CHAPTER 66 ABDOMINOPLASTY AND

BELT LIPECTOMY
AL S. ALY AND EMIL J. KOHAN

INTRODUCTION
Body conrouring of the lower trunk region is an integral part of
the plastic !lll'gCOll's armamentarium. The lower trunk is a circumferential st.rllct:l:lre that begins at the inferior border of the
breasts and ends at the pelvic rim. Although this is a convenient
unit, it is difficult to separate from surrounding structures wch
as the thighs and the thorax. Deformities in the lower truncal
.region are variable in nature and require different approaches
for their treatment.
advances in bariatric surgery have
resulted in a large population of weight loss patients, which has
led to an emphasis on the evaluation and treatment of lower
truncal contour deformities. This chapter will focus on excisional procedures, with or without liposuction, in the treatment
of lower truncal deformities. Problems that can be ameliorated
by liposuction techniques alone are covered in Chapter 65.

PATIENT PRESENTATION
Patients with lower truncal complaints demonstrate a variety
of deformities on a continuum from minimal excess fat to circumferential fat and skin excess accompanied by abdominal
laxity of the fascia1 (Table 66.1).
Weight is the first important factor that affects the presentation of patients with lower truncal deformities. kause
absolute weights can be misleading, body mass index (BMI),
which relates weight to height, is the most commonly used
parameter. It is calculab:d in the following manner:

Body mass index =weight in kilogramsl(height in mettM)2

Body mass index =weight in pounds/(height in inches)1
x703

Patients who present for lower truncal contouring span the

range of BMI from normal to obese.
The upper limit of normal BMI is 25; 26 to 30 is considered overweight; and 30 and above is considered obese. A
variety of surgical approaches are required to treat patients in
different BMI ranges.
A second factor that affects the presentation of patients
is the fat deposition pattern, which is genetically controlled.
Women typically deposit fat in the infraumbilical abdomen,
lateral thighs, hips, and medial thighs. Men tend to deposit fat
in the flanks, the infraumbilical abdomen, and intra-abdominally.1 Although these patterns are common, dramatically difkrent patterns of fat deposition are often present even within
the same gender.
The quality of the skin-fat envelope is a third factor to
evaluate. Some women who have had one or more pregnancies

TAILE 66.1
FACTORS THAT AFFECT THE PRESENTATION OF
THE PATIENT REQUESTING LOWER TRUNCAL
CONTOURING
Body mass index at presentation
Fat deposition pattern
Quality of the skin-fat envelope

688

may present with abdominal skin laxity and stretch marks.

The skin in those patients is stretched beyond its ability to
rebound back to its original elasticity. A similar process occurs
with massive weight gain and subsequent weight loss in which
the skin is overexpanded, leading to a skin-fat envelope that
is loose and indastic.

HBTORYOFBODYCONTOuruNG
Body contouring procedures early in the twentieth century
consisted of dermatolipectomies of hanging abdominal panniculi. In these procedures, excess skin and underlying fat were
removed to rid the patient of hanging tissues with minimal
attention to aesthetic principles. In the second half of the century, advances in abdominoplasty techniques led to improved
scar placement, abdominal wall plication, and umbilical transposition. In the 1980s, liposuction was introduced, and it
became a tremendous tool in the armamentarium of the plastic surgeon for affecting body contour, replacing a number of
excisional procedures. Currently, plastic surgeons routinely
use both excisional and liposuction techniques, alone and in
combination, to improve abdominal contour.

RELEVANT ANATOMY
Fat in the lower trunk is organized into superficial and deep
layers separated by the superficial fascial system, which pervades the entire body. Anteriorly the superficial fascial system
is rekrred to as Scarpa's fascia {Figure 66.1).
The blood supply of the abdominal skin and fat is important to understand. The skin overlying the rectus muscles is
primarily supplied by arteries that originate from the superior
and inkrior epigastric vessels that run within the rectus muscles. Branches from these vessels perforate the overlying rectus
fascia and traverse through the two layers of abdominal fat,
finally reaching the skin. This direct blood supply of abdominal skin is interrupted during the elevation of the abdominal
flap in a traditional abdominoplasty. A secondary blood supply is derived from lateral intercostal, subcostal, and lumbar
vessels that course anteriorly in the fat superficial to Scarpa's
fascia (Figure 66.2). These vessels are the only remaining
blood supply of central abdominal skin after traditional flap
elevation. Intem:1ption of these vessds by scars, such as cholecystectomy, or chevron scars, can lead to necrosis of tissues
inferomedial to the scar. The superficial epigastric vessels
supply blood to the skin of the lower abdomen but are also
divided during abdominoplasty procedures.
The lower trunk has fascial attachments between the skin
and the underlying muscle fascia that act as anchoring points
or zones of adherence' (Figure 66.3). These zones of adherence restrict the overlying skin from moving during the processes of aging and/or weight fluctuations. Posteriorly, the
midline has a zone of adherence that overlies the spine. The
anterior midline of the abdomen has a less well-defined zone
of adherence. Three horizontal zones of adherence are located
in the inkrior aspects of the lower trunk; one is located at
the inguinal region bilaterally and extends toward the anterior
superior iliac spine (ASIS). Another is located just above the
mons pubis and is variable in its adherence properties. The
third is located bilaterally between the hip and lateral thigh fat

