Body contouring by combined abdominoplasty and medial vertical thigh reduction: experience of 14 cases

Transcription

1 The British Association of Plastic Surgeons (2004) 57, Body contouring by combined abdominoplasty and medial vertical thigh reduction: experience of 14 cases M.G. Ellabban*, N.B. Hart Plastic Surgery Unit, Castile Hill Hospital, Cottingham, East Yorkshire, UK Received 31 August 2003; accepted 10 December 2003 KEYWORDS Obesity; Massive weight reduction; Body contouring; Abdominoplasty; Medial vertical thigh reduction Summary The common perception of beauty in the human body has shown a dramatic change over the past few decades culminating in a preoccupation not only with body weight, but also with body image. 1 Obesity is becoming prevalent in our society, and yet generalised redundancy of skin following massive weight reduction can also be an affliction. 2,3 Localised fat deposits in one or more regions of the trunk, upper arms and thighs are common and are virtually impossible to correct by diet, weight loss or exercise. 4 Excision of the excess pendulous skin and/or the localised fat deposits are able to reduce or even eliminate the physical problems associated with the condition and contribute significantly to patient self-esteem. 3 These procedures are usually multiple and extensive. 2,5,6 Combining and reducing the number of such procedures while obtaining optimal results would be most beneficial to both the surgeon and the patient. 2 We report our experience of 14 patients who underwent body contouring operations using combined abdominoplasty and medial thigh reduction with analysis of the results and discussion of the requirements and the advantages of the technique. Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. Patient and method From May 1994 to February 2000, following substantial weight reduction 14 female patients underwent combined abdominoplasty and medial vertical thigh reduction performed all by the senior author (N.B.H.). All patients had long standing obesity that was treated either conservatively by diet and exercise *Corresponding author. Address: Plastic and Reconstructive Surgery Unit, Royal Preston Hospital, Sharoe Green Lane North, Fulwood, Preston PR2 9HT, UK. Tel.: þ ; fax: þ address: mohammedellabban@hotmail.com or surgically by vertical banded gastroplasty and managed to achieve long term (more than a year) weight reduction to a body mass index (BMI) around 30. They were referred to our unit with excessive redundant skin, lipodystrophies or resistant localised fatty areas in the lower abdomen and medial thighs for correction. These patients were otherwise fit nonsmokers or had stopped smoking 6 months prior to surgery. Routine preoperative evaluation and laboratory profile were carried out. Anti-embolism measures in the form of low molecular weight heparin (Fragmin w 2500 units, subcutaneously, once daily) and thrombo embolic deterrent (TED) stockings S /$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /j.bjps

