If you are bothered by loose skin and fat around your waist, consider a belt lipectomy (also called a body lift) at UCI Plastic Surgery in Orange County where a team of plastic surgeons–Dr. Evans, Dr. Paydar, and Dr. Wirth– treat all aspects of massive weight loss body contouring.
Belt lipectomy is a procedure that is performed after massive weight loss, which removes a “belt of loose skin and fat” from the patient’s midsection.
Presentation to Plastic Surgeon
Massive weight loss patients will vary quite a bit in how they present to the plastic surgeon. They will vary in 3 major ways:
- The BMI that is presented
- The fat deposition and fat loss pattern
- The quality of their remaining skin/fat
Massive weight loss patients lose weight to different extents. Some patients will still be in the high BMI range after their significant weight loss, while others will reach normal, and occasionally below normal, BMI levels. There are many reasons that people reach different levels of BMI, including:
- The type of bariatric surgery operation they underwent
- The type of post-bariatric surgery follow-up program in which they participated
- How well they followed their prescribed regimens
- How well their home and family support structure has helped them
- Their body’s natural tendency to “want to live” at a particular weight
Another reason people will present so differently after massive weight loss is their natural fat deposition pattern. All humans are genetically programmed to deposit fat in a particular pattern. For example, many females tend to deposit fat in their outer thighs, lower abdomen or belly, and thighs while many males tend to deposit fat in the “love handle” area and inside their bellies. So, when people gain weight, they will deposit fat in these genetically-prescribed areas preferentially. The same situation occurs with weight loss, where an individual will lose weight in a genetically-prescribed fashion–usually the opposite of their fat deposition pattern, so that in the examples mentioned above, those females will tend to hold on to the fat in their outer thighs and lower belly more vigorously than other areas while the males will tend to hold on to the fat in their love handle areas as well as the fat inside their bellies. Eventually, if a person loses enough weight, even these areas will also lose the fat, but that usually requires drops to very low levels of weight.
Exercise gyms and personal trainers often erroneously tell patients that they can target their weight loss to specific areas that they work out vigorously. Although exercise is always good, it is a fallacy that one can make fat disappear from specific areas with exercise. Exercise will strengthen the underlying muscles, which is good, but the fat loss pattern that an individual has is unaltered by exercise. The reason that the fat deposition/loss pattern is important is that the body contour weight loss problems that result (and have to be dealt with) are dramatically different depending on the patient’s particular pattern.
Note the dramatic difference in the deposition of fat in these two people. On the left, a “pear” shaped pattern, mostly seen in females, is shown. On the right, an “apple” shaped pattern of fat deposition, which is more commonly encountered in males.
The muscles and bones of the body can be thought of as a “mannequin” that is covered by a “skin/fat envelope”. The third factor that affects the presentation of the massive weight loss patient to the plastic surgeon is the quality of their “skin/fat envelope”. The skin/fat envelope is what the plastic surgeon operates on to improve body contour. Its thickness and pliability combine to form what we have coined the “translation of pull.” The translation of pull is demonstrated below and it shows the effects of pinching the skin/fat envelope in and around the waist and how far away from the area of pinch there is an effect, specifically down the thighs.
The translation of pull is very helpful in helping both the surgeon and the patient to see how much of an improvement can be expected after tissue is removed from around the waist region. As a general rule, the greater the drop of BMI from the greatest weight to the final weight of stabilization, the more the extent of the translation of pull, thus more of an effect. This is a generalization that does not apply to people who have very good skin elasticity. Those patients will get a very good result from surgery although the pinch technique demonstrated below may not demonstrate a dramatic improvement.
In this series of photographs of the same patient–on the left before surgery, in the middle demonstrating the potential “translation of pull” utilizing the pinch test, and on the right the same patient after surgery demonstrating the fairly accurate prediction results of the pinch test prior to surgery, especially on the front of the thighs.
Although there is quite a bit of variability in the presentation of the massive weight loss patient to the plastic surgeon, there are also commonalities. The lower trunk is a circumferential structure that spans from the chest to the pelvic area, which has an overall shape of an inverted cone, in almost all patients.
With the expansion and deflation that occurs with massive weight gain and loss, many problems will arise with this entire region. Although not all patients will present with the all of the problems mentioned below, many do and Belt Lipectomy/body lift surgery is designed to alleviate these issues.
Lower Truncal/Thigh Problems at Presentation
Hanging Panniculus/Pannus, or Belly
Massive weight loss patients will most often complain about hanging belly skin and fat which is called a “panniculus, pannus, or more commonly an apron”. The amount of hanging varies from patient to patient with some presenting with a pannus well onto their thighs. The pannus, whether hanging very low or not, seems to bother patients with a lot of sweating and rashes underneath the tissues. In some patients the constant sweat can lead to an odor. A Belt Lipectomy/body lift eliminates a hanging belly and creates as flat an abdomen as possible.