Chapter 66: .Abdominoplasty and Belt Lipectomy

689

Skin
Superficial fat layer
fascial system
(Scarpa fascia anteriorly)
Deep muscular fascia
Muscle

FIGURE 66.2. The abdominal wall vasculature. a, artery.

FIGURE 66.1. Organization of fat and fu<:ia

in the anterior abdomen.

wall laxity and minimal abdominal skin excess limited to the

infraumbilical region are good candidates for mini-abdominoplasty. Patients who present with abdominal wall laxity
of both the infra- and supraumbilical regions and generalized skin excess limited to the anterior aspects of the lower
trunk are good candidates for a full abdominoplasty. As the
deformities increase in magnitude and involve the lateral and
posterior aspects of the lower trunk, circumferential truncal
liposuction and/or dermatolipectomies become necessary. The
indications, goals, and a general description of each procedure
are given below.
Lower truncal body contouring procedures are often long
and extensive in nature. Medical problems such as heart disease, diabetes, and lung disease must be under control before
surgery is contemplated. Cigarette smoking also has a deleterious effect on blood supply and, when combined with the
already compromised vascular supply of the abdominal skin,
can lead to significant tissue necrosis. Many plastic surgeons
avoid performing abdominoplasty on active smokers.

MINI-ABDOMINOPLASTY
Women who present with abdominal wall laxity restricted
to the infraumbilical region that is associated with minimal
infraumbilical skin and fat excess are candidates for a miniabdominoplasty. Physical examination of the abdomen in the
supine position will demonstrate infraumbilical rectlls diastasis, which can be confirmed by the "diver's test" (Figure 66.4).

Strong mnes

Varlible zanee
FIGURE 66.3. Fascial zones of adherence. The zones of adherence
control the movement of tissue associated with aging and/or massive
weight loss. These fascial attacllments result in lateral descent of truncal tisaues, which rotate toward the midline.

deposits. Truncal tissues become lax due to aging, pregnancy,

and/or massive weight loss. They descend the greatest distance
laterally, caused by a combination of tissue laxity and central
tethering of the midline zones of adherence. As tissues descend
around the pelvis they also migrate centrally (see Figure 66.3).
The inguinal and mons pubis zones of adherence are responsible for holding the .6na1 position of abdominoplasty scars in
the lower truncal region. Without their effea:, the scars would
migrate cephalad, possibly above natural underwear lines.

PATIENT SELECTION
Patients who have minimal to moderate subcutaneous fat
excess and no abdominal wall laxity are good candidates
for liposuction alone. Patients who present with abdominal

FIGURE 66.4. The clu1ic "diver's test,. demonstrates how a bend at

the waist will reveal the true extent of abdominal wall laxity.

690

Pan VD:: Body Contouring

These patients are usually young women who have had

one or two pregnancies, have good sldn elasticity, and are not
They may or may not have localized fat deposIts m other areas of the trunk and lower extremity such as
the hips and lateral thighs. The goal of surgery in this patient
population is to eliminate the infraumbilical abdominal waD
laxity and the minimal skin and fat excess.

