Body contouring for the massive loss is a challenge to achieve the ideal technique for the specific deformity at the proper timing with the least complications

1. ‫طه‬:114
Body contouring after massive
weight loss
By
Mohamed Hosam Abd el-moamen
MSc G. Surgery

2. Objectives
 Introduction.
 Aim of the Work.
 Overview of obesity and bariatric Surgeries.
 To review the Patho-Physiologic Changes Of
Skin And Subcutaneous Tissue After MWL.
 To discuss the Management of the Arm ,
Breast , Abdomen and the thigh after MWL.

4. Obesity is defined as excessive fat accumulation and
constitutes a major risk factor for a number of chronic
diseases, including diabetes, cardiovascular diseases and
other chronic illnesses.
The universal definitions of overweight and obesity
have been established using body mass index. *
After the massive weight loss following bariatric
surgery, about 90% of patients tend to display the negative
effects secondary to the large amount of redundant skin. In
addition to the aesthetic problems, this leads to functional
problems, dermatoses and difficulties in carrying on
personal hygiene.
Introduction

6. The aim of this study is to explore the different
options available for correction the body defects
after massive weight loss regarding surgical
techniques and post operative outcomes, to
provide a more pleasing body contour after
successful massive weight loss.
Aim of the work

8. Management of obesity
Non surgical management
Diet: balanced low calorie diet.
Exercise.
Pharmacotherapy:
Indicated in patients with BMI of 27 Kg/ m2 with co
morbid conditions or in patients with BMI of 30
Kg/m2 without comorbidites.

9. Management of obesity
Surgical treatment
Indications:
•BMI > 40 Kg/ m².
•BMI 35- 40 Kg/ m² in presence of co-
morbid conditions.
•Failed medical management. *

10. Management of obesity
Bariatric procedures are characterized by
their mechanism of weight loss.
Current surgical practice can be divided by
the mechanism of weight reduction:
restrictive by decreasing the storage
capacity of the stomach, malabsorptive
through surgical bypass thus excluding
intestinal loops, or a combination of
restriction and malapsorption.

11. Management of obesity
 Vertical banded gastroplasty
(VBG) *
Sleeve Gastrectomy
(SG)
1) Restrictive procedures:

12. Management of obesity
Jejunoileal
bypass
 Biliopancreatic
diversion
2) Malabsorptive Procedures:
Duodenal switch
procedure

13. Management of obesity
Gastric bypass Minigastric bypass
3) Combined procedures:

14. Management of obesity
1) Full clinical a with peculiar emphasis
local examination of liver.
2) Calculation of Body Mass Index.
3) Laboratory investigations including:
4) Abdominal ultrasonography with
special comment on liver
echogenicity and focal lesions.
 Complete blood picture , Liver function tests:
AST, ALT, serum Albumin, T.B ,D.B , GGT,
ALK.P, PT, INR, HBsAg, HCV Ab and Alpha-
fetoprotein .
 Kidney function tests: BUN, creatinine.
 Fasting triglycerides and cholesterol levels.
 Fasting and 2 hours post prandial blood glucose
level.
 Serum fasting insulin via DRG insulin ELISA:
 Normal value :- 2 μ IU/mL to 25 μ IU /Ml.
 Calculation of insulin resistance using HOMA-IR
 [HOMA-IR = fasting glucose (mmol/dL) × fasting
insulin (μU/ml)/22.5]. (Normal HOMA-IR :1.7-2)
 Patients will be considered to have insulin
resistance when HOMA-IR > 2.5.
Management of obesity
• Postoperatively, patients experience rapid weight
reduction, typically peaking in the first 18 to 24
months.
• The post bariatric patients need a
multidisciplinary care after their surgeries.
•The body contouring surgery can be used as an
adjuvant to the bariatric surgery to repair the
deformities following bariatric surgery.
• The ideal time to perform body contouring
procedures is when the weight is stable which is
typically 12 to 18 months after weight reduction
surgery to reduce post-operative complications . *