2 Body contouring by combined abdominoplasty and medial vertical thigh reduction 223 were started preoperatively, while intermittent calf compression (Flowtron w, Huntleigh Healthcare) was used in the operation theatre. The skin incisions were marked with the patient in the standing position with the thighs slightly abducted. Antibiotics were given in theatre before the start of the procedure. With the patient in the supine position, the abdominoplasty operation was done first through a low transverse Regnault type 7 incision. The fascio-cutaneous flap was mobilised up to the costal margins, the umbilicus circumcised on its pedicle and later re-inset after skin re-draping, rectus fascia plicated using a 0 Nylon continuous suture, then the abdominal flap re-draped after excision of the lower excess fat and skin. The wound is drained with suction drains and closed with subcutaneous 3/ 0 vicryl in layers and subcuticular 3/0 monocryl. With the knee flexed and the hip flexed and abducted, easy access to the medial thigh is achieved without the need to change the patient position in the operating theatre. A vertical ellipse of the medial thigh skin and subcutaneous fat is excised, the dimensions of which varies from one patient to the other to allow excision of all the excess redundant tissues and easy wound closure without tension. Care is taken to preserve the integrity of the long saphenous vein if encountered in the resection field. The thigh wound is drained with suction drains and closed in layers using subcutaneous 3/0 vicryl and subcuticular 3/0 monocryl. Postoperative haemoglobin check is done the next morning and the patient is gently mobilised on the second postoperative day. Heparin is stopped on full mobilisation of the patient and the drains are removed when clinically appropriate. Patients were usually discharged home on the fourth or fifth postoperative day. Results During a period of nearly 6 years, 14 female patients had body contouring procedures after massive weight loss using combined abdominoplasty and medial vertical thigh reduction (Table 1). Age of the patients range from 27 to 59 years with a mean of 39.1 years. Operative time range from 1 h 40 min to 2 h 40 min with a mean time of 2 h 01 min. The total weight of tissues removed range from 1490 to 3285 g with a mean of 1995 g. No blood transfusion was required as the postoperative haemoglobin check was 10 g/dl or above for all the patients in the study. Patients were followed up at 1, 3 and 12 months postoperatively and were all pleased with the overall results (Figs. 1 3). Complications Out of the 14 patients in the study, five patients (35.7%) had postoperative complications (Table 2). All were ultimately resolved without the need for surgical intervention. Four patients (28.6%) had trivial lower leg swelling which was treated conservatively by leg elevation, compression stockings and massage and eventually resolved. One patient (7.1%) had an infected seroma of the right thigh which was treated with oral antibiotics and aspiration of the seroma fluid. Another patient (7.1%) had superficial wound infection around the umbilicus which was treated with oral antibiotics and dressings. Discussion Obesity and poor cosmetic appearance after weight loss may cause the individual to have devalued self- Table 1 Patient results Patient no. Sex Age Date of surgery Duration of surgery Total weight removed 1 F 36 27/05/94 1 h 45 min 2008 g 2 F 40 18/08/94 1 h 40 min 1268 g 3 F 37 22/12/94 1 h 50 min 1490 g 4 F 38 23/02/95 2 h 10 min 1625 g 5 F 30 04/04/95 2 h 35 min 2040 g 6 F 48 24/01/96 2 h 15 min 2825 g 7 F 51 07/03/96 2 h 20 min 2500 g 8 F 27 07/08/97 1 h 45 min 1840 g 9 F 30 25/09/97 1 h 40 min 1760 g 10 F 35 17/09/98 1 h 50 min 1985 g 11 F 45 17/12/98 2 h 40 min 3285 g 12 F 59 14/10/99 1 h 45 min 1515 g 13 F 35 24/02/00 1 h 40 min 1554 g 14 F 37 05/08/99 2 h 25 min 2238 g

3 224 M.G. Ellabban, N.B. Hart Figure 1 Patient No. 3. (A C) Preoperative views. (D F) Postoperative views. image, to face difficulty in fitting of clothing and to suffer from physical affliction such as intertrigo, abdominal and back pain, or reduced mobility associated with large amounts of hanging redundant skin. 3 The abdomen, flanks and inner thighs are often specifically more affected by fat accumulation than the rest of the body. Flabbiness and loss of turgor of the skin especially of the upper inner thigh region lead to more ptosis of the tissues that contribute to the aesthetic problem. 4 These areas are improved to a limited degree by dieting and exercise, and suction lipectomy, is of limited benefit and can yield disappointing results due to redundant skin. Abdominoplasty and medial thigh reduction may be performed to correct these deformities In recent years, improvements in surgical and anaesthetic techniques have allowed significant body contouring procedures to be performed safely in obese patients. 12 Combined procedures can be performed safely and successfully without any added morbidity, provided that proper patient selection and good surgical techniques are applied. 6,13 Body contouring for the patients who have experienced massive weight loss involves extensive and multiple procedures. 2,5,6 Combining body contouring procedures has several advantages. In that

4 Body contouring by combined abdominoplasty and medial vertical thigh reduction Figure 2 Patient No. 6. (A and B) Preoperative views. (C and D) Postoperative views. 225

5 226 M.G. Ellabban, N.B. Hart Figure 3 Patient No. 10. (A and B) Preoperative views. (C and D) Postoperative views. it enhances patient satisfaction; it simultaneously corrects several aesthetic problems; it reduces the length of hospital stay and its cost, and reduces any associated risk with multiple anaesthetics. It may also decrease interference of scars with intended future procedures, and there is no difference in several reports in occurrence of clinical complications. 2,5,6 Combined body contouring procedures have been common place for years in plastic surgery. Combined mammaplasty with abdominoplasty, deep plane torso-abdominoplasty with buttocks pexy, brachioplasty with thoracoplasty and mammaplasty, and multiple facial procedures all have been done successfully without any added morbidity. 2,5,6,13,14,15

