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There are many established plastic surgical techniques to address effectively the lax, redundant tissue of the post–weight loss patient. Surgeons who are beginning their involvement in treating these patients are discovering that standard techniques are not always applicable to this rapidly growing group of patients and their extraordinary surgical challenges. Unique to the buttocks and the post-bariatric female breast is a tendency for these areas not only to become loose and ptotic but also to lose their natural fullness after weight loss. This type of contour deformity is not adequately treated with excisional procedures alone. To improve the buttock shape in these patients, the author has developed a soft tissue augmentation of the buttocks using a large random flap of subcutaneous tissue. The flap is transposed as a supramuscular “implant” as part of a belt lipectomy–lower body lift type of procedure. This accomplishes an augmentation buttock-pexy, creating a more full and supple contour to the buttock than can be achieved with skin excision alone. This procedure has been performed in more than 60 patients with consistent, durable results and is a reliable method to improve the cosmetic results of post-bariatric buttock contouring surgery.
Morbid obesity rates continue to rise in the United States and more than 6 million American adults now meet the criteria defined as a body mass index (BMI) of 40 kg/m2 or greater or more than 100 pounds overweight.1 The number of bariatric operations has also risen, with an estimated 150,000 procedures performed in 2003 alone.2 As obesity and bariatric surgery continue to expand in the United States, more patients will seek correction of the cutaneous cosmetic and functional sequelae of massive weight loss. Body contouring has thus become an essential component in the rehabilitation of the formerly morbidly obese patient. It is essential that plastic surgeons treating these patients have a diverse set of procedures in their armamentarium to accommodate each individual patient's needs and desired goals.
Many patients accomplishing dramatic weight loss are left with hanging skin and subcutaneous tissue at the buttocks. Similar to the situation encountered in the post-bariatric breast, the problem is not simply one of excess skin but also a dearth of volume. In areas such as the abdomen, arms, and thighs, post-bariatric procedures are designed to remove as much of the redundant skin and underlying subcutaneous fat as possible, leaving the treated area tightened and thinned. A proper result in the buttocks usually requires a different approach. The skin of the buttocks, stretched by the expansion of the subcutaneous fat, expands to larger than its original surface area, the extent of which is of course dependent on the increase in subcutaneous fat thickness. After extensive weight loss, the subcutaneous fat returns to near its original thickness but the skin does not return to its original surface area. Therefore, when excess skin and its underlying subcutaneous fat are removed, the buttocks loses net volume and thus becomes much flatter than its pre–weight gain appearance. The more weight gain and loss in the buttocks, the more excess skin, and the more of the original volume of the buttocks is lost with excisional surgery. To provide patients with a better postoperative appearance, the author has developed a simple and reliable method of restoring proper buttock contour and volume in the post-bariatric patient and has integrated this technique into an abdominoplasty–lower body lift type of procedure. The procedure is straightforward, has a very short learning curve, follows basic plastic surgical principles, and is easily adjusted to provide a wide range of volumetric options to accommodate most post-bariatric body types. Just as many weight loss patients benefit from augmentation at the time of mastopexy to fill out as well as lift their empty breasts, this procedure produces a fuller, more natural contour to the buttock using autologous tissue that would otherwise be excised.
Patients are selected based on their need for abdominoplasty and lower body lift or circumferential abdominoplasty–belt lipectomy after massive weight loss. These patients not only have excess abdominal tissue but also suffer from hip, lateral thigh, posterior thigh, back, and buttock redundancy, necessitating a circumferential approach. Most patients are post-bariatric, but some patients present after success with conventional weight loss. Although a few patients have a full buttocks despite their weight loss and do not require volume augmentation, most patients present with a loss of buttock mass, which would be exacerbated by a simple buttock lift. In the absence of other alternatives, post-bariatric patients with a loose and flaccid buttocks would be forced to choose between a tighter but still flattened, empty, and unnatural-appearing buttocks or prosthetic augmentation. Current available prostheses include solid Silastic, silicone gel–filled, and saline-filled implants. Each of these prosthetic devices has an obvious set of disadvantages. It is for this reason that the procedure described herein was developed. Our patients underwent autogenous tissue buttock augmentation during excisional body contouring.
