More than 6 million US citizens can be described as morbidly obese.1 Accordingly, over the past 5 years the rate of bariatric surgeries has also exponentially increased.

All of these laparoscopic procedures can lead to massive weight loss and hanging, loose skin. The big change from the former open gastric bypass procedure is the lack of the vertical abdominal scar. Interestingly, the fact that these massive weight loss patients no longer have a vertical scar has indirectly increased the number of gluteal (buttock) lifts now being performed.

The prototypical long vertical scar following a standard open bariatric gastric bypass surgery is, essentially, impossible to remove. For many of the postbariatric patients, an inverted-T (fleur de lis) form of abdominoplasty has been used as there was an existing scar. Many times, the scar can be improved with careful technique.

When compared with the traditional low, transverse incision tummy tuck, the inverted-T abdominoplasty has a significant advantage—the inverted T incision allows better skin tightening laterally and posteriorly.2-4 Medial resection of midline abdominal skin allows a “wrapping around” effect from the inverted-T abdominoplasty, and even the upper buttock has some improvement in laxity.

For many patients, this tightening of the upper gluteal region after a tummy tuck is a pleasant surprise. The resulting vertical abdominal scar required is not an issue, provided that it already existed.

The typical massive weight loss patient these days has only small scattered laparoscopic incisional scars on their abdomen; hence, the problems created by increasing numbers of laparoscopic bariatric surgery. The majority of current bariatric patients prefer to avoid the vertical midline abdominal scar if at all possible. Therefore, the inverted-T abdominoplasty is being replaced by the traditional abdominoplasty, which adequately treats the abdominal laxity but leaves residual gluteal laxity.

Patients who follow bariatric surgery are increasingly savvy about procedures available to rid them of their unwanted excess skin and to lift the associated sagging tissues, including the entire buttock (Figure 1).

The gluteal region undergoes many unwanted changes following massive weight loss. Gluteal ptosis, asymmetry, double infragluteal fold, flattening, hypoplasia, and long buttocks are all examples of classic unwanted changes in the perigluteal regions after massive weight loss.

A study by Cuenca-Guerra et al reviewed 1,320 photographs of the female buttocks and determined that there were five defining features of an aesthetic buttocks.5 Of the five, they concluded that appropriate anterior posterior projection is most responsible for gluteal attractiveness.

A gluteal implant may be required in patients with inadequate tissue to enhance the A-P gluteal shape. However, fat grafting or a dermal pedicle can often be used to enhance the buttock for those who simply require repositioning of fatty tissue (Figure 2).

AVOIDING PROBLEMS WITH BUTT LIFTS

Mark the patient while standing with the superior incision just above the iliac crest. A lower incision will overshorten the buttock and create an aesthetically unpleasing lengthening of the hips. An accordion-like appearance to the buttock can be improved significantly, provided that the incision is positioned correctly (Figure 3).

Ideally, do no undermining superior to the upper incision in the lumbar region. Simultaneous liposuction of the hips and waist can be done safely, but direct undermining superiorly tends to lower the incision and increase the chance for seromas and wound breakdown.

The use of drains appears to lessen the chance of seroma, which is the most likely complication due to undermining in the infralateral buttock.

Use permanent, heavy sutures to elevate Scarpa’s fascia below to the deep lumbar fascia above, in order to avoid relapse and scar widening.

Avoid overmedialization of the incision during closure over the sacrum in order to prevent an elongated intergluteal cleft from extending up the lower back beyond the incision.

Perform the buttock lift as a staged procedure rather than combined with an abdominoplasty (body lift). The two create opposing tension that limits the amount of tissue to be excised and increases risk.

Figure 1. Before (middle) and after (right) a butt lift on a 37-year-old female who had a previous abdominoplasty following a 100-pound weight loss from bariatric surgery.

Overall, a buttock lift is a safe and extremely satisfying procedure that can be offered to patients with gluteal and upper outer thigh ptosis (Figure 2). After massive weight loss following bariatric surgery, patients are by far the most common group interested in gluteal lifts. These are the same patients who desire abdominoplasty, mastopexy with augmentation, brachioplasty, and thigh lifts.

Of the procedures mentioned, a buttock lift can be done safely with any of them. However, performing a simultaneous abdominoplasty increases the chance for potential problems, mostly because of postoperative tension issues as mentioned.

Circumferential belt lipectomies (body lifts) have been performed routinely for years with adequate results.6,7 Yet, despite a relatively good track record, this procedure is a risky surgery compared to many cosmetic surgical procedures performed today. Ideally, combining postbariatric cosmetic procedures that offer the easiest recovery and least risk should be considered first.

A simultaneous gluteal lift and thigh lift is often known as a “spiral lift”—a major procedure that can be performed safely with appropriate precautions.8,9 Because of the large amount of tissue excision, heavy tissue elevation, and lengthy incisions, the postbariatric patient requires respect and attention to preoperative and postoperative care to prevent problems.