Technique (Mini-Abdominoplasty)
An incision is marked in the patient's natural suprapubic
crease and angled toward the ASIS. Often the incision can be
limited to the width of the pubic hair or just beyond its lateral
edges. Intraoperatively, the proposed incision is made and the
dissection extended to the muscle fascia. An abdominal.Bap is
elevated superiorly to the level of the umbilicus. The infraum
bilical rectus muscle diastasis is identified, and rectus fascia
plication is performed. Some surgeons prefer a single layer,
whereas others favor a two-layer plication (Figure 66.5). The
abdominal .Bap is advanced inferiorly and tailored to remove
the excess skin and underlying fat. This advancement will usually pull the umbilicus down 1 to 3 em.
The closure of this incision, as in aU subsequent incisions discussed in this chapter, is performed in multiple layers, with the
most important layer being the reapproximation of the superficial fascial system, or Scarpa's fascia.4 Permanent or long-lasting
sutures are used in this layer in an attempt to limit widening of
the scar in the long run. The authors prefer to use interrupted
monofilament absorbable sutures in the subcuticular layer to
perkctly approximate the skin with an overlying layer of medical-grade skin glue. Drains are inserted and a compression garment is used in the
period by most surgeons.
A variation of this technique can be used in patients who
have minimal lower abdominal skin excess, no upper abdominal skin excess, and both infra- and supraumbilical reaus
diastasis. To aUow access to the supraumbilical rectus diasta
sis, the base of the umbilicus can be amputated. The abdominal flap is then elevated on either side of the midline in the
supraumbilical region, and a supraumbilical rectus plication
and an infraumbilical plication are performed. The umbilical
stalk is then resutured to the plication at the appropriate level,
and the lower aspect of the abdominal .Bap is tailored appropriately. It is also possible to use a minimal-incision approach
to the supraumbilical plication by making an incision in the
superior aspect of the umbilicus and using an endoscope to
perform a dissection superior to the umbilicus that is wide

enough to allow for the desired supraumbilical plication. In

any of the mini-abdominoplasty techniques discussed, liposuction can be used to decrease the thickness of any part of the
abdominal .Bap that has not been elevated.
One of the most difficult aspects of mini-abdominoplasty is
avoiding dog-ears because of the short incision.

ABDOMINOPLASTY
Generally, abdominoplasty is indicated in patients whose laxity involves the supra and infraumbilical regions, limited to
the anterior aspects of the lower trunk. The goals of abdominoplasty depend on the presenting deformities. They include
creating a .Bat abdominal contour, eliminating abdominal wall
laxity, enhancing waist definition in some patients, and eradicating mons pubis ptosis if present.
Stretch marks are common and may be limited to the infraumbilical region or may include both the infra and supraum
bilical skin. Rectus diastasis of the entire vertical extent of the
abdomen is present in these patients, with the infraumbilical
diastasis usually more extensive because of the position of the
uterus during pregnancy. Preoperatively abdominal waD laxity
can again be detected by the "diver's test" and physical examination. Massive-weight-loss patients who reach a near-normal
BMI may also present with lower truncal excess limited to the
anterior abdomen. However, most often they present with c:irc:umferential deformities that require more extensive c:irc:um.ferential excisions.
Patients who present with excess intra-abdominal fat that
would prevent .Battening of the abdominal wall by plication
are not good candidates for abdominoplasty. The outer skin/
fat envelope of the belly always conforms to the shape of an
inner balloon whose anterior wall is made up of the abdominal muscle wall. If that wall is rendered convex in profile by
virtue of overly abundant intra-abdominal contents, then the
final profile of the belly will also be convex. Because abdominal contour .Battening is one of the major goals of surgery,
these patients are better served by weight loss prior to contemplating abdominoplastytype procedures.
By the nature of an abdominoplasty, where an ellipse of
tissue is removed from the lower abdomen, dog-ears can be
created at the edges of the ellipse, especially in patients who
already have lateral excess. Patients who present with defor
mities that extend beyond the anterior aspeas of the lower
trunk may require 1) mending the abdominoplasty exc:ision
laterally, 2) liposuction o the lateral and posterior trunk, and!
or 3) circumferential dermatolipectomy to attain the best possible c.ontour.
Some authors advocate the use of .Beur-de-lis or "T"type
excisions in which an anterior vertical wedge of tissue is
resected, as discussed later in this chapter. Generally, as circumferential lower truncal dermatolipectomy has become
more mainstream in plastic surgery because of the massiveweight-loss population, the indications for isolated abdominoplasty have narrowed.

Technique (Abdominoplasty)

FIGURE 66.5. The abdominal flap elevation and rectus fascia placation in a miDi-abdominoplasty.

The markings for an abdominoplasty are performed prior to

surgery. The proposed excision is marked in the lower abdomen. Centrally, the inferior incision line is often marked in
the natural suprapubic crease and then carried laterally. Some
surgeons utilize a "French bikini/thong pattem" in which the
lateral aspects of the proposed inferior incision are angled
toward the ASIS, while others prefer a flatter pattern, with
many variations described in the literature.5 An attempt is
made to avoid the incision beyond the ASIS, but it is more
important to avoid dog-ears. With the inferior mark in place
the patient is slightly flexed at the waist,. and the pinch technique is used to approximate the superior extent of the excision. IdeaUy, the patient should have enough excess abdominal

Chapter 66: .Abdominoplasty and Belt Lipectomy

skin to allow excision of the skin from just above the umbilicus to the suprapubic crease centtally.
In the operating room. a circumumbHical incision is made
and the umbilical stalk is dissectl:d to the deep fascia. The infe..
rior mark of the proposed abdominal skin excision is incised.
An abdominal flap is elevated superiorly, around the umbilicus,
and up to the xiphoid and costal margins (Figure 66.6). The
flap is classically elevated at the level of the underlying muscle
fascia but many plastic surgeons pre&:r to elevate the flap at
Scarpa's fascia level. lt is felt that this may reduce the rate of
seroma formation. Two theories have been invoked as to the
etiology of this reduction. The most popular is that the remaining subscarpal fat contains intact lymphatic vessels, which help
absorb fluid in the wound. The other possibility is that the fatto-fat intl:.r:face leads to better adhesion between the abdominal
flap and the underlying tissues. Neither theory has been tested
experimentally; thus, it is not currently known why this type of
elevation seems to reduce seroma formation. Wide undermining allows the greatest amount of abdominal flap advancement
at the time of flap tailoring, but it also leads to the division
of the greatest number of superior epigasttic muscle perforator vessels, leaving only the lateral intercostal, subcostal, and
lumbar vessels as the only viable blood supply of the flap. Some
surgeons pre&:r a more limited dissection above the umbilicu.s,
just to the medial edges of the rectll9 muscle fascia, to allow for
supraumbilical rectus fascia plication up to the xiphoid. The
benefit of the limited dissection is the increased number of the
perforator vessels left intact to support the blood supply of the
tailored abdominal.Bap. ln some patients, however, the limited
dissection will not allow the appropriate advancement of the
abdominal flap and may reduce the amount of tissue that may
need to be resected to create the best contour. As a general rule,
flap elevation should be restricted to just what will allow appro
priate rectus fascia plication and appropriate flap advancement.
Often it is best to limit the initial elevation and then release the
tissues incrementally to allow for appropriate contour.
After flap elevation, rectus fascia plication is performed.
Many patterns have been proposed for plication, but a vertical

FIGURE 66.6. The extent of abdominal flap ele'f'lltion and fascial

plication in a traditional abdominoplasty.

691

plication, in one or two layers, is most common. The patient

is then flexed at the waist,. and the abdominal flap is advanced
inferiorly to facilitate the process of flap tailoring. As the
abdominal flap is advanced, the surgeon can conttol where
the greatest tension will be at closure-<:entrally or laterally.
Creating the greatest amount of tension centrally is advantageous in limiting the lateral extent of the .final scar but may
lead to excessive mons pubis elevation and less waist defini
tion. Lockwood, in his uhigh-lateral-tension" approach to
abdominoplasty, espoused placing the greatest tension on the
lateral aspects of the abdominal closure.' This is based on the
fact that the greatest laxity in the lower trunk occurs laterally.
However, the increased lateral tension often necessitates extensions of the scar laterally to eliminate dog-ears. This approach
can lead to better waist definition and an improvement in anterior thigh contour, but often necessitates leaving behind the
original umbilical defect as a closed vertical scar. Thus, placement of tension, oenttally or laterally, in abdominoplasty surgery should depend on the patients' differing needs and desires.
With the tailored abdominal.Bap approximated to the lower
incision, the position of the umbilicus is noted on the flap and a
nco-umbilicus is created. The stalk of the umbilicus is brought
through the abdominal flap using one of various incisions advocated by different authors. The authors prefer a simple vertical
incision, no defating of the underlying soft tissues, and uthreepoint fixation" sutures at 3, 6, and 9 o'clock. Whatever method
the surgeon chooses, the umbilicus should be fairly small, vertically oriented, superiorly hooded, have a slight hollow around
it,. and contain the scar on the inside of the cylindrical structure.
The closure of the abdominal incision is accomplished in
multiple layers, with the most important layer being the superficial .fascial system. or the Scarpa fascia:' This is accomplished
with permanent or long-lasting suture, which, it is hoped,
reduces the significant tension that can be generated at closure,
prevents acute wound dehiscence, and reduces scar widening in
the long run. The authors prefer to use interrupted monofilament absorbable suture in the subcuticular layer to perfectly
approximate skin. An overlying layer of medical-grade skin glue
is then applied. Drains are placed. A compression garment is
used in the postoperative period by most surgeons. Figure 66.7

