Introduction to Procedures

By 12-18 months after your gastric bypass or lap band surgery your weight plateaus and you are ready to begin the journey. Ideally your weight should be stable for 3 months before the first contouring procedure. Body contouring after massive weight loss has emerged as a surgical subspecialty in plastic surgery. Traditional contouring techniques were not designed for the excess skin we currently see when greater than 100 lbs is lost. But Plastic Surgery has risen to the challenge. Techniques developed over the last 5-10 years, now yield outstanding results. Areas generally affected are the arms, breasts, abdomen, buttocks and legs. The face may also appear older once the volume has diminished but this is also related to your age at the time of weight loss surgery.

The distribution of body fat is very variable. Some individuals selectively deposit fat in their trunk sparing the legs. Others deposit the fat in their legs sparing their trunk. The correct surgical procedure is dictated by the individual presentation. Truncal contouring procedures range from abdominoplasty to belt lipectomy to the lower body lift. The abdominoplasty will address the excess skin of the abdomen but not the lower extremities or the back. A belt lipectomy is a circumferential procedure which will address the excess skin of the abdomen and fullness about the waist. A lower body lift is a circumferential procedure which addresses not only the excess skin of the abdomen and flanks but lifts the thighs and buttocks as well. None of these operations directly address the medial thigh which often requires a medial thigh lift as a second stage operation.

Depending on how the weight is lost breast lift or reduction may be required. In fact, with dramatic loss of weight in the breast, consideration of breast augmentation with an implant may be necessary to achieve the desired aesthetic in conjunction with a lifting procedure.

The arms and back can also be areas of significant concern. Traditional brachioplasty can be extended to address the excess skin. Back rolls can also be addressed by direct excision. In extreme cases an upper body lift can be done to remove excess skin of the upper torso not corrected by the lower body lift.

Lower Body Lift

This operation was first described about 12 years ago by a surgeon who was dissatisfied by the limitations of the abdominoplasty. Whereas the abdominoplasty improved the appearance of the front of the abdomen, the lower body lift improved the entire truncal area from the rib cage to the knees with a single operation. Although originally described for the moderate weight loss patient the technique has broad applicability and has been modified to address the current population of individuals who have lost in excess of 100 lbs.

The operation is a circumferential procedure which is essentially three procedures in one. The first component is the high lateral tension abdominoplasty, which addresses the excess skin of the abdomen and the abdominal muscle tightening (see tummy tuck for further description). The continuation of the incision, within a garment line, allows for the lifting of the outer thigh and the buttock. This may be done in conjunction with liposuction of the lateral thigh and flanks to achieve the desired contour.

The procedure is about 6-8 hours and so I do not combine this operation with other contouring procedures. Although the incision is circumferential, the area of most discomfort is where the muscles have been brought together. I use local anesthesia in the muscle during surgery to minimize this discomfort on awakening. The recovery is a bit tougher than the abdominoplasty due to the discomfort of a circumferential incision and also to the length of surgery.

I require my patients to spend the night in the surgical facility with observation by a registered nurse. I strongly recommend another day of nursing care before returning home on the second day after surgery. Most individuals are off their pain medications by a week and are moving about fairly well.  Drains placed at the time of surgery are generally removed between day 7 and 10.Although you are feeling well by the end of the first week, I recommend a 2 week recovery before returning to work.

Brachioplasty

This is a surgical procedure to address the excess skin and fat of the arms. The inner arm skin is thin and as we age the elasticity gives way creating the hanging skin which doesn’t tighten now matter how much we exercise or lose weight. There are variations in surgical techniques which must be applied to your unique contour. They range from liposuction alone to excisions which can be limited to the arm or extend onto the chest wall.

Liposuction alone has limited applicability as few people have excellent skin quality and localized fat. If that is you though you are in luck Liposuction can be done through small incisions placed in cosmetically silent areas. The procedure is done as an outpatient and the recovery is quick. The discomfort is described as “soreness”, like after a vigorous work out. 

Most people however, will require an excision of the excess skin which is present along with removal of the excess fat. There are 2 excisional procedures which I use to achieve your desired contour and that is dictated by your presentation.

The first technique involves incisions in the axilla, arm pit, and one extending onto the arm in the area just below your bicep muscle. This is an excellent operation for mild to moderate excess skin as the length of the incision on the arm is as long as it needs to be to remove the excess skin. I like the incision below the bicep as this is an area which falls into shadow when the arm is extended. In our daily activities the exposure of the inner arm happens infrequently as this area generally is facing the chest wall. Some surgeons place the incisions on the back of the arm or close to it. I do not care for this placement for two reasons. The first is that you may not see the incision but everyone behind you can. The second reason is that the damaged skin responsible for the laxity is the thin inner arm skin, more of it is removed with an incision just below the bicep than on the back of the arm.

The second technique is required when there is more significant skin excess of the arm and fullness is present under the arm overhanging the bra. Instead of ending in the axilla, arm pit, this incision crosses over onto the chest wall and removes excess skin and fat there as well. Not only improving the contour of the arm but also the chest and back.

The operations are done as outpatient surgery. You will have drains for the first few days. You are in a support garment immediately after surgery for at least 4 weeks. The first week movement of your arms should not be above your head. The second week you begin range of motion and resume light activity. The operation can be combined with other procedures but we will need to talk about this. We rely on arms a great deal when recovering from other procedures, so operating on the arms at the same time makes for a tougher recovery.