Keywords
massive weight loss - postbariatric surgery - belt lipectomy - liposuction
The rising obesity rate with weight loss surgery success has created a roaring need
for body contouring surgeries for both men and women.[1] Redundant skin after massive weight loss (MWL) has resulted in extensive circumferential
trunk deformity and exponential increase of body contouring procedures. Despite the
popularity of these procedures, gluteal region deformities were neglected, because
a lower body lift alone failed to create well-projected buttocks.[2]
[3]
Many surgeons were reluctant to operate in such regions for many reasons, one among
them being the high incidence of complications as wound healing problems of surgical
lifting. Therefore, the availability of well-established approaches to fix gluteal
contour was something not addressed thoroughly in the literature.[4]
In the present study, the authors provided a common concept for gluteal reshaping
in patients after MWL. The study considered the skin and adipose tissue status and
the body mass index (BMI) as the main leading factors in decision making to address
the gluteal deformity encountered in such patients.
Methods
This study was conducted between January 2019 and May 2021 and included 52 patients
(41 females and 11 males; age range: 21–66 years). All cases had been diagnosed as
post-MWL seeking gluteal reshaping. Consequently, 15 and 37 patients were treated
with liposculpture and surgical gluteal lifting with or without autologous gluteal
flap augmentation, respectively. BMI, weight constancy periods, previous bariatric
and aesthetic procedures, cardiopulmonary history, and smoking history were recorded.
All cases had a stable weight for at least 6 months preoperatively.
Exclusion criteria included active smoking, hemoglobin level <9 g/dL, albumin level
<3 g/dL, unstable weight, uncooperative patients, patients refusing surgery, and patients
unfit for surgery due to medical illness (e.g., recent stroke, myocardial infarction,
deep venous thrombosis, chemotherapy, or radiotherapy).
Any pre-existing scars in the abdominal and gluteal areas were documented, because
they can impair the blood supply of the tissue flap. Ptosis grade according to Mendieta
classification[5]
[6] was assessed (no ptosis, grade 1, grade 2, or grade 3), with postoperative grade
reduction assessment.
The treatment procedure was personalized following skin assessment and adipose tissue
status taking into consideration the current BMI ([Fig. 1]).
Fig. 1 MWL patient gluteal reshaping decision-making strategy. MWL, massive weight loss.
Fig. 2 A case of adipose tissue excess only. A 40-year-old female with BMI 27.7 kg/m2 was managed with liposculpture only. (A) A preoperative gluteal view. (B) One-year postoperative gluteal view. BMI, body mass index.
Fig. 3 A case of redundant skin/excess-adipose tissue. A 46-year-old female with BMI of
25.6 kg/m2 was managed by combining liposculpture with surgical gluteal lift with autologous
flap augmentation. (A) Preoperative gluteal view. (B) Preoperative abdominal view. (C) Six-month postoperative gluteal view. (D) Six-month postoperative abdominal view.
Fig. 4 A case of redundant skin/low-adipose tissue. A 33-year-old male with preoperative
BMI of 26 kg/m2 was managed with surgical gluteal lift with autologous flap augmentation. (A) Preoperative gluteal view. (B) Preoperative abdominal view. (C) One-year postoperative gluteal view with reduction of ptosis grade, as well as a
masculine projection of the buttocks. (D) One-year postoperative abdominal view.
Fig. 5 Another case of redundant skin/low-adipose tissue. A 44-year-old female with preoperative
BMI of 38.7 kg/m2 was managed with surgical gluteal lift only without liposculpture or autologous flap
augmentation. (A) Preoperative gluteal view. (B) Preoperative abdominal view. (C) One-year postoperative gluteal view. (D) One-year postoperative abdominal view.
In liposculpture, the regions of flanks, saddle bags, upper thighs, and sometimes
the lateral trochanteric aspect of the gluteal region were addressed. Liposuction
was performed with 3- and 4-mm atraumatic cannulas. According to gluteal lift with
belt lipectomy, resection was designed to be more aggressive laterally at the posterior
axillary line level where the greatest skin redundancy occurs to reverse the deformity
with greater elevation of lateral buttock and thighs and lateral contour enhancement
of the infragluteal crease. The midline inferior extent of excision is marked (3–5 cm)
above the intergluteal crease. In male cases, we designed it higher to make the line
more straight avoiding feminine look of contour resulting from lower curved scar.
