Total Body Contouring: How I do it?

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With the advent of laparoscopy, bariatric surgery has increased at a logarithmic scale encouraged by the safety of new procedures such as Roux-Y or single anastomosis gastric bypass, and vertical sleeve gastrectomy. As surgeons got better at performing these operations, many patients have found themselves reaching an ideal weight. Furthermore, many patients have done the procedure seeking improved appearance and self esteem rather than to obtain cure from co-morbid conditions.

While patient satisfaction increased initially the more they lost weight, the degree of skin laxity that resulted rom losing the excess fat has resulted in greater dissatisfaction and social isolation. Aesthetic surgery has existed for many years popularised by greater demand for abdominoplasty and mastopexy following childbirth in what is often referred to as mommy make over, and to a lesser extent by demand for anti-aging procedures for advanced age such as face lift. In th last twenty years, there has been a move in aesthetic surgery towards minimally invasive procedures as well and office procedures. Use of implants in the breast and buttock have become popular and augmentation using autologous fat or synthetic filling material has also become popular in the face and other areas of the body. In addition, liposuction and Lipo-filling have been combined to create the procedure often referred to as lipo-sculpture in which the patient is subjected to key hole surgery to harvest fat from undesired areas and to inject them into areas that need to be augmented..

Massive weight loss results in total body laxity in which the skin creates rolls and saddle appearance in different body parts. The challenge faced was how to address two problems: the first is how to get rid of all the excess skin and the second is how to rebuild areas considered an important part of a gender appropriate silhouette such as the female breast and buttock or a male broad chest and recreate them using autologous tissue or synthetic material.

The term Body Lift Surgery became a reality in the early 1990’s. Body lift surgery started as a three staged comprehensive stages: It starts by a lower body lift or torsoplasty in which a belt in lipectomized circumferentially creating a 360 degrees scar along the lower body instead of the known traditional abdominoplasty. Torsoplasty addressed not only the abdomen creating a waste line but also addressed the buttocks and lower back especially if a dermofat flap is created based on the superior gluteal artery perforators and is directed cephalad into the buttock prominence. Torsoplasty can be modified to correct lateral thigh laxity and the pubis through a monsoplasty.

The second stage is known as the upper body lift which differs between male and female as it addresses gynecomastia or breast sagging. However the upper body lift focuses on the upper back rolls and the epigastric laxity which is difficult to address by the abdominoplasty component of the lower body lift. A wise pattern mastopexy is used to address the lateral upper back rolls with a posterior extension that can be extended vertically to join the arm incision. Medially the mastopexy is crossed over the sternum to address the epigastric laxity via a reverse abdominoplasty incision. Th latter will become the new inframammary crease.

The final stage addresses the inner thigh laxity and if often very difficult to treat without a visible longitudinal or spiral scar.

Over the past ten years, the comprehensive plan used to be done in three stages has become popular as a single stage and is termed the total body lift. To reduce morbidity, resection has been reduced to minimum and the procedure has been modified to include the creation of de-epithelialized dermofat flaps rather than full thickness excision of excess skin. The superficial flaps were anchored to the deep muscle fascia to reduce tension on incisions and prevent further decent.

Many patients cannot afford staging the procedure due to financial reasons and time factor limitation’ hence, a greater number of patients seek single stage total body lift surgery in which retouch procedures on outpatient basis are performed later to address unsightly scars.

In my experience with 41 single stage total body lift surgery including 4 revisional cases and 20 multistage lifts including 6 revisional procedures with a total number of surgeries reaching 383 proceduresThere is no significant difference in terms of complications between single versus multistage procedures whether in wound dehiscence approaching 60% , or in patient satisfaction approaching 87% by one year. However, we have reserved the single stage procedure for patients who are under 45 years of age, have a body mass index below 30 and are in good health.

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