How to select the right procedure from a wide spectrum of surgical options

The recent rapid expansion in the number of bariatric procedures has led to an explosion in the number of postbariatric cosmetic surgeries performed each year. This has rekindled tremendous interest and ingenuity in the practice of major body contouring. It is clear from the bariatric experience thus far that expertise in body contouring demands a great deal of surgical judgment to formulate a sound surgical plan and a clear strategy. Most plastic surgeons, however, have not developed—or may never develop—a significant postbariatric practice. For them, the challenges of body contouring in nonbariatric patients are alive and well, and they demand equal judgment and strategic planning. Furthe­r­more, patients have become increasingly demanding and selective in their pursuit of cosmetic surgery. This has only exacerbated the confusion among patients—and even surgeons—as to what constitutes the right procedure for any given patient.

Body contouring represents the majority of our practice, and we encounter a significant number of patients who have sought multiple surgical opinions. It is surprising how the same patient can receive quite conflicting recommendations for body-contouring problems that most would consider routine. Most patients are familiar only with the mainstays of body contouring: liposuction and “tummy tucks.” Yet there is a wide spectrum of procedures available to us, each with its own advantages and disadvantages (Figure 1).

Liposuction is the most commonly performed cosmetic surgery, and there is a clear consensus that patients with localized adiposity and adequate skin tone are ideal candidates. Similarly, localized laxity of the anterior abdomen, such as after pregnancy, is clearly treated with abdominoplasty. The issue becomes increasingly complicated when multiple anatomical problems coexist over multiple anatomical areas. It is here where a clear strategy and reasoning process is most helpful (Figure 2). The following is a systematic and logical strategy to plan successful body-contouring surgery and achieve satisfactory results.

Step 1: General Assessment

First, you must evaluate the patient’s overall medical, physiological, and psychological health and capacity. This variable, more than any other, will dictate which procedures are suitable for a patient and how aggressive along the spectrum of procedures you can travel. In our practice, we carefully screen for medical conditions such as diabetes, or cardiac or pulmonary problems. As the aesthetic patient population ages, a growing number of our patients are referred for formal medical or cardiology consults to ensure optimal safety.

Key Anatomical Components of the Trunk Contour
Skin redundancy, laxity, and striae Subcutaneous adiposity Musculofascial system Intra-abdominal fat content
Table 1

Furthermore, factors such as weight fluctuations and exercise tolerance—or lack thereof—will help you determine the extent of the operation. Patients with a history of smoking, steroid use, bleeding problems, or certain medications should be carefully counseled on the risks of pursuing major surgery.

And finally, it is critical that you learn how committed, motivated, and realistic your patient is with his or her expectations before you make a recommendation. For example, a patient who requires extensive liposuction as well as an abdominoplasty has to accept multistaged procedures and a potentially extensive recovery. Unrealistic expectations will only lead to unsatisfied patients and disappointed surgeons. You must temper an aggressive plan by considering systemic factors such as age, medical conditions, smoking, exercise tolerance, weight stability, psychological preparedness and motivation, and lab tests.

Step 2: Patient Goals

Patients often have specific complaints during the consultation, which they frequently manifest by grabbing the most undesirable body part first: the “love handles,” stretch marks, or an unsightly panus, followed by ptotic breasts or thighs. Our patients generally want procedures to follow their priority list, even though it might be incongruous with the anatomical deformities you observe.

To further refine your understanding of your patient’s priorities, consider the patient’s lifestyle, occupation, family responsibilities, and the style of clothes he or she wears. A patient who routinely wears bikinis or shorts might require a different plan than a patient who simply wants to look more fit in regular clothes. Once you have a clear concept of what will make the patient happy, you are ready to proceed to the next step.

Step 3: Proper Diagnosis

The next step requires a careful examination and formulation of a clear anatomical diagnosis of each area (abdomen, waist, back, buttocks, and thighs). The patient needs to be reminded that the body does not gain or lose weight in isolated areas, just as women do not select clothes just to fit one part of their body. Therefore, a careful and honest assessment should include the entire trunk and thighs, even if the original complaint is more focused. In particular, the following four components of the trunk “contour” have to be analyzed to form the overall surgical strategy: the skin, the subcutaneous tissue, the musculofascial system, and the intra-abdominal content (Table 1).

Proper diagnosis of each of these anatomical components will provide a clear indication for certain procedures, and/or will provide a clear contraindication to some or all of the procedures. Clearly, patients with significant intra-abdominal adiposity are not ideal candidates for any procedure because none will adequately correct their underlying contour problems, not to mention the safety issues. Similarly, patients with excessive skin laxity have to be warned against unrealistic expectations with liposuction alone. Problems associated with the skin itself are impossible to treat other than by excision (Figure 3).

In select cases of mild to moderate skin laxity, liposuction will help mitigate the problem, particularly with careful ultrasound-assisted treatments. In our practice, a pulsed-ultrasound system has been particularly useful in treating adiposity in areas with overlying laxity to avoid extensive excisions. The most common and often challenging scenario is where a combination of both liposuction and some level of resection is indicated. Here, you have to balance the safety of the combined procedure with the degree of cosmetic correction desired. It is critical to always err on the side of safety, while trying to provide a clear and tangible improvement for the patient.