Figure 2. Before (middle) and 1 year after (right) a butt lift plus a gluteal “tuck” at the infragluteal crease of a 32-year-old female who lost 130 pounds from gastric bypass surgery. The left photo depicts auto gluteal enhancement for the flat buttock by rotating a dermal pedicle into the ideal location for maximum projection.

Nutritional status is critical in assessing the bariatric patient to avoid potential wound-healing difficulties. The most common complications after cosmetic surgery for treatment of the massive weight loss patient include hematoma, seromas, and wound dehiscence.

In a review of my most recent 40 buttock lifts, the rate of the most common complications were actually less than seen in the standard abdominoplasty patient.

Seroma is the most common minor postoperative complication associated with these procedures. In the past, this has been increasingly associated with a greater amount of undermining of the cephalic tissue. Shermak and colleagues found that of 222 patients undergoing recontouring surgery, the major risk factor for seroma formation was the weight of skin excised at the time of surgery.10 They noted a 9% risk increase for every extra pound of skin excised.

Figure 3. Before (left) and 8 months after (center) standard butt lift of a 37-year-old male. The right photos show the level of dissection immediately above deep fascia over the gluteus maximus.

Our own experience has demonstrated similar correlation with higher BMI patients and in patients having major simultaneous liposuction of the hips, waist, and thighs. Judicious use of adjacent liposuction, use of drains, and limited dissection superiorly has all markedly decreased the rate of seroma formation.

In a retrospective case review of 200 body-contouring patients by Nemerofsky, the most common minor complication was skin dehiscence in the cleft and hips.7 This was felt to be due to marking the patient in a standing position, without accounting for flexion tension on the wound and longer periods of time spent supine in bed in the early postop period.

My practice’s rate of wound dehiscence has been very low, with only two minor ischemic incisions in the past 40 procedures performed—even after marking the patient while standing. In one case, I had a patient with simultaneous large gluteal implants that presumably increased tension at the edge.

The vast majority of patients’ incisions following buttock lifting have healed extremely well. The patients are asked to avoid major flexion at the waist for the first 2 weeks and have a drain or drains in place for an average of 1 week. They are also asked to sleep in a prone position for the first 2 weeks, postoperatively.

HAPPY CAMPERS

In large part, postbariatric surgery and massive weight loss patients tend to be a most appreciative group when electing to undergo cosmetic surgery. While the related procedures offer challenging issues, such as gluteal ptosis and massive skin excess, correction of these aesthetic deformities after life-changing weight loss can further build patients’ self-esteem.

Thankfully, the buttock lift has proven to be a safe and effective procedure to correct perigluteal contour problems following massive weight loss. Buttock lifts are definitely rising in popularity, and the thoughtful surgeon must take into account the patient’s ultimate goals when designing the ultimate post-weight-loss surgical treatment plan.

Angelo Cuzalina, MD, is in private practice in Tulsa, Okla, and board certified by the American Board of Cosmetic Surgery. He can be reached at .

REFERENCES

  1. Buchwald H. Overview of bariatric surgery. J Am Coll Surg. 2002;194(3):367-375.
  2. Cuzalina A. Butt lifts on the rise. American Academy of Cosmetic Surgery 25th Anniversary Meeting, session 106, The Arts of Body Contouring, January 16, 2009.
  3. Aly AS, Cram AE, Claudette H. Truncal body contouring surgery in the massive weight loss patient. Clin Plast Surg. 2004;31(4):611-624.
  4. Cuzalina A. New cosmetic surgery territory—massive weight loss surgery. American Academy of Cosmetic Surgery. 2008;2(1):24-25.
  5. Cuenca-Guerra R, Lugo-Beltran I. Beautiful buttocks: Characteristics and surgical techniques. Clin Plast Surg. 2006;33(3):321-332.
  6. Rohrich RJ, Gosman AA, Conrad MH, Coleman J. Simplifying circumferential body contouring: the central body lift evolution. Plast Reconstr Surg. 2006;18(2):525-535.
  7. Nemerofsky RB, Oliak D, Capella JF. Body lift: An account of 200 consecutive cases in the massive weight loss patient. Plast Reconstr Surg. 2006;117(2):414-430.
  8. Sozer SO, Francisco J, Palladino H. Spiral lift: Medial and lateral thigh lift with buttock lift and augmentation. Aesth Plast Surg. 2008;32(1):120-125.
  9. Cannistra C, Valero R, Benelli C, Marmuse JP. Thigh and buttock lift after massive weight loss. Aesth Plast Surg. 2007;31(3):233-237.
  10. Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development following body contouring surgery for massive weight loss: Patient risk factors and treatment strategies. Plast Reconstr Surg. 2008;122(1):280-288.