A random medially based flap is designed along the lower back, over the inferior aspect of the thoracolumbar fascia and superomedial insertion of the gluteus maximus muscle. Perforators from the superior gluteal artery, lateral sacral arteries, and fourth lumbar artery contribute to the blood supply to this flap. Despite the possibility of the flap having axial properties, no studies have yet been done on the blood supply to this flap and therefore it is, for the purposes of this series, designed using the anatomic limitations of a random flap. The flap is designed with a 2:1 length-to-width ratio and is composed of subcutaneous tissue and dermis if desired. It is based at the midline and extends laterally a distance dependent on the length needed to approach the infragluteal fold when transposed if limits on the width of the flap allow. Its exact dimensions, including its thickness, are determined by the volume of tissue deemed necessary to fill out the buttock contour. The width of the flap and the exact position of the flap's lateral borders are determined by the level of the incision lines for the buttock-thigh lifting procedure.
Patients are marked preoperatively in the standing position as shown. The markings for the buttock-thigh lift are posterior extensions of the abdominoplasty markings (Fig. 1). The superior line delineates a gull-wing–shaped incision. If there is no significant hip or lumbar redundancy, the incision is placed at the intended scar position. If hip or lumbar redundancy or both are to be treated, the gull-wing incision is made at a higher level appropriate for intended excision of the redundant hip/lumbar skin and soft tissue. The gull-wing shape of the incision is designed to accept the shape of the inferior skin edge as bilateral medial rotation of the elevated buttock skin and subcutaneous tissue results in a matching “V” defect (Fig. 2). The horizontal inferior marking is then made at a height determined by the extent of buttock, lateral thigh, and posterior thigh skin and soft tissue redundancy. Between these two incisions lie the tissues that would normally be excised in a standard buttock lift type of procedure. This procedure makes proper use of these tissues to augment the buttocks. The size of the flap needed to augment the buttock contour is also estimated at this time. The flap is a random, medially based flap designed along the lower back between the incision lines described previously. It is composed of subcutaneous tissue (and dermis if the additional dermal mass is desired), is based at the midline, and extends laterally a distance based on the length needed to reach approximately the infragluteal fold when rotated but no greater than twice the flap width. Therefore, if the incision lines delineate a narrow strip of skin and subcutaneous tissue, the flap length is severely limited. Although I have not encountered this problem in my experience, it is a conceivable limitation on the length of the flap. Flap thickness is also determined by the volume of tissue necessary to fill the buttock contour properly. If necessary for increased volume, dermis can be included in the flap and the subcutaneous tissue can be taken down to fascia. Ethnic factors and patients' preferences are taken into account when designing the volume of the flap.
The abdominoplasty is done first, extending laterally to at least the posterior axillary line. The patient is then placed in the prone position (Fig. 3). Skin incisions are as described previously, and dissection is carried down to fascia. The transposition flap is then deepithelialized if the need for all possible bulk requires preservation of the dermis or simply deskinned if conservation of dermal mass is not critical. The skin and subcutaneous tissue of the buttock below the inferior incision are then elevated in the prefascial plane (Fig. 4). This dissection is carried down to the limits of skin redundancy and can be carried down to the infragluteal fold, especially if posterior thigh skin redundancy is to be treated. The flap is then separated from surrounding tissue except several centimeters at its medial aspect where this random flap (Fig. 5) is based, and it is rotated inferiorly toward the infragluteal crease. Depending on the flaccidity or rigidity of the subcutaneous tissues of the individual patient, it is sometimes easier to transpose the flap as a turn-down flap rather than to rotate the flap inferiorly. The distal end of the flap is sutured to the desired position without tension to the gluteal fascia with a 0-Maxon suture. The skin is redraped over the flap and adjustments are made to its size and contour. With one side completed, the extent of augmentation is obvious (Fig. 6). Excess skin is then excised with care taken to account for the increase in buttock volume. Until the surgeon acquires adequate familiarity with this procedure, it is advised that preexcision not be done to avoid skin closure problems. The medial transposition of the buttock skin and subcutaneous tissue results in a V shape to the inferior incision line, matching the gull-wing shape of the upper incision (Fig. 7). The elevation of the buttock skin and subcutaneous tissue tightens the buttock and the posterior thigh. The medial rotation tightens the lateral thigh. Suction drains are placed within the open areas and Tisseel (Tisseel VH Fibrin Sealant, Baxter Healthcare Corporation) is used prior to closure. The deep tissues are closed with 0-Maxon, the deep dermis with 2–0 Dexon, and the skin with a running 4–0 Maxon subcuticular suture.