FIGURE 66.7. Traditional abdominoplasty. A young woman who

presented after two pregnancies desiring an improvement in her
abdominal contour. She complained of loose abdominal skin and protrusion of her belly, despite a regular exercise program. Her abdominal wall laxity was more prominent in the infraumbilical region,
consistent with her pregnancies. She underwent an abdominoplasty
using a French bikini pattern of excision and ill shown 6 months after
surgery. Because her dc:formitics were limited to the anterior abdomen
and she was within the normal weight range, there was no need to
combine othc:.r procedu.n:s with hc:.r traditional abdominoplasty.

692

Pan Vll: Body Contouriag

shows an example of abdomiooplasty in an ideal patient. Many

surgeons including the authors, use quilting sutures in an
tt, decreaae the rate of aeromas by reducing dead space
between the flap and the underlying muscle wal1.7
Combining liposuction with traditional abdominoplasty
techniques is controversial and is often left to the surgec;m's
of the. abdouunal
experience and philosophy.1
flap in nonundermined areas .1s generally constdered
Liposuction oE undermined regtons oE the Oap can potentially
lead to flap necrosis because oE the compounding effect oE liposuction on the already compromised blood supply. Certa.!nly,
liposuction of areas outside the bounds of the
abdominal flap, such as the hip region and the lateral
flap
can be performed without concern
Studies have demonstrated that oomblDlDg liposuction With
abdominoplasty, whether the liposuction is performed on the
elevated Sap or the non-Oap contiguous areas, may lead to
inaeascd risk o seroma formation.'

CIRCUMFERENTIAL LOWER
TRUNCAL DERMATOLIPECTOMY
OR CIRUMFERENTIAL LIPECTOMY
to
As a basic principle of plastic surgery, it is always
reconstruct an anatomic unit in its entirety when poss1ble.
Abdominoplasty treats deformities limited to the
lower trunk. When defonnities involve more than the antenor
abdomen, other procedures are required to adequatdy
all the deformities. If the surrounding areas such as the thighs,
buttocks hips and lower back regions contain excess fat
without ptosis: liposuction can be added to abdomiooplasty
to create a better overall lower truncal contour. However, for
of
laxity an.d/or
patients who present with
those areas, circumferentiallipcctormes are required.
weight-loss patients make up the largest group of such
who require circumferential excisional procedures. They will
continue to grow in numbers, given that obesity has been recognized as a major health-care issue in the United States. and
the world. In addition, women who gain moderate weight,
not
30 to 40 lb, usually with childbirth and/or aging, and
able to lose the weight through normal means of exerose and
nutritional changes may be candidates. They often present
with a desire to eliminate anterior abdominal excess, but careful examination wiD demonstrate circumferential excess that is
best treatx:d with a circumferential lipectomy. Finally, normalweight-range patients who desire remarkable improvements in
their lower truncal contour may be candidates as well.
There is a variety of names used to describe circumferential
lower truncal dermatolipectomies: extended or circumferential abdominoplasty, central body lift, tarsoplasty, and body
lift. The authors prefer to divide these different variations into
two general categories based on what they treat and what they
accomplish. The fint category is made up of
procedures that mainly treat the lower trunc;al un1t, whkh
will be referred to as belt lipectomies, u espoused by Aly and
Cram. to,n The second category includes procedures that treat
the lower trunk and thighs as unit, which will be referred
to as lower body lifts, as aponsed by Loc::kwood.17u
procedure has its benefits and drawbacks. Both should be m
the armamentarium of the plastic surgeon who performs body
contouring surgery. The choice of procedure is based on the
.
patient's desires and presenting deformities.
Both procedures eliminate a circumferential wedge of tissue from the lower trunk. A belt lipectomy removes a wedge
that is more superiorly located than that removed in a lower
is
body lift (Figure 66.8). The final scar after belt
located above the widest aspect of the bony pelVIc nm, at
the junction between the lower back and buttocks,
th1s
may be visible outside of brief undergaz:ments.
allows cinching at waist level, more wa1st definition can be

