Chicago — Contrary to what many cosmetic surgeons believe, scar placement and scar quality are a big concern for many post-bariatric body contouring patients.
Joseph F. Capella, M.D., says cosmetic surgeons do not necessarily place the same importance on scars as do body contouring patients after significant weight loss.
"Many cosmetic surgeons feel that because the deformity is so severe, then the scars, their location and quality are not that important," explains Dr. Capella, clinical assistant professor of surgery at the University Medical and Dental School of New Jersey at Newark. Dr. Capella also is in private practice in Ramsey, N.J."Some patients initially say they do not care about scars, but as their appearance changes, they become very concerned."
In a presentation at the annual meeting of the American Society of Plastic Surgeons here, Dr. Capella offered insights on placing scars in areas that are least perceptible and on improving the quality of scars. He discussed the body lift, medial thigh lift and brachioplasty.
Dr. Capella says he has seen "tremendous growth in patients seeking body contouring after massive weight loss," due to the popularity of gastric bybass and gastric banding surgeries. Still, patient selection is important, he says.
He notes that the best candidates for a body lift — the largest of the three contouring procedures — are individuals who have a body mass index less than 35, a stable weight and a hemoglobin count greater than 12, and who are younger than 55 years old.
Dr. Capella tells Cosmetic Surgery Times the ideal location for a body lift scar is along the waistline where most garments would provide scar coverage. Posteriorally and laterally, the scar should lie at the level of the anterior superior iliac spine, or approximately three finger-breadths from the top of the iliac crest. Anteriorally, the scar should be at the interface between the hair-bearing pubic area and the lower abdomen.
Dr. Capella uses tissue traction and bony anatomic landmarks to assist in controlling for scar placement.
While marking the anterior abdominal region, Dr. Capella applies upward traction to the lower abdomen with patients in a flat and supine position. This stretches out the redundant hair-bearing pubic area and ensures proper scar placement at approximately 6 cm superior to the vulvar anterior commissure or base of the penis.
Dr. Capella finds that the body lift's considerable tension at the waistline does not have to result in a wide scar. He recommends skin redundancy at closure even though a palpable ridge will persist for three months postoperatively.
"During this critical phase of healing, there is very little tension along the skin edges," he says. "You mimic a low-tension closure in a high-tension situation."
Medial thigh lift
Dr. Capella says the traditional medial thigh lift limited to the thigh perineal crease does little to address circumferential skin excess, which is unique to massive weight loss and unlike what occurs with aging.
"A more useful procedure is a medial thighplasty that addresses circumferential excess with a vertical or longitudinal component. The scar down the inner thigh is not visible from the front or back."
Dr. Capella advises placing the scar several centimeters posterior to the insertion of the abductor longus muscle at the proximal thigh and along the medial aspect of the thigh to knee. The scar should extend to just distal to the deformity to be corrected. This means the scar may not need to reach the knee in some cases, and in other instances, it may need to go onto the leg.
Before committing to a medial thigh lift in a patient with massive weight loss, he first performs a body lift and waits at least three months. The body lift corrects for the inferomedial collapse of tissues toward the inner thighs. The procedure elevates the lower abdomen, pubic area, thighs and buttocks in a vertical vector, but does not address the circumferential excess at the thighs.
For excess tissue in a horizontal vector, a medial thighplasty with a vertical component is needed. In some younger patients, the body lift alone on the inner thighs may make a medial thighplasty unnecessary.