15. PATHO-PHYSIOLOGIC
CHANGES OF SKIN AND
SUBCUTANEOUS TISSUE AFTER
MASSIVE WEIGHT LOSS

16. PATHO-PHYSIOLOGIY
•Once the skin appears taut when fully inflated (high
weight), the loss of the underlying fat support causes a
deflation of the skin cover much like the deflation of a
balloon.
•The skin does not ‟snap back‟ for 2 reasons: First, the
slow (or rapid) expansion of fat and weight stretches the
skin and actually makes more skin as it expands.. Secondly,
stretching beyond a certain point causes the elastic fibers
in the skin to become permanently deformed. The elastic
fibers and collagen are responsible for skin elasticity. The
combination of more skin that is no longer elastic results in
hanging sagging skin.

17. PATHO-PHYSIOLOGIY
Factors that determine the degree of
redundancy include:
I. Age *
II. Degree of MWL
III. Inherent tissue type and elasticity:
IV. Hormonal effect (estrogen)

18. MANAGEMENT OF THE ARM
AFTER MASSIVE WEIGHT LOSS
(Brachioplasty)

19. Brachioplasty
* Depending on the skin-fat envelope of the arm excess, the
approach can be tailored as follows:
1. Patients who present with extensively deflated arms
and a thin layer of remaining subcutaneous fat are
excellent candidates for excisional brachioplasty.
2. Patients who present with a significant amount of
remaining subcutaneous fat, the arm should be
aggressively liposuctioned in a preliminary
procedure and a secondary excisional procedure can
then be performed in 6 to 12 months.
3. A third group of patients present with an
intermediate amount of subcutaneous fat. The
patients should be given the choice of undergoing
excisional procedures but attaining a less-then-ideal
result, or undergoing a preliminary liposuction
procedure.

20. Brachioplasty
A) The double ellipse technique:
It is helpful determine the appropriate amount of resection as overly
aggressive resection cause compression of the neurovasculature and
an inability to close the wound. In this procedure an Elliptical
excision and Design a Z-plasty at the axillary crease to prevent scar
contracture across the axilla.
Procedures of Brachioplasty

21. Brachioplasty
B) The L brachioplasty technique:
The ‘‘L’’ represents the shape of the excision, with the
long limb along the medial axis of the upper arm and the
short limb meeting at right angles across the axilla along
the midlateral chest.

22. Brachioplasty
C) Full brachioplasty:
It places the scar in the
bicipital groove.
The Flap excision is done
in a segmental fashion.

23. Brachioplasty
Preoperative and postoperative view showing scar in the
bicipital groove.

24. Brachioplasty
D- Short-scar brachioplasty (T-pattern)
the T pattern brachioplasty is the most frequently used
option.
This procedure is performed under local anesthesia with
intravenous sedation or general anesthesia
Short-scar brachioplasty with liposuction, before and after.
Scar is relatively well concealed in the axilla.

25. MANAGEMENT OF THE BREAST
AFTER MASSIVE WEIGHT LOSS
(MASTOPEXY)

26. Mastopexy
* Characteristic changes in the breast typically follow
massive weight loss are:
•Volume deflation
•Stretched skin envelope
•Significant ptosis
•Flattening of shape
•Medialized nipple areola complex

27. Brachioplasty
Depending on the skin-fat envelope of the arm excess, the
approach can be tailored as follows:
1. Patients who present with extensively deflated arms
and a thin layer of remaining subcutaneous fat are
excellent candidates for excisional brachioplasty.
2. Patients who present with a significant amount of
remaining subcutaneous fat, the arm should be
aggressively liposuctioned in a preliminary
procedure and a secondary excisional procedure can
then be performed in 6 to 12 months.
3. A third group of patients present with an
intermediate amount of subcutaneous fat. The
patients should be given the choice of undergoing
excisional procedures but attaining a less-then-ideal
result, or undergoing a preliminary liposuction
procedure.
Mastopexy
Algorithm for reshaping the MWL breast