FIGURE 66.8. Belt lipectomy and lower body lift. Two patients who
underwent a belt lipectomy tlbove and a lower body lift below. In a
belt lipectomy the scar is piacfld at the junction between the buttocks
and lower back which helps to frame the natural buttocks contour
narrowing. In a lower body lift the &ear
and accentuall:
m
placed!
the buttocks proper and is overall more
its latx:ral and pota:rior aspects. The combmatton of elirmnatmg tlu:
pelvic zones of adherence and the lower position of the excised wedge
al1owt the lower body lift to elevate the thighs more eflec:tively than
in a belt lipectOmy.

created by this technique. This is often desired in women but

may be less desirable in men. Pelvic rim zones of adherence
help to prevent the descent of lower truncal tissues as well as
inhibit elevation of lower extremity tissues (see Ftgure 66.4).
These fascial attachments are interrupted but not completely
and they prevent
eliminated during a belt
sive lifting of lower thigh tissues. Thus, overall, a belt lipectomy is capable of creating excellent lower truncal contour by
z:om
the
accentuating waist definition,
the lower back, and lifting the lateral thighs, but It has hrmted
capability in lifting the distal thighs.
A lower body lift treat! the lower trunk and thighs as a unit.
The pelvic rim zones of adherence are
as completely as possible, which allows 1nfer1or thigh tissues,
down to knee level, to be lifted. This leads to a significant
reduction in anterior and lateral thigh laxity. The final scar
is located within the buttocks proper, which can blunt waist
men but
definition (see Figure 66.8). This is often
may be less so in women. The resultant scar 1s easily covered
by normal undergarments, and the thighs are dramatical.ly
lift
improved down to the knee levd. However, a lower
is less efficient in creating waist definition and can result m less
than ideal buttocks definition because the scar does not respect
buttocks. .
the natmal junction between the lower
The majority of patients undergo10g a orcumferent1al
p.reKilt
lipectomy are massive-weight-loss patic:nts.
with a hanging panniculus, mons pubis ptosiS, an
waist lower back rolls, hip-fat excess, lateral thigh ptosis,
types of buttocks deformity. 1}:te goals of surgery
and
include elimination of the hanging panniculus, mons pub1s
elevation, creation of waist definition (especially in women),
decrease or elimination of lawer back: rolls, lifting of the outer
thighs, and increase in buttocks definition.
---

Techniques (Truncal Dermatolipectomy)

Although a circumferential lipectomy is a combination of an

abdominoplasty, a lateral thigh lift, and a buttocks lift, the
tJ_tem. The
procedure is more complex than simJ?lY
lower trunk of patients who present w1th arcu.mferentlal excess
has the shape of an inverted cone (Figure 66..9). A wedge of tissue is marked for proposed excision around the lower trunk.
The wedge brings a narrower part of the cone down to
level of a wider part of the cone located at, or near, the pelvic

Chapter 66: .Abdominoplasty and Belt Lipectomy

693

FIGURE 66.9. Truncal deformity in weight loss patients. In the massive-weight-loss patient, the ptetenting lower truncal deformity is in the
shape of an inverted cone. In a citcumlerentiallipectomy a wedge of tissue ill removed. The diameter of the wedge at its superior edge is smaller
than its diameter at the inferior edge.

rim (see Figure 66.9). As previously noted. the wedge to be

excised is generally located in a more superior position in belt
lipectomy when compared with the wedge to be excised in a
lower body lift. In either method. the anterior aspect of the
wedge is wider (in vertical distance) than the latl!ral or postl!rior aspects. The latl!ral resection is the ne:xt widest aspect so
as to reverse the lateral truncal descent (Figure 66.10).

FIGURE 66.10. A 31-year-old woman presented alter an 80-lb

weight loss to reach a body mass index of 27.31. (Above) Shown with
preoperative markings fur a ciraunfe.rential belt lipectomy. Note that
the excision laterally ill generally aggressive to counteract the lateral
descent that occurs with maS&ive weight loss and/or aging. Vertical
marb are placed along the ciraunfereDCe of the proposed resection
to help alignment at closure. Surrounding areas of the thigh are also
marked for liposuction. (Below) The patient 6 months after surgery,
demonstrating dramatic waist narrowing, elimination of the panniculus and lower bad rolls, and improved buttoclcs definition.

