal fat deposits. Complication rates were equal to or less than those of
historical controls and did not increase with significant adjunctive liposuction. The key
technical elements of this procedure include direct undermining limited to the
paramedian area, discontinuous undermining to costal margins and flanks as needed, skin
resection pattern with significant lateral resection and highest-tension wound closure
placed laterally, superficial fascial system repair with permanent sutures along the entire
incision, and liberal use of adjunctive liposuction in the upper abdomen and the lateral
and posterior trunk.
Tumescent liposuction. A surgeon's perspective.
Clin Plast Surg 1996 Oct;23(4):633-41; discussion 642-5
Pitman GH
The tumescent technique consists of injection of large amounts of dilute lidocaine and
epinephrine into the subcutaneous fat prior to performing liposuction. This preinjection
provides local anesthesia and reduction in postoperative pain. Blood loss, bruising, and
swelling are significantly reduced. The large volume of injectate is a complete fluid
replacement, eliminating the need for intravenous fluid support. In the authors'
experience, patients are most comfortable when the tumescent technique is combined
with monitored intravenous sedation.