Treating the Abdominotorso Region ofthe Massive Weight Loss Patient: AnAlgorithmic Approach
Steven G. Wallach, M.D.
New York, N.Y.Summary: There has been tremendous growth in the number of patients seek-ing body contouring procedures after massive weight loss. Most patients desireimprovement of the abdominotorso region first. After massive weight loss, thereis enormous variability of body proportions, and therefore there have been manysurgical options proposed based on the quality of the skin, subcutaneous fatcomponent, and location of the lax tissue. Each area needs to be assessed to seewhether there is a significant lower abdominal component, an upper midlineabdominal component, or contributions from the buttocks and flanks. Analgorithm for treatment is presented to simplify the decision-making process.Patient examples are also shown to demonstrate the usefulness of thealgorithm. (Plast. Reconstr. Surg. 121: 1431, 2008.)
As a result of the increasing popularity ofbariatric surgery, plastic surgeons are treat-ing greater numbers of massive weight loss
patients. These patients typically lose more than100 pounds and have significant skin laxity withvarying amounts of subcutaneous tissue excess.Commonly, the abdominotorso region is treatedfirst; it often gives patients the most grief. Theoverhanging pannus may predispose this region torashes and can make it difficult for patients to wearproperly fitted clothing.
Several authors have proposed systems that havebecome useful tools for classifying and treating pa-tients desiring abdominal contour surgery.1–3 How-ever, these systems do not adequately classify themassive weight loss patients who are now seekingtreatment.
Recently, a classification of contour deformi-ties after bariatric weight loss was described bySong et al.4 The system involved evaluating 10different anatomical regions commonly treatedafter massive weight loss. A table was used to il-lustrate preferred treatment plans for different
anatomical regions based on this rating system,but details regarding the different treatment planswere not elucidated.
It is rare for a massive weight loss patient toundergo just a full abdominoplasty; treatment ofthe flanks and buttocks has become common.Therefore, many patients require a more involvedprocedure such as a circumferential abdomino-plasty or even one that uses a fleur-de-lis approach.It stands to reason that a new system is necessaryto classify and treat this subset of abdominotorsocontour patients. In a fashion similar to the ap-proach for arm contouring described by Appelt etal.,5 the author has developed an algorithm fortreatment and classification of the abdominotorsoregion specifically for the massive weight loss pa-tient. Included are descriptions of the proceduresand patient examples illustrating the usefulness ofthe algorithm (Fig. 1).
PREOPERATIVE EVALUATIONA discussion with the patient is performed re-
garding their surgical goals, the various surgicaltreatment options, and the impact that their med-ical conditions can have on the surgical outcome.Surgery is usually delayed until the weight loss has
Disclosure: The author has no commercial associ-ations or financial disclosures that would pose orcreate a conflict of interest with information pre-sented in this article.
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plateaued; for a bariatric surgery patient, this isusually after at least a 100-pound weight loss orlonger than 1 year after the gastric procedure.Sometimes, surgery is performed sooner for a pa-tient who requires a panniculectomy to assist inthe management of other conditions.
The patient is first examined in supine posi-tion and evaluated for hernias and the extent ofrectus diastasis. A patient that has had an openabdominal procedure has an increased risk of her-nia formation.6,7 A massive weight loss patient mayhave an excess subcutaneous fat component,which can make palpation of a hernia difficult.Therefore, the hernia can remain occult until thetime of surgery.
The patient is then examined in the standingposition. The abdominal region is evaluated for skinlaxity and the extent of the subcutaneous fat com-ponent. Often, the patient will have striae, poor skinelasticity, and recalcitrant rashes not amenable toconservative treatment. A pinch test is performed ina horizontal fashion to evaluate the amount of tissuethat can be excised. The horizontal pinch is per-formed on the lower transverse abdominal tissuethat would be excised commonly during a routine
full abdominoplasty. The laxity and quality of theskin are evaluated in a vertical dimension in thesupraumbilical region as well. Using the vertical up-per abdominal midline as a reference point, a ver-tical pinch is performed pinching tissue from eachside of the midline to evaluate the upper abdominalmidline excess and laxity. If a vertical pinch improvesthe upper abdominal waistline and can eliminatesupraumbilical fullness, the possibility of performinga vertical midline incision is discussed. The thresh-old for using this additional incision is lowered if thepatient has a preexisting paramedian or midlinevertical scar.