Because of the circumferential nature of the procedure,

more than one position is necessary to accomplish the resec
tion in the operating room. No matter what sequence is preferred by a particular surgeon, the abdominal part of the
procedure is performed in the supine position. Surgeons who
advocate prone/supine or supine/prone positioning cite the
single tum required in the operating room and the ability to
control buttock symmetry as their reasons for choosing the
"two-position" sequences. The supine/lateralllateral or lateral/lateral/supine proponents prefer these "three-position"
sequences because they allow for easier lateral thigh liposuction and hip abduction in the lateral decubitus position, which
facilitates maximal lateral resections. All body positions have
potential complications associated with them, especially if the
patient is to be maintained in those positions for extended
periods of time. The surgeon should be familiar with those
complications and how to prevent them.
The extent of anterior flap elevation in the abdominoplasty
portion of the circumferential procedure is based on surgeon
preference. The lateral elevation is usually more extensive
than in an abdominoplasty, which compromises the remaining
blood supply to the abdominal flap to a greater e:xb!nt. Thus,
it is important that an effort is made to preserve as many lat
eral feeding vessels as possible. The plication of the rectus fascia is similar to abdominoplasty plication except that it may
sometimes require plication distances that far exceed the usual
S to 7 em encountl!red with routine abdominoplasty. Closure
of the circumferential wound should include reapproximation
of the superficial fascial system with permanent and/or longlasting suture.
During the lateral and posterior resection, some surgeons
prefer to incise the superior marks first and dissect an inferior
skin-fat flap, whereas others prefer the opposite. Some surgeons incise both the superior and inferior extents and excise
a predetermined marked amount. The authors prefer to incise
the superior side first and tailor the inferior-based flap based
on tension and creation of the appropriate contour.

694

Pan VD:: Body Contouring

Some surgeons choose to combine extensive liposuction of

the surrounding regions, such as the lower back, the upper
back. and thighs, whe.n:as others limit their liposuction to the
lateral thighs. A major diffi:rence between belt lipeaomy and
a lower body lift is in the treatment of the pelvic rim's zones of
adherence. In belt lipectomy, these attachments are disrupted
by liposuction of the lateral thighs, but they are not completely
eliminated. In a lower body lift, discontinuous undermining of
the anterior and lateral thighs, down to knee level, intentionally destroys the pelvic rim zones of adherence. lhis allows
significant thigh elevation.11
The results attained from circumferential lipectomies
depend, to a great extent, on the presentation of the patient
and the type of procedure chosen (see Figure 66.10). As a general rule, the lower B.Mis at presentation lead to better aesthetic results and lower rates of c::omplic:ations.1011

COMPLICATIONS
Table 66.21ists c::omplications that can occur with lower trun
cal c::ontouring procedures.14 Circumferential procedures are
associated with more complications, but they are often per
formed on patients with higher BMis. When complications
are stratified by BMI, noncircumferential and cirCUIIlkrential
procedures have similar rates.
Superficial wound healing problems are the most com
mon complication that occurs with any body contouring
excisional procedure because of the high tension created
at the wound edges. Conservative wound care will usually
allow healing to occur, with the possible need for subse
quent scar revisions. Wound dehiscences, defined as separation of the wound at the level of the superficial fascial
system, are possible with any of the procedures discussed
in this chapter but tend to occur more frequently with cir
cumferential procedures. In procedures limited to anterior
resections, mini-abdominoplasty, and abdominoplasty,
dehiscences can be prevented by keeping patients flexed
at the waist for 5 to 7 days after surgery and educating
patients on a slow return to the full upright position over
the second week after surgery. Circumferential procedures
create competing anterior and posterior tensions, making
it difficult to place patients in positions that do not stress
at least one aspect of the closure. Avoidance of dehiscences
in this patient population entails adjustments of the c::ompeting resections to account for opposing tensions, careful ambulation of the patients in the early postoperative
period, and education of patients on how to help prevent
dehiscences.u
Seromas are common complications with lower truncal
c::ontouring procedures. They are due to large dissection sur
face areas and can develop anywhere in the surgical field but
tend to be located posteriorly in circumferential procedures.

TABLE 66.2
COMPLICATIONS ASSOCIATED WITH LOWER
TRUNCAL BODY CONTOURING PROCEDURES
Seroma
Wound-healing
Infections
Tissue necrosis
Bleedinglhematoma
Thrombotic events (deep venous thrombosis pulmouary emboli)
Psychiatric difficulties
Scar and contour asymmetry

