BODY CONTOURING IN MASSIVE WEIGHT LOSS PATIENTS
Lower Body Lift and Thigh Lift
As the demand for gastric bypass surgery has grown, so has the specialized field of plastic surgery for massive weight loss patients, who have unique body contouring needs. Patients who achieve massive weight loss from either gastric bypass and rigorous diet and exercise programs face the same issue–loose, hanging folds of tissue that hide a thinner figure underneath.
Plastic surgery in massive weight loss patients is a relatively new field, and techniques for achieving desirable aesthetic results are evolving rapidly. Dr. Centeno has extensive experience in massive weight loss body contouring and has developed several innovative techniques for massive weight loss patients. He is nationally recognized as a leader in the field and as such, teaches massive weight loss body contouring to surgeons around the country who are entering this specialized area of surgery.
- The Special Needs Of Massive Weight Loss Patients
- Good Candidates For Body Contouring Surgery After Weight Loss
- Surgical Options for Massive Weight Loss Patients
- Circumferential Body Lift
- Liposuction
- Gluteal Augmentation
- Mons Reduction and Genital Procedures
- Inner Thigh Lift or Thighplasty
- Breast Lift and/or Augmentation
- Upper Arms and Armpit Region
- Upper Body Lift
- Facial Procedures
Click below to view a presentation about the procedure, preparation and post surgery details.
The Special Needs Of Massive Weight Loss Patients
Dr. Centeno consults with many massive weight loss professionals, including gastric bypass surgeons, physicians who specialize in obesity, nutritionists, and support groups that provide counseling for those engaged in the weight loss process. Through these resources, along with our own patients, we have gained great respect for people willing to work hard to reach a healthy body weight. With all its difficulty, this special group of patients has persevered to improve their self–image.
Weight loss does not occur uniformly over the body, no matter the amount of weight lost. Bulky fat deposits remain in areas that further weight loss is not likely to correct. In addition, roughly the same amount of severely stretched, unsupported, and non–elastic skin exists. The only way to reduce that excess is to have it surgically removed–it will likely never shrink enough to conform to your reduced body size.
Body areas that most commonly have sagging pockets of skin and tissue after massive weight loss include:
- face, neck, and jowls: produces a droopy, sad appearance
- upper arms and armpits: gives a “bat–wing” like appearance
- breasts: appear flattened, hang with nipples pointed downward, and cause rashes and chaffing beneath the breasts
- abdomen and sides of the body: a large apron–like overhang of skin interferes with bodily functions, cleansing, and sexual activity
- buttocks, groin, and thighs: causes chaffing and interference with bodily functions and hygiene
Unfortunately, an excess of heavy, weak and sagging skin that is chronically moist and irritated may develop healing problems or infections that pose serious health risks. Many massive weight loss patients suffer from functional and hygienic issues caused by significant amounts of excess skin in the genital area, anal region, and breasts. For example, large hanging folds or flaps of skin and tissue can create significant problems with urination and hygiene in the genital area. They also cause constant chaffing and difficulty with simply moving around.
For the patients we have treated, body contouring after weight loss completed their transformation. They finally see the results of the weight loss goal they had been working toward. Their self–esteem and self–confidence soar as they finally feel “normal” and can show their new trimmer contour to the world. These patients can finally wear clothes in smaller sizes because they no longer have to buy large clothing to accommodate all the excess bulk they still carried after weight loss. They are also much more physically comfortable and active.
Good Candidates For Body Contouring Surgery After Weight Loss
Patients who wish to undergo body contouring after massive weight loss must maintain a stable weight for 12–18 months prior to surgery. Those who continue to lose weight will redevelop the sagging pockets of skin and tissue. Conversely, if weight is rapidly regained, the weakened and thinned skin will be further stressed, which can lead to wider scars and visible stretch marks.
In addition to having stable weight, good candidates for body contouring are adults who do not have medical conditions that may impair healing or increase surgical risks. Candidates should also have a positive outlook and realistic goals for what the procedure can accomplish. They must be committed to leading a healthy lifestyle that includes proper nutrition and fitness. Current smokers are poor candidates, as smoking prevents quick healing, which is necessary with the long incisions that are required for most body contouring procedures.
If weight loss resulted from bariatric surgery, Dr. Centeno will work closely with your physician to determine when body contouring can begin, learn more about your medical history, and evaluate your nutritional status. This information will let us know if special measures are needed for optimal safety and healing.
Body contouring after massive weight loss is not simple. A lengthy surgery is usually required and is followed by three to five days in the hospital. Long scars are produced by many of the surgical procedures, though we make every effort to keep them as inconspicuous as possible and in a location that will most likely be covered by clothing. If multiple body areas are contoured, multiple incisions are required. The length and placement of each incision depends on the amount and location of the skin that will be removed.