The patient is then examined for mons pubisptosis.8 This is marked in accordance with Baroudi’sdescription, leaving a 5- to 7-cm length from thevulvar commissure to the top of the mons pubis.9The patient is evaluated in a right lateral, leftlateral, and posterior standing position using thehorizontal pinch test to evaluate the impact thepinch has on lateral and anterior thigh laxity andbuttock ptosis10 (Table 1).
The preoperative examination is essential be-cause there is tremendous variability of skin qual-ity, amount of the subcutaneous fat, and distribu-
Fig. 1. Algorithm for treatment and classification of the abdominotorso region after massive weight loss.
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tion of tissue laxity in these patients. Furthermore,it is during this period when the risks, benefits,and alternatives of all procedure options can bediscussed thoroughly with the patient.
CLASSIFICATION SYSTEMType I: Full Abdominoplasty
This patient has moderate abdominal skin lax-ity with variable amounts of subcutaneous fat. Thevertical skin and subcutaneous component con-tributing to the abdominal girth is minimal. Thelaxity in the upper abdomen can be treated bysuperior elevation and excision in a transversefashion along the lower abdomen as performedfor non–massive weight loss patients. The flanksand buttocks are not significantly lax and are nottreated. Repair of the rectus diastasis is performed.This patient has fairly good skin elasticity thatcontributes to the resiliency of the tissues, pre-cluding the need for a more involved procedure.I have found this more commonly in the youngermassive weight loss patient or in those patientswho have had less than a 100-pound weight loss.However, in general, this massive weight loss pa-tient is not common. Traditional abdominoplastyprocedures have been described elsewhere.11–16
Two closed suction drains are placed in the monspubis region through separate stab incisions. Theyare removed once the total fluid is less than 30cc/24-hour period, usually within 1 week. Thepatient is encouraged to ambulate the first nightof surgery and is to wear an abdominal binder for3 to 6 weeks (Fig. 2).
Type II: Fleur-de-Lis AbdominoplastyA massive weight loss patient ideally fitting this
profile is more theoretical than an actual patient.If individuals have enough vertical laxity to war-rant a fleur-de-lis, they will likely have similar laxityof the flanks and buttocks, requiring a circumfer-ential procedure. Unlike the type I patient, thereis significant vertical laxity contributing to theoverall girth that cannot be treated alone by un-dermining and excision along the lower abdo-men. Furthermore, diastasis repair alone will notsignificantly narrow this patient. The superior flap
is undermined and the redundant tissue is re-sected in the vertical midline to decrease the over-all girth. The redundant transverse componentis then resected once the vertical component isreconciled.17–21 The key to the closure is minimaltension. This patient is not flexed more than 20 to30 degrees to remove the excess tissue. The post-surgical care is similar to that used for the type Ipatient; however, I find that the drains stay in forseveral days longer (Fig. 3).
Type III: Circumferential AbdominoplastyThis procedure is indicated for a patient with
moderate to severe skin laxity of the abdominalskin with a significant flank/buttock component.The patient may have minimal to moderate excessin the supraumbilical component that can betreated by undermining alone and excising alongthe lower transverse abdomen.10,22–26 In addition, thepatient requires resection of the flank/buttock com-ponent to treat the laxity. After anesthetic induction,the patient is placed prone and the buttocks andflanks are treated first. The excess tissue is resectedand closed without tension or significant undermin-ing. The patient is then placed supine and the ab-dominal component is treated. The patient is flexed5 to 10 degrees for final excision and closure of thelower transverse abdomen. The postsurgical care issimilar to that described earlier, with the exceptionthat four closed suction drains are placed. Two drainthe buttock and flank region and two drain the ab-dominal region. These drains will often be kept infor 2 to 3 weeks (Fig. 4).
