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Trochanteric Dermolipectomy for Correction of Drooping Buttocks and Interfemoral Flaccidity
Prior to the advent of liposuction, this procedure was used for most cases of large trochanteric lipodystrophy and offered satisfactory results when well understood and executed. Although the treatment of choice is currently liposuction alone, in very large deformities this surgical technique associated with liposuction can result in a very satisfactory contour while maintaining well-hidden incisions. This is particularly effective for the treatment of interfemoral flaccidity and the heavy, ill-defined drooping buttocks. The patient must be properly informed of the placement of final scars and should actively participate in decision-making, understanding that there will be a definite enhancement of contour, while accepting the inevitable scars. There have been many secondary cases of trochanteric lipodystrophy referred from other services that had been treated by liposuction alone and were more satisfactorily addressed by the dermolipectomy procedure. With the patient in the standing position, the areas to be corrected are marked. The planned excision of skin and subcutaneous tissue corresponds to a fusiform area that extends laterally and upward toward the anterior–superior iliac spine and medially along the inner aspects of the thigh. This incision may be extended to the inguinal region in cases of associated anterior crural flaccidity. The inferior segment of the demarcation falls in the gluteal crease.
The incision is carried out initially along the superior border of the demarcated area and the flap is lifted off the aponeurosis and undermined, including the lateral depression that is sometimes present. The inferior flap is then advanced upward in three vectors: superiorly, medially, and laterally. The excess tissue is excised in segments, equally distributed, and adapted to its new bed. Recently, a smaller resection for the treatment of the drooping buttocks was performed, associated with liposuction of the flanks and trochanteric region. This technique can also be associated with liposuction of the inner thighs and the knee. Interfemoral flaccidity is corrected by dermolipectomy, placing the scar in the natural crease. Excessive tension on the flap must be avoided, especially medially, so as not to cause the pulling down of the labia majora. The resultant scar should be well disguised within the gluteal and inguinal folds.
The Upper Limbs
Treatment of contour deformities of the upper limbs requires a very critical appraisal of the patient’s complaints and expectations. The cosmetic surgeon should be emphatic regarding limitations and possibilities of surgical procedures. A scar placed along the inner aspect of the arm is relatively visible when treating brachial lipodystrophies; therefore, resection of excess tissue is only indicated in very selected cases where the deformity causes a significant disharmony between the upper limbs and the patient’s overall body contour. Liposuction has become the procedure of choice in moderate cases of fat accumulation on the posterior aspect of the arm, removing excess adipose tissue through minimal incisions. Skin resection is warranted when the patient presents with visible looseness of skin secondary to the aging process or after considerable weight loss. An elliptical demarcation is done along the posterior and inner aspects of the arm, thus assuring that the final scar is placed at the least visible location of the upper limb, which is at the internal bicipital sulcus. Dissection of tissues is done in a posterior direction in order to bring the excess flap inward. Some patients present with excess tissue that affects the elbow, the upper limbs, and the lateral aspect of the thorax. These cases are treated by a technique that was described in 1975, called a thoraco-brachial dermolipectomy.
The patient is examined and marked standing up and with the arms open so as to demonstrate excess ptotic tissue. A sinuous demarcation begins distally, at the elbows, and moves along the inner aspect of the arms, continues along the armpit, where it is “broken” by a z-plasty, avoiding scar retraction. The demarcation proceeds along the lateral aspect of the upper trunk and finishes at the submammary sulcus. The final scar is more satisfactory with this sinuous demarcation than when compared with other techniques that employ straight lines, which risk developing a “bow-string” deformity along anatomical creases with consequent unfavorable retractions. Suction-assisted lipectomy has become a valuable adjunct to this procedure.
The Abdomen
Abdominal alterations may be summarized as cutaneous (redundancies, stretch marks, scars, flaccidity, and retractions), accumulation of subcutaneous tissue (lipodystrophy), and those affecting the musculo-aponeurotic system (diastasis, hernia, eventration, and convexity). Procedures have, therefore, been described to correct the integument (skin and loose subcutaneous cellular tissue), the aponeurosis, and the muscle structure. The ultimate goal of liposuction surgery is to achieve an aesthetic contour with acceptable scars and the return of full function of the abdominal girth. A system of classification has been established to correlate between presenting deformity and surgical planning. In association with the classic procedure, liposuction has decreased the necessity for extensive undermining of the abdomen, thus contributing to a lesser rate of complications such as serosanguinous collection and flap ischemia.
It should be emphasized that liposuction should be restricted to non-undermined areas. Two primary arterial plexi are responsible for the irrigation of the abdominal wall: (1) a subdermal superficial system and (2) a deeper, more profound musculo-aponeurotic system. Many blood vessels form anastomotic connections between the two levels, particularly in the periumbilical region. This vascular anatomy must be respected so as not to risk causing a decrease in vascularization of the abdominal flap. The senior cosmetic surgeon’s personal approach to abdominal deformities was described in 1967, where attention to both function and aesthetics was emphasized. The functional aspect of abdominoplasties was deemed to be especially pertinent in the older, overweight, multiparous woman. The reinforcement of the abdominal wall, as proposed, was done by plication of the aponeurosis from top to bottom, without opening the fascia. A pleasing curvature was given to the waist, not by pulling on the skin, but by tension on the aponeurosis and the muscles.
The surgical treatment of body contour deformities is a constantly evolving art that seeks to improve individual alterations while maintaining an overall well-proportioned balance. Liposuction has revolutionized the surgical treatment of contour alterations by removing excess adiposity through minimal incisions. On the other hand, patients may still present with deformities that require a dermolipectomy, and planning must be based on sound surgical experience. More important than the technical procedure, however, are a correct diagnosis of the deformity and a thorough interpretation of the psychological and motivational structure of the patient. The real goal of body contour surgery is to reestablish the structural and psychosocial harmony of the individual, so that he or she may achieve a balance between his or her self-image and the environment.