It will take many months before you achieve the look you want, and there will likely be discomfort along the way. Body contouring after massive weight loss can be a very important and rewarding phase of your challenge to have a healthier, trimmer, and more proportionate body.
Surgical Options for Massive Weight Loss Patients
Your anatomy, the results you desire, the areas to be treated, and the state of your overall health contribute to determining whether you will require one or multiple surgeries. Your safety and comfort are also important factors when deciding how to proceed. Dr. Centeno will help you to determine the best plan for achieving your body contouring goals through extensive discussions about options and risks.
The most popular body contouring procedures for massive weight loss patients are described below.
Circumferential Body Lift: The circumferential body lift is the core procedure of body contouring after massive weight loss. In a single surgery that takes approximately four hours, the “belt” of skin and fat that surrounds the circumference of the lower trunk is removed. This re–contours the abdomen, waist, flanks, buttocks, hips, and outer thighs. Typically, there is one incision that goes all the way around the circumference of the lower body to lift the front, back, and sides.
On the front of the body, an incision is made just above the pubic bone and extended toward the back in a curved fashion, below the protrusions of the hipbones. The skin and tissue above and below the incision are elevated as tissue flaps are pulled downward or upward into a new position. The excess skin and fat of the flaps are then excised. Deeper tissues that have been elevated and repositioned are secured to provide support and prevent them from moving. If the skin around the navel has been removed, a new navel is created in a procedure called an umbilicoplasty. The skin and underlying tissues around the navel and above the waist are pulled downward to contour the waist and upper part of the tummy. When the skin and tissues below the incision are pulled upward, the front of the thighs and sagging in the groin area are “lifted”.
To treat the back, an incision is made around the hips and across the back below the waist and across the buttocks. This incision is placed slightly lower than what is called the bikini line. When the skin flaps are raised, the tissue above the incision is pulled downward to re–contour and smooth the waist and flank area (roughly that region over the kidneys). The skin and tissue below the incision are pulled upward to lift the outer and posterior thighs and the buttocks into a new position. The excess skin is trimmed from the upper and lower flaps, and the underlying tissues are secured in the new position.
The skin above and below the incision in front and in back is stitched together and sealed with DermaBond (the medical equivalent of superglue) to keep the wound clean, dry, and secure.
Liposuction: Large–volume liposuction (LVL) is sometimes performed as the first stage of body re–contouring, especially in patients who have large deposits of fat in multiple areas. In these cases, there is too much fatty bulk to achieve the best possible result with a circumferential body lift, which primarily addresses excess sagging skin. To solve this problem, large–volume liposuction is used to de–bulk the excess fat so that lifting procedures performed later will be more effective. Sometimes LVL can re–contour body areas sufficiently so that excisional surgery is either not necessary or is less extensive.
Large–volume liposuction is usually a separate procedure, but standard liposuction of smaller volumes can be combined with various types of lifts. For example, liposuction of the thighs or arms and upper back may be done in the same surgery as a circumferential body lift. For safety reasons, we generally do not perform liposuction in the same body area where tissue will be excised.
Gluteal Augmentation: Many years of obesity cause the spine and posture to change, which can give the buttocks a flattened appearance. A circumferential body lift sometimes makes the lack of buttock projection more obvious as the excess lower body tissues are lifted and tightened. Therefore, many of our patients choose to have gluteal augmentation with their own tissue (called autologous tissue) at the same time as a body lift. The excess tissue of the lower back that is normally discarded during a body lift is fashioned into a tissue flap that can be safely used to preserve or enhance projection of the buttocks.
Dr. Centeno has developed innovative approaches to gluteal augmentation with tissue flaps in massive weight loss patients. This tissue is molded and then inset beneath the skin in such a way that it adds volume and projection to the buttocks. The flap is anchored with stitches to the deeper tissues so it will not move, and skin that normally would be pulled downward and removed in a circumferential body lift is used to cover the flap.
Gluteal augmentation adds about one hour to the operating time of a circumferential body lift and requires no additional skin incisions.
Mons Reduction and Genital Procedures: The mons is a prominent pad of fatty tissue that lies over the pubic bone and is covered with hair. Patients often have an enlarged mons after weight loss due to fatty deposits and excess sagging skin. This tissue will not shrink with additional weight loss or exercise. The size of a large mons can interfere with going to the bathroom, hygiene, and sexual function. Mons reduction, which is typically combined with a circumferential body lift, removes the excess fat and skin. When the mons is reduced to a more normal size, bathroom and sexual functions, hygiene, comfort, and appearance are greatly improved.