Type IV: Fleur-de-Lis CircumferentialAbdominoplasty
This patient has significant upper abdominallaxity, and redundancy in the lower abdomen re-quiring both vertical and transverse excision. Theflank and buttock regions contribute to the overalllaxity and require treatment. There is noticeablelaxity in the upper midline that contributes to theoverall girth of the patient that cannot be treated by
Table 1. Massive Weight Loss Abdominotorso Classification System
Type Fat Vertical Abdomen Laxity (girth) Flank/Buttock Component Treatment
I Variable Minimal Minimal Full abdominoplastyII Variable Moderate to severe Moderate to severe Fleur-de-lis abdominoplastyIII Variable Minimal to moderate Moderate to severe Circumferential abdominoplastyIV Variable Severe Moderate to severe Fleur-de-lis circumferential abdominoplastyV Severe Moderate to severe Moderate to severe Panniculectomy
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just undermining of the superior flap and resectionalong the inferior abdominal incision. Technicalvariations for treatment have been describedelsewhere.17–21 As with the type III patient, the pa-tient is placed prone and the buttock and flank tissueis excised without undermining and with minimaltension. The patient is then placed supine and theabdominal component is treated. Once the superiorflap is elevated, the excess in the vertical midline istreated. The patient is flexed 5 to 10 degrees and the
redundant lower abdominal transverse componentis excised. There is no tension on the closure. Thekeys to this procedure are in the initial marking ofthe patient, which is used as a guideline during thesurgical procedure, and minimizing the abdominalclosure tension (Figs. 5 and 6).
Type V: PanniculectomyThis is reserved for a patient who has signif-
icant amounts of subcutaneous fat with moder-
Fig. 2. A 36-year-old woman, 5 feet 2 inches tall, after a 78-pound weight loss, with goodskin tone and laxity confined mainly to the lower abdomen. Preoperative (left) and 3-weekpostoperative appearance (right) following a full abdominoplasty.
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ate to severe skin laxity. This patient is besttreated after his or her goal weight is achieved,when the patient can be assigned to a type I toIV abdominotorso group. Unfortunately, be-cause of hygiene issues or the need to performother surgical procedures (i.e., general surgical,gynecologic, or urologic procedures), the pan-nus is obstructing access and requires excision.This patient is still overweight and has signifi-
cant surgical risks including delayed woundhealing.27–29 Delaying surgery until weight loss iscomplete is preferable, because the risks of sur-gery are significantly diminished.28 Excision ofthe pannus is performed without underminingto avoid creating poorly perfused tissue and todecrease the risk of seroma formation. In someinstances, the umbilicus may have to be sacrificed26,28,29
(Fig. 7).
Fig. 3. A 48-year-old woman, 5 feet 2 inches tall, after a 101-pound weight loss. She had hada recurrent umbilical hernia and multiple scars on her abdomen. The patient had significantlaxity of her lower abdomen, her vertical midline abdomen, and her flanks and buttocks. Thepatient chose not to have the flanks and buttocks treated at the time of surgery. Appearancepreoperatively (left) and 7 months after fleur-de-lis abdominoplasty and 1 month after um-bilicoplasty (right).
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CASE REPORTS
Case 1A 36-year-old woman, 5 feet 2 inches tall and initially
weighing 228 pounds, lost 78 pounds after undergoing alaparoscopic gastric bypass and weighed 150 pounds. Onphysical examination, she had moderate skin laxity confinedto her lower abdomen, with minimal upper midline verticalskin laxity. She was classified as a type I patient that under-went a full abdominoplasty. Her 3-week postoperative pho-tographs are shown (Fig. 2).
Case 2A 48-year-old woman, 5 feet 2 inches tall and initially weigh-
ing 275 pounds, lost 101 pounds after her gastric bypass andweighed 174 pounds. The patient had significant skin laxity ofher abdomen, flanks, and buttocks, including severe supraum-bilical laxity. She had a reducible umbilical hernia. She also hadan upper vertical midline scar, a prior appendectomy scar, andprevious laparoscopic bypass incisions. Although she was a goodcandidate for a type IV procedure, she opted to be down-stagedto a type II, fleur-de-lis abdominoplasty for financial reasons. Atthe time of her combined type II procedure and umbilical
Fig. 4. A 34-year-old man, 6 feet 1 inch tall, after a 145-pound weight loss, with moderate skinlaxity and significant lower abdominal transverse laxity and significant buttock and flank lax-ity. He had an upper midline vertical scar. He did not have significant vertical abdominal skinlaxity. He was a good candidate for a circumferential abdominoplasty. Preoperative (left) and3-month postoperative (right) appearance following a full abdominoplasty.