Using the pinch technique helped to mark the superior line after asking the patient
to bend the waist anteriorly (semi-kneeling) to prevent posterior dehiscence. A few
quantities of areolar adipose tissue were left on the posterior side especially flanks
to avoid seroma. Moreover, the skin flap was removed as one unit from the prone to
the supine positions to reduce excision time.
In butterfly gluteal lift, we had not performed a complete abdominoplasty, so we did
only marking for surgical lift with fusiform incision lines starting from the posterior
midline point just above the intergluteal cleft to some point on the inguinal ligament
anteriorly. The two lines were marked with a pinch test of the skin making the inguinal
ligament as the axis of them.
If gluteal island flap was planned, then with the patient in a prone position, we
drew the inferior marking centrally, predicting a postoperative gluteal height of
16 cm. Medial border of the dermal fat flap was marked 2 to 3 cm laterally from the
midline and with a width between 15 and 18 cm according to the body type and intended
contour. An adipo-dermal flap was de-epithelialized as an island flap using the lower
back sacral and supragluteal skin. Then a pocket for the flap was dissected above
the muscle fascia with a caudal limit at 5 cm above infragluteal crease to avoid numbness
of the buttock postoperative. Then, the flap was advanced into the pocket without
any undermining to its deep surface.
Outcomes and Complications
Operative time, hospital stay, and the need for blood unit transfusion were reported.
Surgery should not be longer than 6 hours to avoid the thromboembolic events, and
has to be associated with the use of anticoagulation prophylaxis with low-molecular-weight
heparin and pressure garments as well as early mobilization and hydration of the patient
from the first day. Drains were left until they produced <40 mL/day. They were simultaneously
removed avoiding a break of their connected drainage cycles. Flexed position (only
15°) of the trunk was advisable for the first week after surgery with slow straightening
exercises. Limited activity was advised for the first 1.5 months, whereas strenuous
exercise was discouraged for 3 months.
Complications (e.g., wound dehiscence, hematoma, seroma, dressing hypersensitivity,
skin hyperesthesia, infection, thromboembolic events, and skin necrosis) were considered.
Patients were followed up weekly for dressing, draining, removing of sutures, and
checking any complaints or early complications monthly, then once every 3 months.
The existence or persistence of any complications and gluteal ptosis grade reduction
were assessed after 1 year. Also, the self-satisfaction of the patient regarding the
shape of gluteal region compared with before the procedure was assessed on a 5-point
Likert scale; (1, strongly unsatisfied with low self-esteem; 2, unsatisfied; 3, neutral;
4, satisfied; and 5, strongly satisfied with a better lifestyle).
Statistical Analysis
The collected data were analyzed using SPSS, version 15 (IBM, Armonk, NY). Normally
distributed variables were expressed in mean ± standard deviation (SD). Nonnormally
distributed variables were expressed in median and range. Paired t-test or paired Wilcoxon tests were used when appropriate to compare preoperative
and postoperative satisfaction scores and ptosis grades.
Results
Seventy patients with MWL requesting gluteal reshaping were observed in the last 2.5
years. Moreover, 8 patients were not admitted to surgery because of compromised general
status (5 and 3 patients showed cardiovascular problems and diabetes, respectively),
10 patients were not included in the study because of nonadherence to any postoperative
follow-up, and 52 underwent gluteal reshaping and were enrolled in the study.
The average age was 42.7 years with a SD of 10.4. Females represented 79% of the cases.
The follow-up period was 15 months on average. In addition, 85% of the cases did not
give a history of smoking, whereas 15% were previous smokers and smoked occasionally
but stopped before the procedure with a minimum period of 6 months. No comorbidities
were recorded preoperatively except for three patients with a history of controlled
hypertension. The cause of MWL was postbariatric surgery in 63% of the cases, whereas
it was after diet in the other 19 cases. The average BMI before weight loss was approximately
48 kg/m2, whereas it was approximately 33 kg/m2 after weight loss stabilization.
