Maximizing aesthetics and safety in circumferential-incision lower body lift with selective undermining and liposuction

Circumferential dermolipectomy has been an effective means of reducing excess skin and fat after massive weight loss, however, regions of residual midabdominal and epigastric fat frequently confer a suboptimal contour, and often mediocre cosmetic results. Liposuction in association with lower body lift surgery has been regarded with caution, for fear of ischemia or necrosis of the undermined flaps as potential dire consequences. In this study, a theoretical and technical approach that maximizes safety and aesthetics in circumferential lower body lift after massive weight loss with contouring using liposuction is described and evaluated. Twenty-four patients were treated with follow-up ranging from 6 to 40 months (mean follow-up 17 months). All patients were treated with the resection of circumferential skin and fat maintaining a low-lying transverse suture line with a prone-to-supine approach. Dorsally, liberal liposuction is performed after the instillation of lidocaine-free wetting solution above and below the resection lines. Ventrally, the upper flap is elevated widely to the umbilical horizontal. The umbilicus is circumcised, and the dissection then progresses in a narrow column above the rectus sheaths to the xiphoid. Judicious subcostal undermining is performed, maintaining an intact bilateral subcostal "perforator zone" of 4 to 6 cm. Diastasis repair and anterior sheath plication are performed, and the umbilicus is anchored to the fascia. Wetting solution is instilled, and suction-assisted lipoplasty of the entire flap, particularly in the midline and in the region of the neo-umbilicus, is performed, removing excess fat and providing discontinuous lateral flap "undermining." There was 1 hematoma (4%) requiring re-exploration and 4 seromas (17%) treated with percutaneous aspiration. There was no infection, skin loss, or wound dehiscence. Unlike standard dermolipectomy procedures with wide undermining, the maintenance of a broad subcostal blood supply with selective direct undermining allows for liberal flap contouring with suction and the establishment of lower suture-line position. With this technique, liposuction can be safely used during lower body lift to maximize aesthetic outcomes.