28. Brachioplasty
Depending on the skin-fat envelope of the arm excess, the
approach can be tailored as follows:
1. Patients who present with extensively deflated arms
and a thin layer of remaining subcutaneous fat are
excellent candidates for excisional brachioplasty.
2. Patients who present with a significant amount of
remaining subcutaneous fat, the arm should be
aggressively liposuctioned in a preliminary
procedure and a secondary excisional procedure can
then be performed in 6 to 12 months.
3. A third group of patients present with an
intermediate amount of subcutaneous fat. The
patients should be given the choice of undergoing
excisional procedures but attaining a less-then-ideal
result, or undergoing a preliminary liposuction
procedure.
Mastopexy
I. Mastopexy with insufficient breast volume:
1) Augmentation mastopexy with breast implants:
The safest strategy in this population is a 2-stage
approach separating the mastopexy and the
augmentation into 2 separate procedures.
•Transaxillary Breast Augmentation / Wise
Pattern Mastopexy:
Advantages: Minimal manipulation of the
pectoralis major muscle and subsequently
decrease postoperative pain. Preservation of
intact muscle for coverage of the implant.
Disadvantage: Presence of axillary scar in addition
to the anchor incision performed

29. Brachioplasty
Depending on the skin-fat envelope of the arm excess, the
approach can be tailored as follows:
1. Patients who present with extensively deflated arms
and a thin layer of remaining subcutaneous fat are
excellent candidates for excisional brachioplasty.
2. Patients who present with a significant amount of
remaining subcutaneous fat, the arm should be
aggressively liposuctioned in a preliminary
procedure and a secondary excisional procedure can
then be performed in 6 to 12 months.
3. A third group of patients present with an
intermediate amount of subcutaneous fat. The
patients should be given the choice of undergoing
excisional procedures but attaining a less-then-ideal
result, or undergoing a preliminary liposuction
procedure.
Mastopexy

30. Brachioplasty
Depending on the skin-fat envelope of the arm excess, the
approach can be tailored as follows:
1. Patients who present with extensively deflated arms
and a thin layer of remaining subcutaneous fat are
excellent candidates for excisional brachioplasty.
2. Patients who present with a significant amount of
remaining subcutaneous fat, the arm should be
aggressively liposuctioned in a preliminary
procedure and a secondary excisional procedure can
then be performed in 6 to 12 months.
3. A third group of patients present with an
intermediate amount of subcutaneous fat. The
patients should be given the choice of undergoing
excisional procedures but attaining a less-then-ideal
result, or undergoing a preliminary liposuction
procedure.
Mastopexy
•Lateral breast flap with superomedial pedicle breast

31. Brachioplasty
Depending on the skin-fat envelope of the arm excess, the
approach can be tailored as follows:
1. Patients who present with extensively deflated arms
and a thin layer of remaining subcutaneous fat are
excellent candidates for excisional brachioplasty.
2. Patients who present with a significant amount of
remaining subcutaneous fat, the arm should be
aggressively liposuctioned in a preliminary
procedure and a secondary excisional procedure can
then be performed in 6 to 12 months.
3. A third group of patients present with an
intermediate amount of subcutaneous fat. The
patients should be given the choice of undergoing
excisional procedures but attaining a less-then-ideal
result, or undergoing a preliminary liposuction
procedure.
Mastopexy
Final closure of the wound, the IMF is elevated and
sutured to rib periosteum to maintain its position

32. Comparison between the two groups regarding HOMA-
IR
Results
0
1
2
3
4
5
6
7
8
9
10
Group A Group B
Mean±SD
HOMA.IR
Brachioplasty
Depending on the skin-fat envelope of the arm excess, the
approach can be tailored as follows:
1. Patients who present with extensively deflated arms
and a thin layer of remaining subcutaneous fat are
excellent candidates for excisional brachioplasty.
2. Patients who present with a significant amount of
remaining subcutaneous fat, the arm should be
aggressively liposuctioned in a preliminary
procedure and a secondary excisional procedure can
then be performed in 6 to 12 months.
3. A third group of patients present with an
intermediate amount of subcutaneous fat. The
patients should be given the choice of undergoing
excisional procedures but attaining a less-then-ideal
result, or undergoing a preliminary liposuction
procedure.
Mastopexy
2) Augmentation Mastopexy With Lateral Thoracic Flap:
•The spiral flap:
Advantage: Using the spiral flap, breasts are not only enlarged and
better shaped, but are soft and shift naturally with change in body
position. The constricted inferior breast is beautifully filled with
redundant epigastric tissue.
Disadvatage: possible flap tip necrosis, and is treated by flap
debridement possibly with future implant augmentation.