If an enlarged mons is caused primarily by excess fat deposits, standard liposuction of the area around the pubic bone is usually sufficient. If removal of excess skin is also needed, a triangular–shaped wedge of skin and tissue is excised. This procedure requires a separate incision, about four inches long, which extends vertically over the mons. Mons reduction takes less than one hour, so it does not greatly increase the time of a circumferential body lift, but it will make a substantial difference in comfort and function.
For women, the most severe cases of skin, tissue, and fat excess in the pubic region may extend to the labia (the folds of tissue, or “lips,” lying on either side of the vaginal opening). The labia collects fat deposits like every other part of the body. When a large amount of weight is lost, the over–stretched labial tissues may hang in folds and have a major impact on function and hygiene. If this problem is severe, the triangular wedge excision of a mons reduction is extended to include removal of the excess labial tissue. This procedure is known as a labioplasty or labial reduction.
Obesity in men may also cause genital problems. If the mons area is very large, the penis may become nearly inverted and must be physically pulled out of surrounding skin folds for urination or sexual activity. This problem is treated with liposuction and mons reduction, usually at the time of a circumferential body lift. In severe cases, a second mons reduction and additional liposuction may be required.
Surgery in or near the genital region is not without risks and side effects. Skin sensation may be temporarily decreased, but sensitivity of the clitoris may be increased. Prolonged swelling and redness are not unusual following mons reduction or other genital procedures. Dr. Centeno will further explain what to expect if you are interested in mons or labial reduction.
Inner Thigh Lift or Thighplasty: While massive weight loss patients tend to lose large amounts of fat in the thighs, localized fat deposits and folds of sagging, wrinkled skin along the upper half of the inner thighs and in the groin tend to remain. This excess skin is uncomfortable and unattractive. Although a circumferential body lift can make a remarkable improvement in the contour of the front, back, and outer thighs, it is less effective in reducing the skin excess of the inner thighs. In this case, an inner thigh lift is a good corrective option.
If there is an excessive amount of skin laxity at the top of the inner thigh and extending along the entire length of the inner thigh, a thighplasty may be required to remove excess skin. Thigh re–contouring takes two to three hours and may be performed at the same time as a circumferential body lift or as a separate procedure.
For an inner (medial) thigh lift, an incision is made in the natural groin crease where the inner thigh meets the torso (between the thigh and labia or scrotum) and extends to the gluteal crease. In other words, the incisions run a few inches alongside the genitals from front to back. This incision location allows scars to be hidden by underwear and swim suits. Through the incisions, an ellipse of skin and underlying fat deposits are removed from each upper inner thigh. The skin lower on the thighs is then lifted to a higher position and the incision closed with stitches.
A thighplasty incorporates the inner thigh lift with another incision in each thigh that extends down toward the knee. This permits removal of larger quantities of loose, sagging skin. In addition to removing excess fat and lifting the skin upward, a thighplasty allows Dr. Centeno to pull the skin on the front of the thigh toward the back and the skin on the back of the thigh toward the front. The skin along the length of the medial thigh can therefore be tightened more effectively. The obvious disadvantage of a thighplasty is the scar that extends from the groin toward the knee. Although the scars will fade over time, they will never be invisible.
In people with large amounts of fat in the inner thighs (in addition to sagging skin), two surgeries are required to achieve the best results. First, liposuction of the inner thighs is done to “de–bulk” the excess fat. This can be done at the same time as a circumferential body lift or other re–contouring procedure. About six months later, an inner thigh lift and/or thighplasty is performed to remove the excess skin.
Breast Lift and/or Augmentation: After massive weight loss, many women are left with long, flat breasts that have no shape that may cause skin rashes beneath the breasts. Fatty tissue in the breasts is effectively reduced with weight loss, but obesity so severely stretches the skin that breast re–contouring is the only option for reducing this common deformity among women.
Several types of breast reshaping procedures are available, but all of them involve removing excess skin and basically rearranging the breast tissue to create a more natural–looking breast mound. Because fatty tissue is a major component of the breasts, significant weight loss often means that volume needs to be added to fill out the skin “envelope.” Contouring the breasts after massive weight loss can be done in several ways:
- breast lift only
- breast lift plus a tissue flap taken from a nearby area in the same surgery
- breast lift followed by the addition of breast implants three to six months later
The main procedure for re–contouring the breast after massive weight loss is a breast lift, or mastopexy, which usually takes about two to three hours. In a mastopexy, the skin excess is removed through an incision made around the areola and extended vertically between the areola and the inframammary crease (the natural fold where the breast joins the chest wall). The incision around the areola allows the nipple and areola to be raised to a higher position.
Long, flattened breasts are typical after massive weight loss. This condition usually involves nipples that point downward and are located at the lowest part of the breast. After excess skin is removed around the incisions, the skin and tissue that remain are re–draped to create a natural breast contour. If there is a large excess of skin, another incision that runs horizontally along the inframammary crease may be needed.