A surgical gluteal lift procedure was performed in 71% of the cases with an average
BMI of 33 kg/m2. Among them 15 cases were operated with an additional autoaugmentation flap with
a BMI average of 25 kg/m2. Furthermore, the rest 15 (28.8%) cases were treated with liposculpture without surgical
gluteal lift ([Table 1]). The average BMI was approximately 32.5 kg/m2. Liposculpture was a stage of contouring in nine cases either preceded or planned
to be followed by surgical lift (average BMI: 37.7 kg/m2). Six cases complained of adipose tissue excess in the gluteal region without skin
redundancy (average BMI: 27.4 kg/m2).
Table 1
Case distribution according to gender and procedure done
|
Category
|
Liposculpture only
|
Surgical lift
|
|
Without autologous flap
|
Lift with autologous flap
|
|
Female number
|
15
|
14
|
12
|
|
Male number
|
0
|
8
|
3
|
|
Percent %
(N = 52)
|
29
|
42
|
29
|
Other aesthetic procedures were combined with the main one in eight cases with an
average BMI of approximately 28.23 kg/m2. Inguino-crural lift, thigh lift, and gynecomastia surgical repair were associated
with five, two, and one case, respectively. The mean intraoperative time was 172 minutes.
Outcomes and Complications
The postoperative hospital stay period was approximately 4 days. Drains were removed
after 5.6 days on average. Only three cases needed postoperative blood transfusion
(one unit). They were of the liposuction cases, with preoperative Hb around 11 and
postoperative 2 to 3 gm/dL drop.[7] Postoperative ptosis grade was reduced by 1.1 grades on average. A postoperative
self-satisfaction score of 4.3 after the preoperative score was reported. Changes
in value from preoperative to postoperative points are significant with all p-values <0.001 using paired t-test and paired Wilcoxon test ([Table 2]).
Table 2
Gluteal ptosis grade and patient self-satisfaction score when comparing preoperative
results with postoperative results
|
Category
|
Preoperative
(N = 52)
|
Postoperative
(N = 52)
|
p-Value
|
|
Gluteal ptosis grade,
median (range)
|
3 (0–3)
|
1 (0–3)
|
<0.05[a]
|
|
Satisfaction score
(mean ± SD)
|
1.85 ± 0.61
|
4.31 ± 0.61
|
<0.05[a]
|
Abbreviation: SD, standard deviation.
a
p-Value is statistically significant.
The most represented complications were superficial wound dehiscence and seroma ([Table 3]). Three cases of postoperative seroma managed by syringe drainage 1 week apart within
the first month until it resolved, mostly after the third one, were reported. One
case had hyperesthesia at the upper right thigh inguinal region for 2 months that
improved with anti-inflammatory prescription. Eight cases had a little degree of wound
dehiscence that healed with secondary intention, and two of them needed local anesthetic
revision. No reports of any major complications (e.g., infection, pulmonary embolism,
deep vein thrombosis, or mortality) were noted.
Table 3
Complications
|
Complication
|
Percentage %
(N = 52)
|
|
Superficial wound dehiscence
|
11.54
|
|
Wound dehiscence needed revision
|
3.85
|
|
Seroma
|
5.77
|
|
Hematoma
|
0
|
|
Skin flap necrosis
|
0
|
|
Postoperative blood transfusion
|
5.77
|
|
Dressing hypersensitivity
|
1.9
|
|
Thigh hyperesthesia
|
1.9
|
|
Infection
|
0
|
|
Thromboembolic events
|
0
|
|
Mortality
|
0
|
Discussion
Patients with MWL nowadays seek gluteal region contouring of ptosic skin, lipodystrophy,
or flattened projection. There are many described articles addressing this with different
techniques.[8] Pitanguy and Regnault tried skin excision of the trochanteric area and gluteal fold,
whereas Gonzalez-Ulloa and Lockwood decided to conduct total surgical gluteal lifting
with very good improvement at the expense of extensive scaring.[9]
[10]
[11]
Levan and Bassilios Habre described their algorithm to address gluteal deformities
according to different analyzed body types based on body morphology, redundancy degree,
and pre-existing gluteal projection. Recommending a superiorly placed belt lipectomy
for cases with flank lipodystrophy with a minimal deformity in the lower buttocks
is also agreeable for the aforementioned authors.[12]
Based on the scientific fact that confirms that there is a significant increase in
complication incidence among morbidly obese and severely morbid obese patients undergoing
even a single body contouring procedure,[13] this study considered the (post-MWL) BMI at the time of body contouring surgery
as a main factor for decision making, being an important predictor for postoperative
complications. Considering morbidly obese degree starting from 35 kg/m2,[13] so we considered this as the cut-off point that we will decide at which if we can
combine more than one procedure or not.
BMI was a landmark for the current study to simultaneously decide in doing more than
one procedure. The current study preferred the staging of the gluteal reshaping procedures
with BMI ≥35 kg/m2 and not combining surgical gluteal lift with autoaugmentation or even with long abdominoplasty
procedure as an inverted T technique. The staging was also the policy with cases with
BMI >35 kg/m2 and required liposculpture with the surgical lift.
Small et al stated that MWL patients had a statistically significant increase in complication
incidence when even performed an abdominoplasty with the surgical gluteal lift.[14] Marchica et al reported higher complication rates in patients with MWL due to dietary,
metabolic, or psychosocial issues and combined surgery.[15] However, the statistical results of Levan and Bassilios Habre showed no significant
increase in complication rate when more than one procedure is combined.[12]
In their comparative study between the combination and the noncombination of autogluteal
flap augmentation with belt lipectomy, Levan and Bassilios Habre reported that postoperative
projection of the belt lipectomy-only procedure was less than that of the autoflap
augmentation. Moreover, they preferred using implants to increase projection.[12] In the current study, we did not use any implants in such kind of patients to avoid
any increase of complication incidence.
This study follows the study of Pajula et al's stydy[16] where no significant relationship exists between the type of weight-loss procedure
and the incidence of the complications. Post-drain removal seroma is a common problem
in gluteal reshaping mainly due to the abdominal region association (i.e., just liposuction
or belt lipectomy). The current study practiced managing with serial weekly-apart
aspiration. This is in agreement with the study of Richer-Stoff highlighting the importance
of quick seroma handling to avoid superinfections.[17] Aly and Mueller stated that injecting a sclerosing agent (e.g., doxycycline) through
the drains every 2 to 3 days to decrease the pocket size subsequently reduces seroma.
In addition, they also supported progressive tension closure.[18] Small and colleagues showed their experience using barbed sutures for rectus plication,
progressive tension closure, and dermal closure. They claimed that these sutures help
to reduce seroma incidence and reduce surgery time by 1 hour.[14]
The postoperative evaluation depended on the objective and easily applicable means
as standardized photographic comparisons as well as assessment of patient self-satisfaction
based on Likert scale enable the patients easily express without confusion. Moreover,
Levan and Bassilios Habre complicated the satisfaction assessment by involving three
unrelated surgeons' studies to assess their evaluation of the cases using preoperative
and postoperative photographs; however, they reported high satisfaction rates in MWL
patients whatever technique used.[12]
We can consider that one among the pros of this strategy is that it is a simple and
uncomplicated strategy that relies on fixed elements, which makes it easier for surgeons
to make a decision, and also makes it easier for them to explain simply to this kind
of patients with high ambitions after MWL. Thus, we can create and unify treatment
plans, which make the matter smooth and proceed in successive well-organized steps.
Additionally, using simple and widely available techniques that needed no special
equipment or trained specialized technicians was one of the advantages of this study.
It is possible to see some shortcomings in this strategy because it did not take into
account some other considerations such as the type and distribution of skin redundancy
that may affect the way of thinking about the integration of more than two surgical
procedures together, and therefore it is difficult to apply it to all ethnic groups,
but it can be considered at least an initial step in developing a preliminary surgical
plan.
Despite being limited by its small sample size for causes related to the strict selection
of included patients to obtain more significant results, this study is unique in determining
objective findings such as the BMI and the adipose tissue status. Moreover, the study
was applied on similar ethnic groups with the same style of distribution of the adipose
tissue and the skin redundancy, as well as similar concepts of the concerns of that
kind of patients about the gluteal region contouring. However, this is an initial
study that requires more large-scale patients and further assessment to validate the
data in a more evidence-based manner.
To conclude, this study personalized an easy strategic approach on each patient to
treat considering adipose tissue distribution, gluteal skin status, and BMI as the
main factors that can forcefully affect the plan to guarantee reduction of unpleasant
results and complications and improve patient satisfaction.