This procedure has been performed on more than 60 patients with follow-up of up to 4 years. All patients achieved an improved buttock contour that has persisted for the duration of follow-up. All patients expressed satisfaction with the postoperative shape of their buttocks.
Among the initial patients, wound dehiscence was the most common complication. Small openings were treated with progressive reapproximation. Large openings (Fig. 8) were closed with a wound vacuum apparatus. The use of fibrin sealant along with more experience with the procedure soon eliminated this problem. The sample size is too small to determine whether the use of fibrin sealant or technical factors alone actually account for the improvement, and such a study is beyond the scope of this article. To avoid wound dehiscence, patients are instructed not to sit or flex at the waist and hip for at least 10 days after surgery.
Other complications in the series were skin necrosis related to a patient sleeping on a heating pad (Fig. 9) and a scar mass from an unilateral distal flap necrosis. The most common complication was seroma formation. Total seromas including very minor ones approached 25%. Minor seromas were treated with serial percutaneous drainage; persistent seromas were treated with reinsertion of drains. Patients in whom drainage persisted more than three or more weeks were effectively treated with a wound vacuum apparatus.
After massive weight loss, patients are usually left with redundant skin and subcutaneous tissue causing both cosmetic deformity and functional difficulties at various areas of their bodies. Established body contouring procedures attempt to address each of these problems.3 Gonzalez-Ulloa described belt lipectomy to deal with circumferential obesity.4 Lockwood described the lower body lift, including elevation of the transverse flank, thigh, and buttocks, thus addressing several contour deformities in one procedure.5 These procedures have been shown to be effective at correcting post–weight loss deformities.5,6,7,8 However, in the case of the buttocks, as in the breasts, a “lift” alone does not sufficiently improve contour in an area that is naturally full and rounded. Whereas volume deficiency of the breast is easily treated with a prosthetic implant at the time of mastopexy, this is not the case with the buttocks. The new procedure described here is a technique of rearranging autologous lower back and buttock tissue that would otherwise be excised and discarded and using it to produce a better buttock shape. These patients have enough excess tissue in this area to enable the safe elevation of a subcutaneous flap that is rotated to fill out the buttock contour. Patients' preferences and ethnic congruity are taken into consideration when designing the shape and position of the flap.9
Several techniques have been described to improve buttock shape, including the use of implants10,11 and lipoinjection.12 These techniques have been presented as having produced good results, but each has its limitations when applied to post–bariatric surgery patients. Augmentation gluteoplasty with implants introduces a foreign body into patients already susceptible to wound complications.13 Solid Silastic implants cause a very uncomfortable mass effect whether placed subcutaneously or submuscularly, and filled implants risk rupture related to the innate trauma to the area.14 Lipoinjection is more appropriate when a moderate increase without excisional surgery is needed to improve contour. Fat injection has been reported to be useful,15,16 but the author sincerely doubts whether a significant volume augmentation can be permanently achieved in an area that requires the addition of 200 mL or more to achieve an adequate result. Patients with massive weight loss require a substantial addition of volume when buttocks tightening is done, and an adequate cosmetic result cannot be achieved by skin excision alone. This procedure creates an autologous filler of substantial and intraoperatively adjustable volume using tissue that would otherwise be discarded in a standard belt lipectomy or lower body lift procedure. This flap of subcutaneous tissue and dermis serves to augment the volume of the buttock to provide an improved postoperative result compared with standard techniques (Figs. 10–15).
Post–bariatric surgery patients represent an ever increasing group of prospective surgical candidates seeking the cosmetic and functional rehabilitative procedures of body contouring. As we gain experience in treating these patients, we continue to refine our methods and adapt various procedures to improve our cosmetic results. Presented here is a new surgical technique to provide a proper buttock contour after dramatic weight loss using autologous tissue. This technique is simple and can easily be performed as part of a belt lipectomy or lower body lift to achieve a rounder, more naturally shaped buttock.