Hanging Excessive Mons Pubis (Pubic area)
The pubic area (mons pubis in medical terminology) in almost all massive weight loss patients hangs down lower than it should be. This is due to the expansion, and subsequent deflation, of weight gain and loss. In females the vulvar (vaginal) opening points downwards and the hair bearing pubic skin is excessive. In males the pubic skin and fat push the penis downwards and sometime may partially or completely obliterate the penis. A Belt Lipectomy/body lift in Orange County should eliminate, or greatly reduce the bulk of the pubic area and create more normal anatomy where the vulvar opening faces forward in a female, and the take off of the penis is more appropriately positioned in the male.
Abdominal Wall Weakness
The area of the lower trunk can be thought of as two balloons, one inside of the other, with a fat layer in between them. The outer balloon is the skin of the lower trunk. The inner balloon is made up of the muscles of the abdominal area, which in a thin muscular person is evident as a “six pack.” The inner balloon contains the internal organs as well as fat, called “intra-abdominal fat”. When people gain weight they gain weight both in the layer between the two balloons, external fat, which can be pinched easily, as well as in the intra-abdominal fat. When people lose weight, fat will be lost from both areas; external and intra-abdominal. The loss of external fat causes the deflation of the outer balloon which leads to the hanging rolls seen from the outside. Loss of intra-abdominal fat leads to deflation of the internal balloon, which will become loose and relaxed, somewhat similar to a “water bed” that is under filled. This is called abdominal wall laxity or weakness. If the inner balloon is loose, the belly will appear convex, or protruding, because the content of the inner balloon will press out on the outer balloon. As a result, the outer balloon, or the skin, simply takes the shape of the loose inner balloon. Belt Lipectomy/body lift tightens up the abdominal wall and thus flattens the belly of the massive weight loss patient.
Lack of Waist Definition
Obese individuals often do not have waist definition because fat deposition encompasses the entire hip region; front, sides and back. After weight loss, as was the case when the patient was obese, the excess tissue is not limited to the front of the patient; it usually will again encompass the front, sides, and back leading to a persistence of the lack of definition of the waist. Belt Lipectomy/body lift in Orange County eliminates a wedge that goes all the way around the waist region, directly eliminating the excess to create narrowing of the waist, especially in female patients.
Excess Rolls of the Lower Back
Many, but not all massive weight loss patients will present with back rolls. Some of those back rolls are located in the upper back and those would be addressed by an upper body lift (described elsewhere on this web site). Lower back rolls are located above the buttocks, at or near waist level. Those are usually either eliminated or greatly reduced by a Belt Lipectomy/body lift. In almost all patients, whatever remnant of the lower back rolls persists after a Belt Lipectomy/body lift would then be addressed by an upper body lift in Orange County & Los Angeles.
Droopy Buttocks that Lack Definition
As in many other areas, massive weight loss patients will vary in the presentation of their buttocks when they see a plastic surgeon. Patients that are still in the high BMI ranges will also still have fairly large buttocks that are over- projected, or large. Patients that present in mid-to-low BMI ranges will have buttocks that are droopy and lack definition. In some patients the buttocks will be under-projected, or too small. If the buttocks are observed carefully in most massive weight loss patients, a smooth skin surface will be noted over the lower back and the top of the buttocks. At a particular point, down onto the buttocks, dimpling of skin (to varying degrees) can be seen in most patients. This point of transition from smooth to dimply skin is where the buttocks have dropped to, and they have to be lifted during a Belt Lipectomy/body lift.
There is quite a bit of variability in how thighs will react to the inflation of obesity and the subsequent deflation of weight loss. In most patients there will be a drop in the thighs and a Belt Lipectomy/body lift elevates from half to two-thirds of the thighs. In patients where the thighs still maintain a great deal of persistent fat deposits after weight loss, liposuction is used to deflate the thighs as an addition to the Belt Lipectomy/body lift. This is often the first stage setting up the thighs for subsequent thigh reduction.
Work-Up for Belt Lipectomy / Body Lift
Belt Lipectomy/body lift is an extensive surgical procedure that needs to be approached with caution by the patient and surgeon. With the exception of a few unusual surgeries, Belt Lipectomy/body lift is probably the largest surgical procedure that an ordinary person can undergo. It requires all of the patient’s physical and emotional energies to recover from.