33. Brachioplasty
Depending on the skin-fat envelope of the arm excess, the
approach can be tailored as follows:
1. Patients who present with extensively deflated arms
and a thin layer of remaining subcutaneous fat are
excellent candidates for excisional brachioplasty.
2. Patients who present with a significant amount of
remaining subcutaneous fat, the arm should be
aggressively liposuctioned in a preliminary
procedure and a secondary excisional procedure can
then be performed in 6 to 12 months.
3. A third group of patients present with an
intermediate amount of subcutaneous fat. The
patients should be given the choice of undergoing
excisional procedures but attaining a less-then-ideal
result, or undergoing a preliminary liposuction
procedure.
Mastopexy
II. Mastopexy with sufficient breast volume:
1) Dermal suspension and total parenchymal reshaping mastopexy:
The advantage of The dermal
suspension with parenchymal
reshaping technique is a safe and
reliable procedure that may be
performed in conjunction with other
body contouring procedures. If
further volume is needed, implant
placement in the subpectoral plane
may be added
Disadvantages include the need to
create lengthy scars, a longer
operative time for extensive
deepithelialization.

34. Mastopexy
Rotation-advancement
Technique
Inferior chest wall flap
2) Vertical mastopexy
Passage of the inferior chest flap under a loop of
pectoralis muscle

35. Brachioplasty
Depending on the skin-fat envelope of the arm excess, the
approach can be tailored as follows:
1. Patients who present with extensively deflated arms
and a thin layer of remaining subcutaneous fat are
excellent candidates for excisional brachioplasty.
2. Patients who present with a significant amount of
remaining subcutaneous fat, the arm should be
aggressively liposuctioned in a preliminary
procedure and a secondary excisional procedure can
then be performed in 6 to 12 months.
3. A third group of patients present with an
intermediate amount of subcutaneous fat. The
patients should be given the choice of undergoing
excisional procedures but attaining a less-then-ideal
result, or undergoing a preliminary liposuction
procedure.
Mastopexy
III. Mastopexy with excess autologous volume:
Although unusual in the MWL population, an occasional
patient presents with excess breast volume. In these cases,
the inferior pedicle or superomedial pedicle mastopexy
procedures can be combined with resection of breast
parenchyma as in a standard reduction mammaplasty.
Short scar reduction mammoplasty: The procedure started
with suction-assisted lipectomy in the IMF and the lateral
chest wall to contour the inferolateral aspect of the breast to
define the lateral breast border.

36. MANAGEMENT OF THE
ABDOMEN AFTER MASSIVE
WEIGHT LOSS
(ABDOMINOPLASTY)

37. Abdominoplasty
Abdominoplasty
The decision for the type of abdominoplasty depends on
the amount of loose skin, extent of excess fat, and muscle
laxity and muscle diastasis.
Choice of operation:
 Full abdominoplasty: Healthy patients with
infraumbilical striae, moderate excess adiposity, skin and
soft-tissue laxity, and rectus diastasis or myofascial laxity
are ideal candidates for full abdominoplasty.

38. Abdominoplasty
Intraoperative view of
abdominoplasty with
umbilical transection
(A) Markings in the
supine position;
(B,C) preservation of
Scarpa fascia;
(D,E) preparation of the
umbilical stalk
(F) closure of the
umbilical base with
nonresorbable
suture material.

39. Abdominoplasty
 Mini-abdominoplasty is a great
procedure for patients with minimal
abdominal skin excess limited to the
infraumbilical region or an unsatisfactory
suprapubic scar who desire skin tightening.
These patients are usually young women
who have had one or two pregnancies, have
good skin elasticity, and are not overweight.
 Extended abdominoplasty indicated in patients who are overweight
or modertly obese, and those who have had significant weight fluctuations and
or weight loss. These patients are concerned about the fullness of the central
abdomen, as well as the fullness and laxity of the tissues in the flank area.