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hernia repair, the general surgeon elected to amputate herumbilical stalk. The patient underwent an umbilicoplasty 6½months after the type II operation. Photographs of the 7½-month result from the type II procedure and 1 month after herumbilicoplasty are shown (Fig. 3).
Case 3A 34-year-old man, 6 feet 1 inch tall and initially weighing 360
pounds, lost 145 pounds after an open gastric bypass procedureand subsequently weighed 215 pounds. On physical examination,
he had moderate skin laxity confined to the lower abdomen anda moderate amount of subcutaneous fat. He also had significantbuttock and flank laxity. The patient had an upper midline verticalscar that he did not want revised. He was classified as a type IIIpatient. His 3-month postoperative result is shown (Fig. 4).
Case 4A 47-year-old woman, 5 feet 6 inches tall and initially weigh-
ing 285 pounds, subsequently weighed 178 pounds after a lapa-roscopic gastric bypass. On physical examination, she had sig-
Fig. 5. A 47-year-old woman, 5 feet 6 inches tall, after a 107-pound weight loss. She hadsignificant transverse and vertical abdominal skin laxity. She also had significant flankand buttock laxity. She had prior cesarean section surgery resulting in a lower midlinevertical incision and a Pfannenstiel incision. Appearance preoperatively (left) and 6months after a fleur-de-lis circumferential abdominoplasty (right).
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nificant transverse and vertical laxity of the abdomen andsignificant flank and buttock laxity. She had undergone threeprior cesarean sections: one by means of a lower midline verticalabdominal incision and the others through a Pfannenstiel in-
cision. She was an excellent candidate for a type IV procedure.Her 6½-month postoperative photographs are shown (Figs. 5and 6). She was pleased with her postoperative result but de-veloped meralgia paresthetica in her left upper thigh.
Fig. 6. Additional views of the patient shown in Figure 5.
Fig. 7. A 43-year-old woman, 5 feet 6 inches tall, after a 78-pound weight loss, with a largepainful umbilical hernia. The patient had significant skin laxity and rashes below her largeabdominal pannus. She had a significant amount of fat in her subcutaneous componentcircumferentially and had a previous upper vertical midline incision. She was still activelylosing weight. Because she needed to have her umbilical hernia treated but was still se-verely overweight, she was a good candidate for a panniculectomy. Preoperative view (left)and 16 months after panniculectomy with umbilical sacrifice (right).
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Case 5A 43 year-old woman, 5 feet 6 inches tall and initially weigh-
ing 303 pounds, weighed 225 pounds after an open gastricbypass and was not at her ideal weight. She was referred by herbariatric surgeon to remove the pannus in conjunction withtreatment of her painful umbilical hernia. On physical exam-ination, the patient had a large reducible umbilical hernia andan upper midline vertical scar. She had significant skin laxityand rashes below her abdominal pannus. She was a candidatefor type V procedure at this time and desired further treatmentof other anatomical regions once her weight loss was complete.The patient underwent a type V procedure (panniculectomy)combined with an umbilical hernia repair and sacrifice of herumbilicus. Sixteen-month postoperative results are shown (Fig. 7).
DISCUSSIONThe algorithm described is based on ideal pa-
tient conditions so that general guidelines can beused as a starting point for patient classificationand treatment. Most massive weight loss patientswho desire abdominal contour surgery fall intothe five general treatment categories that I havedescribed previously. Types I through IV are thosepatients who have reached their goal weight. Thetype V patient (i.e., one that requires a pannicu-lectomy) is the one that has not reached her idealbody weight but requires excision of the abdom-inal pannus to facilitate other surgical procedures(i.e., gynecologic, urologic, or general surgicalprocedures).
