As the number of patients undergoing lap band procedures or gastric bypass procedures grows, so will the need for reconstructive surgery for massive weight loss.

Whereas the abdomen and breast tend to be the most common areas for weight-loss reconstruction, the extremities can also fall near the top of patients’ priority lists.

The optimal outcome of these procedures depends on the amount of skin laxity, the residual fatty tissue, and the surgical technique utilized.

Several procedures, combinations, and skin-resection patterns are described to manage the upper extremity—management differs depending on the amount of deflation in the arms. Of course, a better outcome can be expected with a deflated arm. If the arm continues to have significant fatty deposits, I prefer to stage the procedure by liposuction initially followed by a resection procedure several months later.

My preference is to address the arm, axilla, and possibly the upper chest wall at the same operation.

A plasty is incorporated in the axilla to prevent contracture. In addition, I prefer to use a pattern of resection that leaves the scar not along the bicipital groove but more postero medial.

Figure 1. The arm lift is designed to remove loose skin from the upper arms. Liposuction does not address skin laxity; lipoplasty is typically not an effective surgery option in this case.

Figure 2. The optimal outcome depends on the amount of skin laxity, the residual fatty tissue, and the surgical technique used.

This pattern of resection also allows for more tissue removal in the area that requires the greatest amount of contouring. I do not use fasial anchoring sutures for the closure.

Compression garments are worn for 3 to 4 weeks. The most common postoperative complaints are sensory nerve irritation, occasional lymphocele at the elbow, and hypertrophic scarring.

The lower extremities are even more challenging technically, as well as the postoperative management.

The patient is placed in a lithotomy position during surgery. I utilize a vertical resection pattern, which results in a scar shaped like a number seven.

Figure 3. Thigh lift with intraoperative positioning. Intraoperative positioning is the art of securing human anatomy into place to ensure the best surgical site exposure with minimal compromise of the patient’s physiologic functions.

Figure 4. An inner thigh lift may also be used to treat reduced skin elasticity caused by the aging process or extreme weight loss.

The resection in not taken down all the way to the fascia. In addition, the saphenous vein is protected.

The excisions may need to extend beyond the knee for optimal contouring. Blake drains are utilized for postoperative drainage and may remain in place for 2 weeks, during which time the patient is expected to wear compression garments.

See also “Special Surgery-Unique Patients,” by George John Bitar, MD, in the May 2006 issue of PSP.

Despite these measures, fluid occasionally collects at the knee. Other minor complications include wound separation at the groin crease due to postoperative moisture and inadvertent trauma.

Patients are marked in the office the day before surgery, and markings are sometimes slightly adjusted on the operating table.

During the preoperative consultation with the patient, I emphasize issues such as recurrent laxity and hypertrophic or pink scars, as well as touch-up procedures. Around 20% to 25% of patients will require some scar touch-up. This depends on the patient’s expectations as well as the surgeon’s desire to get an optimal outcome.

Munish K. Batra, MD, FACS, is double board certified by The American Board of Plastic Surgery and the American Board of Surgery. He has worked with national authorities in the field of aesthetic breast surgery and body contouring. He has written articles and chapters in numerous publications.