In order to make sure that the patient can undergo Belt Lipectomy/body lift as safely as possible, we perform an extensive workup to rule out any potentially preventable problems. A detailed history and physical is performed when the patient is first seen. Specifically, we want to know how the patient lost the weight, their greatest weight, their lowest weight, their current weight, and how long their weight has been stable. If they had bariatric surgery, are they followed up by their bariatric surgeon, are they on vitamins, and whether they see their medical doctor on a regular basis. We check for any major medical problems such as diabetes, high blood pressure, heart disease. We also take a psychological/psychiatric history and inquire about the patient’s potential social support system, especially in the postoperative period. All patients slated for Belt Lipectomy/body lift in Orange County are required to undergo psychiatric clearance.
We obtain a complete set of photographs to help us study and determine the problems that need to be addressed. We also obtain photographs while the patient pulls on the area to be removed, to help us predict the results that we are likely to expect after surgery.
Who Is a Good Candidate for Surgery?
Patients who have lost a significant of weight most often undergo Belt Lipectomy/body lift. However, there are three other groups that may also need Belt Lipectomy/body lift. Those will be covered below. For massive weight loss patients we have the following requirements:
1. Patients need to be medically stable with no active problems that would interfere with a good surgical outcome.
2. Patients need to be psychiatrically stable, and we require a psychiatric clearance prior to undergoing this surgery. Patients may utilize their existing or previous mental health care provider to accomplish this requirement. If that is not available, we can help in finding an appropriate mental health care provider.
3. Patients need to have stabilized their weight loss. We prefer patients that have stabilized their weight loss for up to a year but recognize that many are anxious to start their body contouring transformation as soon as possible. The average time it takes to reach weight stability tends to vary from patient to patient and also depends on the type of bariatric surgery procedure (if the patient underwent bariatric surgery.) For Lap-Band patients, the average length of time to reach stability is two years after surgery. For gastric bypass or gastric sleeve patients, the average length of time is eighteen months after gastric bypass. For duodenal switch patients, the time to stability is a little closer to one year. It is important to note that these are average times and will vary for each individual.
4. Patients have to have lost enough weight so that their “inner balloon”, which contains the internal organs as well as fat called “intra-abdominal fat”, will allow us to tighten it and flatten it surgically. So, if the internal balloon is still too full of fat, just like a regular balloon, you cannot tighten it, and the patient will end up with a convex surface, or a “pot belly”, which cannot be improved by removing skin or the fat around the inner balloon.
5. Smokers are not good candidates for Belt Lipectomy/body lift because smoking reduces the blood supply of tissues which will prevent wounds from healing normally.
Belt Lipectomy/body lift is a fairly complex surgery that requires a “road map” for the surgeon to follow. We place marks on our patients one to two days prior to surgery, which will allow us to create the best possible contour. The marking process takes between 30 to 45 minutes and is performed in the office, rather than on the day of surgery in the preoperative area. We feel this is more private for our patients and gives us the opportunity to take as much time as is needed to create the best possible game plan for the operating room. The markings are photographed, and we evaluate the photographs prior to surgery to determine their accuracy. If need be, we adjust the markings at the time of surgery.
The figure above shows a typical set of body lift markings.
All the skin and fat from the upper line to the lower line is removed. The reason for the double upper line in the front is that the upper one of the two is a “wish line” that we hope we can get to, but, in case we cannot, then the lower line is reached. The vertical marks are made to help align the upper circumference with the lower circumference at the time of closing the wounds. If patients need liposuction of the outer and frontal thighs, as was the case here, those areas are marked as seen here. It is important to note that these markings are adjusted to each particular patient and are made with the idea in mind of:
- Performing the surgery as safely as possible
- Creating the best possible contour
- Leading to as much symmetry, or balance, in the created contour, as possible
- Putting the scars where they will produce the best contour
The Goals of Belt Lipectomy/Body Lift
- Flattening the belly and getting rid of any hanging apron
- Lifting the pubic area
- Creating a waist in the female
- Eliminating hip and waist excess
- Lifting the front of the thighs
- Lifting the outer thighs
- Creating an ending point for the lower back and a beginning of the buttocks
- Lifting the buttocks
- Making a smaller buttocks for people who have considerably large buttocks
- Creating more buttocks prominence in people who start out with small buttocks
Belt Lipectomy/Body Lift Surgery
On the day of surgery the anesthesia team sees the patient first. They will start an IV, administer sedation, place an epidural catheter, and then place the patient under general anesthesia. The epidural catheter will have medicine infused through it for one to two days after surgery to facilitate a dramatic reduction of postoperative discomfort. We have also found that the epidural catheter infusion has greatly reduced the most dangerous risk of this surgery, which is a clot that can develop in the calf region, called deep venous thrombosis, or DVT, that may travel to the lungs and become a pulmonary embolus, or PE. Since a PE is potentially life threatening, we feel that the epidural is a very important part of the surgical regimen.
