Obesity is the new epidemic of this century and is associated with other medical conditions including hypertension, diabetes mellitus, gout, obstructive sleep apnea and osteoarthritis of joints. Bariatric surgery encompasses a range of procedures designed to help individuals lose weight. Despite achieving healthy weight, many individuals are left with significant physical changes following weight loss that adversely affect their health and social integration.
The ideal abdominal contour is that of taut abdominal skin with a thin layer of subcutaneous fat and a well-toned muscle wall. In women, the ideal abdominal contour is one that is maximally tapered at the waist at the level of the umbilicus, smoothly transitioning from the chest to the abdomen and then on to the thighs, also commonly known as the hourglass figure. Men often desire reduction of lower abdominal and flank fat and accentuation of the muscle contour to project a more athletic and masculine image. Many individuals seek body contour improvement as the final step in their weight loss journey and seek to erase the legacy of their obese past.
Abdominal laxity following significant weight loss manifests as stretch marks, excess skin folds and significant generalized abdominal muscle bulge. Lower abdominal skin folds accumulate perspiration, leading to fungal infections, skin irritation and inflammation and malodour. Persistent localized fat deposits may cause contour irregularities. Finding well-fitting clothing may be difficult. A common complaint is that trousers tend to slip off the skin folds and require frequent readjustment. The soft tissue of the lateral (outer) thighs undergoes deflation and descent, and the buttocks become flattened and droopy. Many individuals are initially elated after weight reduction, but become gradually bothered by these physical changes. Many of such individuals seek post-weight loss body contouring to relieve their symptoms, improve body image and facilitate social reintegration.
Anatomical changes may develop at the different tissue layers in the body as a result of previous obesity. Previous obesity causes the skin to become thinned and stretched out, and individuals develop stretch marks (striae). Following weight loss, there is reduction in the volume and thickness of the subcutaneous fat resulting in skin excess. Areas of skin that are supported by fibrous attachments to the underlying muscle wall (zones of adhesion) do not droop downwards; areas not within the zones of adhesion descend and form redundant skin folds. The abdominal skin droops downwards and outwards, whereas the hips and buttocks the loose skin drapes vertically downwards.
Persistent subcutaneous fat deposits occur due to changes in adipocyte (fat storage cells) metabolism that render them resistant to weight loss. These present as contour irregularities and result in an unnatural and unaesthetic silhouette.
The muscle wall is significantly stretched out by obesity and this is only partially reversed by weight loss. There is generalized abdominal muscle weakness that manifests as a poorly-defined abdominal bulge. Hernias, which are areas of focal abdominal muscle weakness, may occur especially at previous abdominal scars.
There are some significant differences in the bariatric weight loss patient as compared with regular abdominoplasty cases. These include:
The anatomical changes in body contouring in bariatric weight loss cases are different from regular body contouring cases and thus require different surgical approaches. Intimate knowledge of these differences and tailoring the treatment accordingly delivers optimal and bespoke outcomes.
The circumferential body lift reverses and removes many of the changes in the abdomen, buttock and hips in a single stage surgery while limiting the scar to inconspicuous locations. This procedure alleviates the individuals of their medical symptoms, improves self-image and facilitates social reintegration. This surgery is performed under general anesthesia and requires postoperative inpatient admission.
Individuals with stable body weight for at least 3 months and have excess skin may consider undergoing a circumferential body lift. The best results are obtained in individuals who have achieved normal BMI. Individuals who have a high BMI may wish to consider other forms of weight loss interventions (e.g. diet and exercise interventions, or bariatric surgery) to achieve ideal weight prior to circumferential body lift for best results.
The circumferential body lift is improves the body contour and silhouette by excision of excess abdominal skin, tightening of the abdominal wall and removal of localized fat deposits. Hernias, if present, are reduced and repaired. The buttocks and outer thighs are elevated. The scar is well-concealed and hidden within the undergarment or swimwear. This surgery delivers taut abdominal skin devoid of excess folds, good abdominal contour and repositions buttocks and hips. It restores an aesthetic body form.
Individuals are advised to stop herbal supplements and traditional medicine 7 days prior to surgery to minimize bruising and swelling. Smoking cessation for at least 2 to 4 weeks prior to surgery reduces the incidence of wound complications. Preoperative blood tests may be required to ascertain the current nutritional status.
Preoperative assessment is performed in the standing position and identifies areas and extent of excess skin and fat. The incision is performed in the lower abdomen, above the groin creases, and the upper buttocks. The skin and fat is lifted off the abdominal wall muscle up to the lower edge of the chest and hernias are identified, reduced and repaired using sutures and meshes. Further abdominal wall tightening is performed using proprietary techniques at Picasso Plastic Surgery. Most of the lower abdominal skin is removed in this procedure. The appropriate amount of skin to be excised is a fine art: sufficient to tighten the abdominal wall and restore an aesthetic appearance, while avoiding excessive wound tension and complications. A new opening is made in the abdominal wall to reposition the umbilicus at a natural-looking and youthful position.
Most individuals will require an inpatient hospitalization of about 3 to 5 days. Mild swelling and minimal bruising is expected, and will mostly resolve by the 10th postoperative day. Many individuals are able to resume work after the 10th postoperative day.
Showering is possible after the drainage tubes are removed on the 3rd to 5th postoperative day. Stitch removal is usually unnecessary as the stiches used are self-dissolving. Scar management is commenced two weeks after surgery to optimize wound healing. Individuals may return to their regular exercise routines 3 weeks post surgery. An abdominal binder is used for a month postoperatively to protect the underlying muscle tightening and repair.
Circumferential body lift surgery is a niche and emerging field within plastic surgery. At Picasso Plastic Surgery, we are pleased to have embraced this subspecialty very early on in Singapore. Dr Yeo is privileged to have visited and learnt from some of the foremost overseas experts in this field. He is similarly privileged to have worked with outstanding bariatric general surgeons and has accumulated experience in this area. Dr Yeo is regularly invited to speak on post-bariatric weight loss contouring at plastic surgery conferences in the Asia Pacific region.
Complementary procedures enhance the result of the circumferential body lift, and often may be performed at the same sitting if desired. These include: