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Bota et al. Plast Aesthet Res 2018;5:30 I http://dx.doi.org/10.20517/2347-9264.2018.47 Page 5 of 8

Breast contouring surgery after massive weight loss encompasses a wide spectrum of operations, includ-
ing breast reduction techniques, mastopexy as well as autologous and implant augmentation. Most of these
techniques use the Wise pattern skin incision, which results in an inversed-T scar. The majority of the post-
operative wound complications appear in the inverted T-junction area [Figure 5], resulting from poor vascu-
larization of the two pillars and excessive suture tension. Fatty tissue necrosis from rearrangement of tissue
can also appear, causing delayed wound healing, infection and increased surgical revision rates. The nipple-
areola complex (NAC) represents a special issue in breast contouring. Breasts after massive weight loss are
characterized by advanced ptosis and subsequent extra-long NAC pedicles. This often causes deficient NAC
vascularization followed necrosis and delayed wound healing. The overall complication rate for postbariatric
breast contouring surgery is reported to be between 35.7% and 57%, mostly consisting of surgical wound
problems [15,20] . We prefer the use of autoaugmentation with a lateral and medial flap for breast reshaping, as
this means killing two birds with one stone: achieving the breast augmentation without foreign matter while
performing a lateral lift at the same time.

Abdominoplasty is the most frequent performed BCS. The presence of an abdominal apron represents the
most common complaint of patients after massive weight loss. Skin macerations, intertrigo, rashes, difficult
hygiene cause a great amount of discomfort for the patient, even more than before the weight loss. The ad-
dition of the hypertrophy of mons pubis renders this as a high symptomatic area which has to be addressed
primarily, in order to improve the patient’s life quality. These patients usually associate redundant fat tis-
sue and skin in the epigastric, flank and back areas. The anterior abdominal wall can be addressed in one
procedure, associating the abdominoplasty with a mons pubis lift. The epigastric and the flank regions can
be approached either by a fleur-de-lis procedure or by performing a liposuction of the upper and lateral
quadrants and the flanks before performing the paniculectomy, in a lipoabdominoplasty procedure. The
fleur-de-lis procedure offers the largest amount of tissue excision in exchange for the longest scars. In this
case the reduced vascularity of the skin flaps around the T-scar, the suture tension and the patient specific
risk factors represent a hot spot for wound complications. The lipoabdominoplasty removes the excessive fat
remaining in the abdominal wall while preserving the innervation and blood supply. The upper flap can be
then caudally mobilized without extended undermining while preserving the vascularization of zones I and
III while resecting zone II. The umbilicus can be repositioned by dissecting a narrow cranial tunnel and the
skin can finally be tensioned and repositioned in order to achieve a tight, aesthetical result, while lifting the
mons pubis at the same time. By maintaining the flap vascularity and removing the troublesome excessive
[24]
fat tissue at the same time, this technique provides improved wound healing rates . We prefer the lift of the
lower back in a secondary procedure in a prone position, as the circumferential body lift provides enhanced
[25]
wound complications while being economically disadvantageous .

The incidence of postoperative complications after abdominoplasty is estimated around 57%, mostly consist-
ing of seromas, wound healing problems and hematomas. Avoiding these problems requires good patient se-
lection and operative planning, the placement of the operative incision below the contaminated infraabdom-
inal fold, preserving the scarpa fascia, using liposuction when possible, using progressive tension sutures to
reduce the dead space and seroma formation [26,27] and ensuring a tensionless wound closure.

The medial thigh lift may be considered the “problem child” of the postbariatric BCS. Although the opera-
tive indication is strongly motivated by the patient discomforts, including friction, rashes and difficulty
with ambulation, this intervention is marked by the high rate of postoperative complications. Complication
rates as high as 69% to 78% [16,20] have been reported. The troublesome anatomical area, with superficial veins
and lymph collectors running in the subcutaneous tissue predispose the patient to development of seromas,
lymphoceles [Figures 6 and 7], hematomas and delayed wound healing. The use of the horizontal inguinal
excision with the resulting T-scar adds more risk for wound dehiscence in this area. The use of liposuction