Patients who present in the high BMI ranges are more likely
to develop seromas. Measures that are used to reduce their
occurrence include the use of suction drains, compression gar
ments. reduction of activity, and use of quilting sutures. When
they do occur, they can most often be treated with serial aspiseromas, sclerosing agents and seroma
rations. For
catheter insertions may be utilized.
Seromas are the most common source of infection after
lower truncal procedures. Simple cellulitis is fairly uncommon
and is usually treated by appropriate antibiotic coverage and
dose follow-up. Seroma pockets that become infected usually
present with overlying cellulitis, fluid collections that may or
may not spontaneously drain, fever, and generalized malaise.
A diligent effort should be made to find seromas and treat
them whenever suspected. Once seromas become infected,
aggressive intravenous therapy and appropriate surgical
drainage should be instituted.
Toxic shock syndrome can occur with any body contouring procedure. Postoperatively, patients who appear toxic
with fever, chills, generalized malaise, and elevated white
blood cell counts should be investigated. Although there is
often no evidence of frank pus or large fluid collection in the
wounds, aggressive surgical drainage is urgently required in
this group of patients.
Vascular compromise can occur with lower truncal body
c::ontouring procedures, leading to tissue necrosis. Most commonly the necrosis occurs in the inferomedial aspect of the
abdominal flap. A number of factors can contribute to this
problem, which include excessive tension on the abdominal
closure, aggressive thinning of the abdominal flap, overly
aggressive liposuction, and anything that may lead to compromising the lateral feeding vessels of the abdominal flap
such as open cholecystectomy incisions. If necrosis occurs,
the wound is treated conservatively and eventually allowed to
heal by secondary intention. Eventually, a scar revision may
be required.
Bleeding after lower truncal contouring procedures can be
extensive because of the surface area within which blood can
accumulate prior to detection. Although drains do not prevent
hematomas, they can often warn the surgeon of a developing hematoma. Small hematomas that are well evacuated by
drains in place can be managed expectantly. Large hematomas
should be treau:d by surgical drainage.
Procedures that tighten the abdominal wall are theorized
to increase intra-abdominal pressure, leading to a decrease
in venous return from the lower extremities. The possible
resultant stasis of blood in the deep venous system may
cause deep venous thrombosis and/or pulmonary emboli.
Measures that are commonly used in the prevention of
thrombotic events include early ambulation and sequential
compression garments. Some surgeons feel that chemopro
phylaxis, low molecular weight heparin (enoxaparin prophylaxis), is indicated in the perioperative period. At the
time of the writing of this chapter it is not dear what the
proper course of action should be in this arena. The authors
prefer to utilize epidural catheter infusions, which help
reduce pain, but have been found to reduce the risk of deep
vein thrombosis/pulmonary embolism as well, and avoid the
use of chemoprophylaxisY;
Patients who undergo large excisional procedures of the
lower trunk, especially massive-weight-loss patients, can
have psychiatric difficulties in the postoperative period that
may interfere with their recovery. Although this can occur
with any surgery, the long recovery period that is required
after circumferential procedures makes it wise for the plastic
surgeon to activdy investigate a patient's psychiatric reserves
and consider obtaining psychiatric clearance prior to sur
gery. The tendency of massive-weight-loss patients to have
lifelong psychiatric problems that are not solved by weight
loss alone also contributes to the relatively high incidence of
these problems.

Chapter 66: .Abdominoplasty and Belt Lipectomy

Although careful marking techniques can help reduce scar
and contour asymmetry, it is not possible to eliminate these
problems in many patients because of intrinsic skeletal and
soft tissue asymmetry. It is best for the surgeon to recognize
these natural asymmetries and point them out to patients
prior to surgery.

FLEUR-DE-LIS OR T-TYPE
PROCEDURES
A fleur-de-lis or T-shaped excision, whether used as an
abdominoplasty pattem or in combination with a circumferential lipectomy, is advocated by some authors. The
advantage of the vertical wedge is to eliminate horizontal
excess, create more waist definition, and decrease lateral
fullness. Traditionally, this pattem has not been frequendy
used because it is difficult to justify a vertical midline incision without a preexisting vertical scar. Recendy, however,
it has found more use because many massive-weight-loss
patients have midline incisions and/or deformities that supersede the created vertical scar in unattractiveness. Even with
a preexisting scar, however, there are major disadvantages
to the vertical aspect of the T pattem. There is an increased
chance of flap necrosis at the T intersection. When used to
treat circumferential excess, a leur-de-lis resection pattern
does not eliminate all lateral excess and does not affect lateral
thigh descent or buttocks ptosis. When the pattern is used
in conjunction with a circu.rnfi!rentiallipectomy, it can create
a greater mismatch between the upper and lower circumferences of the inverted cone-shaped edges to be reapproximated
(see Figure 66.9). Finally, the vertical wedge excised can often
lead to epigastric fullness secondary to the dog-ear effect created by the excision. Due to these disadvantages the authors
do not utilize this pattern of excision.14

695

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