6 Body contouring by combined abdominoplasty and medial vertical thigh reduction 227 Table 2 Patient complications Patient no. Complications Management 1 Non 2 Right leg swelling Conservative 3 Non 4 Bilateral leg swelling Conservative 5 Infected seroma right thigh Seroma drained and conservative treatment of leg swelling Right leg swelling 6 Swelling of legs Conservative 7 Non 8 Non 9 Non 10 Non 11 Non 12 Non 13 Non 14 Umbilical wound infection Antibiotics and dressings In our study we combined abdominoplasty with medial vertical thigh reduction as sagging of the lower abdominal skin and fat, and friction of the inner thighs with their associated problems were the two main distressing complaints of our patients after massive weight reduction. Using a vertical medial thigh reduction as opposed to the procedure described by Lewis 16 provides the advantages of being an easy technique that can be performed effectively and rapidly without adding much extra time to the original abdominoplasty operation. It is performed with the patient supine and so no need to change the position in theatre. It directly tackles the problem of the redundant skin and fat of the upper inner thighs and alleviates the mechanical friction that these patient encounter, and the resultant wound usually heals well with linear scar that is hidden in the inner aspects of the thigh. The commonest complication (28.6%) we had postoperatively in our patients was a transient leg swelling that we believe was due to the sacrifice of the long saphenous vein in our early cases with the resected medial thigh skin and fat that carries some of the leg lymphatics. A change of our technique was adopted with the careful preservation of the long saphenous vein and this complication was not encountered in the subsequent cases of the study. Patients recovery was uneventful and all were pleased with the overall result at the end of our follow-up (12 months). Combined abdominoplasty with vertical medial thigh reduction is effective in correcting aesthetic and physical problems after massive weight reduction. It is safe and easy to perform in carefully selected patients with excellent predictable outcome. References 1. Rohrich RJ. Body contouring. SRPS 1995;7(38): Hallock GG, Altobelli JA. Simultaneous brachioplasty, thoracoplasty and mammaplasty. Aesthetic Plast Surg 1985;9: Schechner SA, Jacobs JS, O loughlin KC. Plastic and reconstructive body contouring in the post-vertical banded gastroplasty patient: a retrospective review. Obesity Surg 1991;1: Baroudi R. Body contour surgery. Clin Plast Surg 1989;16(2): Hauben DJ, Benmeir P, Charuzi I. One-stage body contouring. Ann Plast Surg 1988;21(5): Pitanguy I, Ceravolo MP. Our experience with combined procedures in aesthetic plastic surgery. Plast Reconstr Surg 1983;71(1): Regnault P. Abdominoplasty by the w technique. Plast Reconstr Surg 1975;55: Matarasso A. Abdominoplasty. Clin Plast Surg 1989;16(2): Lookwood TE. Medial thighplasty. In: Hetter GP, editor. Lipoplasty the theory and practiceof blunt suction lipectomy, 2nd ed. Boston: Little Brown; p Kesseling UK. Regional fat aspiration for body contouring. Plast Reconstr Surg 1983;72(5): Vilain R, Dardour JC. Aesthetic surgery of the medial thigh. Ann Plast Surg 1986;17(3): Hustad JP. Body contouring in the obese patient. Clin Plast Surg 1996;23(4): Grazer FM. Abdominoplasty. In: McCarthy JG, editor. Plastic surgery. Philadelphia: WB Saunders; p Barrett Jr BM, Kelly MV. Combined abdominoplasty and augmentation mammaplasty through a transverse suprapubic incision. Ann Plast Surg 1980;4(4): Gonzalez M, Guerrerosantos J. Deep planed torso-abdominoplasty combined with buttocks pexy. Aesthetic Plast Surg 1997;21: Lewis Jr JR. The thigh lift. J Int Coll Surg 1957;27(3):