Step 4: Technique Selection

After assessing the above variables, you should be able to formulate a plan to meet the patient’s priorities and expectations. In our practice, a surprisingly large number of patients are referred for abdominoplasty without a clear understanding of the underlying problem and, hence, the proper solution. With nearly 50% of these patients who anticipate some type of major procedure,  we recommend a more limited procedure, or often just liposuction alone. This is particularly true of the nulliparous patients. At least 25% of patients who do require major surgery are persuaded to undergo a staged procedure. To help guide us in such decision-making, we ask the following questions:

1) Which procedure(s) does the patient need?

2) Is the patient a reasonable candidate?

3) Do I need to stage this procedure?

4) In what order do I proceed?

Which procedure(s) does the patient need from a purely anatomical standpoint? The answer is based entirely on the physical findings noted above and how you will restore each aesthetic unit to its natural or ideal position. In the trunk, the primary goal is a flat abdomen with a more defined waistline, and the elimination of a panus and striae. A natural midline and periumbilical depression with some definition overlying the rectus muscle are ideal. In patients with adequate skin elasticity and musculofascial tone, liposuction is sufficient.

If there is any soft-tissue laxity, an abdominoplasty is indicated based on the presence of upper or lower laxity (Figure 4). This procedure nearly always includes fascial plication to create a more scaphoid abdomen. Cases of isolated musculofascial laxity with minimal skin laxity and minimal adiposity are extremely rare. Such cases are much more frequent in male patients and require fascial plication only, using limited incisions or endoscopy (Figure 5).

A Detailed Perioperative Protocol
    Plan the surgery sequence
    Choice of anesthesia
    DVT prophylaxis
    Hemodynamic monitoring (foley catheter)
    Thermoregualtion (upper-body and lower-body warmers)
    Choice of wetting solution
    Liberal use of drains
    Pain management (pain pump for early ambulation and lower narcotic use)
    Recovery facility for major surgery
    Homeopathic agents (Arnica Montana & Bromelain)
    Aggressive use of garments
    Frequent visits minimize complications
Table 2

Global circumferential laxity is ideally treated with a circumferential lipectomy, even in those patients who have not had major weight loss. If the problem is primarily ptotic buttocks and thighs, a lower-body lift is more appropriate, whereas primary laxity of the waist and lower back is better treated with a circumferential or belt lipectomy (Figure 6).

In the nonbariatric population, there is no need for a concomitant vertical and horizontal resection, since the elasticity is generally superior. Anterolateral thigh laxity is a common but challenging problem, since most patients reject the large, visible scars. Scars from a medial thigh lift are more palatable if performed well, but patients have to be warned that there will always be some degree of recurrence. For the most durable results, the correction of thigh contours nearly always requires some liposuction for simple debulking as well as to allow for better mobilization of the soft tissues superiorly.

Next, we ask whether the patient is a candidate for the “ideal” procedure(s) based on our general assessment of the patient (Step 1) and the patient’s objectives (Step 2). If the patient is not a good candidate, a less-extensive procedure from our armamentarium is selected. Similarly, if the patient’s goals can be reasonably met with a less-extensive procedure, the lesser procedure is offered. It is critical to use multiple samples of before-and-after pictures of each type of surgery to fully educate the patient about results and reasonable expectations. Patients should also fully understand what to expect during recovery to make an informed decision.

The next key question is whether the proposed operation can be performed in one stage. Since most of our procedures are performed in an outpatient facility, we typically limit our operative time to maximize patient safety and ease of recovery, as well as to minimize surgeon fatigue. In our practice, our goal is to complete most procedures within 4 hours, and nearly always within 6 hours. The majority of patients who have a clear understanding of the extent of their surgical problem accept this rationale and appreciate our emphasis on safety. There are certain procedure combinations that inherently require separation into stages, such as an abdominoplasty or body lift followed by a medial thigh lift.

The final question is in what order to perform the appropriate procedures. Again, the answer is based on the patient’s priorities. Most often, the primary focus is the anterior abdomen, followed by the waist and lower back, the anterolateral lateral thighs, and finally the medial thighs. In patients who have significant subcutaneous fat deposits and laxity despite diet and exercise, we often have to offer extensive liposuction as well as some type of resection. In candidates with an overhanging panus, it is much more practical and satisfactory to the patient to perform the lipectomy first, followed by a subsequent treatment with liposuction. In the majority of cases, however, we prefer to perform the liposuction first, followed by a later resection. This usually allows for maximal weight loss and tissue laxity to develop before committing to a lipectomy. Thigh lifts are generally reserved until the end, usually after breast and arm rejuvenation is complete.

Step 5: A Detailed Protocol

The final step is to formulate a detailed perioperative protocol to improve safety, efficiency, and outcome (Table 2). You should have a similar protocol in place to ensure optimal safety.

As the popularity of cosmetic surgery increases, the diversity in our patient population will similarly grow. Fortunately, there is a wide spectrum of body-contouring procedures available to us to treat the great variability in our patients’ goals and priorities. The preceding principles will help you and your patient formulate an effective surgical strategy. n

Dan Yamini, MD, and Steven Svehlak, MD, are both plastic surgeons and partners at Beverly Hills Body, Cosmetic Surgery Specialists, Beverly Hills, Calif. Yamini, the lead author, focuses on breast and body-contouring surgery. He can be reached at [email protected] or (310) 276-3183.