40. Abdominoplasty
 Circumferential abdominoplasty is an ideal
procedure for patients who have experienced massive
weight loss and who have circumferential tissue laxity of
the trunk plus buttock ptosis, lateral and posterior thigh
laxity, and patient acceptance of a circumferential
incision.

41. Abdominoplasty
 High lateral tension abdominoplasty (HLT) avoids
raising and distorting the mons pubis. It corrects
epigastric flaccidity better than traditional
abdominoplasty by pulling from 2 inferolateral directions.
The patient is flexed, the abdominal
flaps are fixed at the midline, and
each half is demarcated. The excess
flaps are incised and resected

42. Abdominoplasty
 Fleur‐de‐lis abdominoplasty is the most powerful
procedure for maximal tightening of the entire abdomen
and reshaping the lower body. Using this approach, a
maximum improvement of body shape and reduction of
waist circumference is achievable.
The Fleur‐de‐lis (FDL)
technique removes
supraumbilical horizontal
excess via a vertical
excision, in addition to the
transverse incision.

43. Abdominoplasty
A 45-year-old patient with weight reduction of 80
kg,underwent a fleur-delis abdominoplasty. (A,B) Pre-
and (C,D) 3 months‟ postoperative oblique and front
images of a fleur-de-lis abdominoplasty procedure
with fascial tightening and breast reshaping.

44.  The present study revealed the best cutoff value of serum leptin
in predicting IR among patients with CHC to be ≤ 10 ng/mL.
This value had 59.26 % sensitivity, 53.85 % specificity and an
overall accuracy of51.3% for detection of insulin resistance
among patients with chronic HCV infection.
 On the other side, the best cutoff value of serum leptin in
predicting IR among patients with HCC was > 15 ng/mL. This
value had 40 % sensitivity, 100 % specificity and an overall
accuracy of 72.2% for detection of insulin resistance among
patients with HCC.
Results
MANAGEMENT OF THE THIGH
AFTER MASSIVE WEIGHT LOSS
(THIGH LIFT)

45. Thigh Lift
The medial upper thigh area particularly, is often subject to
ptosis and skin wrinkling, due to the thinness of the skin
and frequent fat deposition.
Medial Thigh Lift procedures:
I- Transverse medial thigh lift
Indications
Patients with skin laxity but
limited to the upper third of
the thigh only.

46. Thigh Lift
II- Vertical medial lift *
Surgical markings of vertical medial
thigh lift with a horizontal component Right thigh → wound closed.
Left thigh → surgical dissection

47. Thigh Lift
(A–-C) A 55-year-old woman 13 months following gastric bypass surgery and
weight loss of 52 kg. Current weight and BMI: 71 kg, 30, respectively. (D–-F) 22
months following body lift and 10 months following medial thigh lift with a
vertical component extending onto leg

48. Thigh Lift
III- Short vertical scar medial thigh lift
Indications
It is indicated where there is a vertical descent of tissue immediately
beneath the groin crease as it extends into the perineum and hence
into the buttocks. The principle is simply to excise an ellipse of skin and
fat and hitch up the distal tissues onto the adductor tubercle and
fascia.

49. Thigh Lift
Skin Excision of short vertical scar
medial thigh lift.
Excision of skin and superficial fat,
is limited down by the Scarpa‘s
fascia. thus veins and lymphatics
are preserved.
Frog‘s leg”position. View of short
vertical scar medial thigh lift
medial thigh lift scars

50. Finally the optimization of results in body
contouring requires simultaneous visualization
of all body regions. This goal is achieved
through circumferential and balanced surgical
approach. There are several factors affecting
choice of the technique such as, gender of the
patient, age, general condition and patient
wishes.

51. Body contouring for the massive
loss is a challenge to achieve the
ideal technique for the specific
deformity at the proper timing
with the least complications.

52. Thank you