The classification system described is simpleand straightforward (Fig. 1). Although many ofthe patient categories appear to have very similarcharacteristics, there are unique differences. Atype I patient has minimal supraumbilical verticalpinch laxity and does not have flank or buttocklaxity. Both the type II patient and the type IVpatient have severe vertical abdominal laxity dem-onstrated by a significant vertical pinch; this dif-ferentiates them from the other types. Whatshould differentiate the type II from the type IVpatient is that the type IV patient also has signif-icant flank and buttock laxity, warranting a cir-cumferential procedure. In my experience, a typeII patient is a theoretical entity. I do not think thepatient really exists in the sense that she could onlyhave significant vertical upper midline laxity with-out also having flank and buttock laxity. The typeII patient that I encounter is originally classified asa type IV patient but, because the patient may notbe able to afford the circumferential procedure ormay not want the increased surgical risk of alengthier and more complex surgical procedureand/or the potential increased downtime fromthe procedure, opts to be down-staged to have atype II procedure. The type III patient does not
have significant supraumbilical fullness or laxitythat, on performing a vertical pinch, warrants afleur-de-lis procedure yet still has the laxity in theflanks and buttocks that warrants a circumferen-tial procedure.
Abdominotorso contour surgery in the mas-sive weight loss patient involves a complex deci-sion-making process to ensure the best result withthe least amount of complications.20,21,26,30,31 Withthis, there are certain tradeoffs that a massiveweight loss patient must consider when choosingan abdominotorso contouring procedure. Theseinclude the following: reconciliation of scarringversus additional contour improvement, the amountof time that the patient can take off from work ordaily activities, and the potential financial obliga-tions that may impact the choice of surgical proce-dure. More extensive procedures will probably re-quire a longer convalescence period, additionalincisions, and often a greater financial burden, all ofwhich impact the patient’s decision. Certainly, manyvariables including those described above can im-pact the procedure choice, and in some cases down-staging to a lesser procedure may be appropriate.
Prior surgical procedures can impact thechoice of treatment. There has been some debateregarding abdominoplasty after open cholecystec-tomy because of the potential of having a limitedblood supply to tissue that would end up betweenthe new lower abdominal scar and the cholecys-tectomy scar.32,33 Chevron incisions in the uppermidline may lead to consideration of using a re-verse abdominoplasty.34–36 Commonly, a McBur-ney incision, a lower midline or paramedian ver-tical incision, and a Pfannenstiel incision canusually be removed when performing one of thefive procedures described. Having a vertical uppermidline abdominal scar may tether and restrictmovement of the upper abdominal flap. A simplescar revision for a patient without significant mid-line vertical laxity or using a fleur-de-lis approachfor the patient that does have significant verticallaxity can alleviate this problem.
Often, the massive weight loss patient requeststreatment of several different anatomical regions.Combining surgical procedures in addition to theabdominotorso contour procedure can impactthe treatment choice as well. Sometimes, thesemay be performed together during the same op-erative session. However, performing combinedprocedures will increase the length of surgery andcomplexity, and may increase the risk of compli-cations, requirement for blood transfusions, andneed for extended hospital stays,37,38 although
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some studies do not support the potential in-creased complication risk.39–41 The patient may bedown-staged to a less invasive abdominotorso pro-cedure while also treating the additional anatom-ical region, so that these risks can be minimized.For instance, a mastopexy or breast reduction pro-cedure using a Wise pattern performed in com-bination with an abdominal contour proceduremay impact the blood supply to the abdominalflap, especially with a fleur-de-lis approach, and sodown-staging may be appropriate.
Sometimes, the massive weight loss patientrequires hernia repair, and this can be per-formed in conjunction with their abdomino-torso contour procedure. An umbilical or inci-sional hernia usually does not affect the choiceof surgical procedure but may impact the com-plexity and length of the procedure, potentiallyincreasing the risks as well.37– 41 Hernia repair inconjunction with an abdominotorso contourprocedure may impact the viability of the um-bilicus (see case 2), and when a ventral herniais repaired, it may impede the quality of thediastasis repair.
The algorithmic approach is set up for theideal situation, barring contributory medical con-ditions, scarring, hernia repair, or combined pro-cedures. The algorithm is presented to provide aneasy, reliable method with which to classify pa-tients so that an adequate treatment plan can beoffered.
Steven G. Wallach, M.D.1049 Fifth Avenue, Suite 2D
ACKNOWLEDGMENTSThe author thanks Eric A. Appelt, M.D., Jeffrey E.
Janis, M.D., and Rod J. Rohrich, M.D., for inspiringhim to submit this article after reading their article en-titled “An Algorithmic Approach to Upper Arm Contour”(Plast. Reconstr. Surg. 118: 237, 2006).
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Volume 121, Number 4 • Contouring after Massive Weight Loss