Although a mastopexy will eliminate the problem of long hanging breasts after massive weight loss, many women find they then have breasts that lack sufficient volume. A good option for adding breast volume is to take excess tissue from the armpit area or side of the chest wall and add it to the breast mound at the same time as a breast lift. The tissue used is typically discarded during body contouring of the upper body.
Similar to gluteal augmentation, your own tissue (autologous tissue) from an area near the breast is transferred as a flap and molded to augment the breast volume. A real advantage of this type of breast augmentation is that the upper body (where the excess tissue comes from) is simultaneously re–contoured along with the breasts. Instead of discarding this tissue, it can be safely and effectively used to add volume where you want it.
Breast volume lost with massive weight loss can also be added with implants. As with the use of autologous tissue, breast augmentation with implants requires a breast lift to shorten the breast length and move the nipple and areola to a more natural position. Because of safety concerns about wound healing, we prefer to add breast implants several months after a breast lift. Breast implants have risks of their own, and the thin and non–elastic breast skin left after massive weight loss is likely to increase these risks.
If you are interested in any of these options, Dr. Centeno will explain them and help you decide which method is best for you.
Upper Arms and Armpit Region: Massive weight loss may leave large excesses of skin and tissue along the underside of the upper arm, the side of the chest, and in the armpit area. These areas can be re–contoured in a single surgery that often includes a breast lift and/or breast augmentation with your own tissue transferred from the side of the chest or armpit area. These procedures are called brachioplasty and axilloplasty.
Brachioplasty removes loose, sagging skin from the inner side of the upper arm (from the armpit to the elbow). Massive weight loss causes the thin skin in this area to hang down when the arm is raised, which creates what is commonly called a “bat–wing” appearance. Women, in particular, are very self–conscious about this deformity. Although they may be extremely self–conscious about wearing short sleeves, they have difficulty finding long sleeves to accommodate all the loose skin.
A brachioplasty removes sagging skin through an incision that runs along the inner portion of the upper arm. This incision will probably be visible when the arm is raised, but many patients prefer the scar to the hanging tissue. A brachioplasty takes one–and–a–half to two hours and can be done at the same time as other body contouring procedures.
An axilloplasty removes excess skin and fatty tissue in the armpit area (called the axilla) that may hang in a large fold down the side of the chest following massive weight loss. This procedure takes one or two hours, depending on the extent of excision needed. Because tissue from the axilla area is useful for adding volume to the breast, an axilloplasty is often combined with a breast lift and breast augmentation with a patient’s own tissue to restore breast volume. (See the preceding section on breast lift and augmentation.)
Axilloplasty requires an incision that begins near the front of the armpit and extends downward several inches toward the base of the breast. The sagging skin is pulled forward, the excess skin is cut off, and the incision is closed with stitches. The resulting scar is well hidden in the body’s natural contours.
Upper Body Lift: Upper body lifts have been around for decades but were rarely used because they produce significant scars. However, some patients who have lost massive amounts of weight and are left with hanging folds of skin in the upper body area are willing to accept the scarring in exchange for greater comfort and better fitting clothes. Surgical procedures that fall into this category are upper abdominoplasty, axilloplasty and torsoplasty.
A circumferential body lift removes some excess skin and tissue from the upper abdomen. However, this lower body lift cannot solve the problem completely in patients with severe skin laxity between the waist and breast area. An upper abdominoplasty, which removes loose folds of skin in this area, is usually performed three to six months after a circumferential body lift.
A torsoplasty addresses excess skin and tissue that remains on the sides of the upper body and back. It may be combined with an axilloplasty or upper abdominoplasty because the areas being re–contoured are in close proximity. In a torsoplasty, the skin excess is removed through incisions that depend on each patient’s needs, though generally they are placed in the area beneath the arms, down the side of the chest, and may extend onto the back.
Upper body lifts may require liposuction if significant subcutaneous fat remains in the area. In some cases, liposuction may be done at the time of the upper body lift, but it is usually scheduled as a staged procedure performed a few months before or after the lift. Recovery from these upper body procedures takes two to three weeks, during which time normal physical activity and upper body motion should be restricted. Many patients choose to have upper body lifts performed at the same time as breast re–contouring or facial procedures.
Facial Procedures: Following massive weight loss, the face may appear hollow or sunken. The best way to restore volume is through fat transfer, which involves using liposuction to take fat from an area that has excess and then inject into the cheeks. For excess sagging facial skin, a facelift is a common remedy. Patients who have lost tissue volume in the face receive the greatest benefit from both a facelift and fat transfer.
Facial re–contouring may be performed in the office, but is more often combined with another, more major body contouring procedure in the operating room.