Once the patient is asleep, the surgery begins. We prefer to work on the front of the patient first, eliminating the excess tissues there and tightening the abdominal wall, or the inner balloon. We start out by cutting around the belly button and leaving it where it was originally located. A cut is then made at the lower horizontal mark, as seen on the markings above, going through the fat between the outer skin and the inner muscle layer of the inner balloon. The skin and fat are then lifted off in an upward direction. This is very similar to lifting a sheet off of a bed, with a hole in it where the belly button used to be. Once this is accomplished, the abdominal wall, or the covering of the inner balloon, is exposed. In most patients, it feels and acts like a loose water bed with a larger than normal separation between the two “six pack muscles.” Those separated muscle edges are then brought together and tightened to create a “taut water bed” appearance and feel.
At this point, the skin and fat that was lifted off of the abdominal wall is pulled in a downward direction, like pulling a sheet down over the edge of the bed. The excess skin and fat are removed in a similar fashion to cutting off the excess sheet that has been pulled down, right at the edge of the bed. The belly button at this point would be buried, and a hole is created in the sheet to bring it through. The skin that has been brought down is sutured to the edge at the bottom of the belly, where the original incision was made.
Once the front is done, it will be obvious that the belly is flat, but there will be large bulges on either side of the belly, which will be taken care of by the remainder of the Belt Lipectomy/body lift Surgery. Thus the patient is then turned on his or her side, and the excess tissue is removed starting from the bulge on the one side to the middle of the back, lifting the thighs and buttocks and creating waist definition. In this position, the tissue between the upper and lower markings of the back are cut out, and the thighs are liposuctioned as well, in most patients. The patient is then turned to the other side, and the same procedure is performed. All incisions are closed with inside sutures, so there are not external sutures to remove. The incisions are covered with medical grade glue to both hold the incisions together and prevent bacteria from entering the wounds. Drains, usually little plastic tubes, are placed in the wounds and brought out through the skin, prior to closing the incisions. At the end of the procedure, the patient is placed on his or her hospital bed which is bent at the waist and transferred to the recovery room.
Postoperative Recovery from Body Lift Surgery in Orange County & Los Angeles areas
Patients are expected to walk the same day of surgery, once they are awake and alert. We expect patients to stay in the hospital for a minimum of two days. The first day is spent learning to get out of bed and returning to a normal diet. The epidural infusion is stopped the second day, and, if the patient is able to fit the criteria listed below, they are discharged.
Criteria for Discharge from the Hospital
- Control of pain with pain medication taken by mouth
- Patients are able to urinate on their own
- Patients are eating a normal diet for them
- Patients can get in and out of bed with the help of one person
- Patients are asked to walk slightly bent at the waist for one full week after surgery.
- Most patients will need the help of a second person during this time.
- Many patients can work on a computer during this period.
- Patients are not allowed vigorous exercise during the first week, but are expected to walk 4 to 6 times a day.
Initial visits back to the office are centered on the management of the drains. Most drains are removed within two weeks. Once the drains are removed patient activities are advanced back to normal. Patients are usually required to wear a compression garment a few days after surgery to avoid any potential problems with the compression leading to skin damage.
Although the effects of surgery are very significant immediately after surgery, especially for those with large hanging aprons, the results will continue to dramatically change and improve over a one-year period. Scar quality will continue to mature and improve for that same one-year period. However, the color of the scar will continue to improve for up to three years in some patients.
Many patients ask how much weight reduction Belt Lipectomy/body lift Surgery will produce. It is important to note that this kind of surgery is effective in changing the contour of the body, but it will have a less dramatic effect on the actual weight of the patient. Thus, Belt Lipectomy/body lift Surgery should not be thought of as weight reduction surgery.
There are many things that affect the final result after Belt Lipectomy/body lift Surgery. They include:
- BMI at presentation
- Experience and skill of the plastic surgeon
- The patient’s fat deposition pattern
- The quality of the skin/fat envelope of the patient at presentation
Of the above, the first two; BMI and surgeon’s experience and skill seem to affect the results the most in my experience.
As a general rule:
Results Correlate with BMI
Below we have divided up patients into groups based on BMI. As a general rule, higher BMIs at presentation to the plastic surgeon are associated with more complications and less impressive results. Thus, patients that present in the highest BMI ranges will get a significant improvement of their lower trunk with Belt Lipectomy/body lift Surgery, but they will have less aesthetic, or cosmetically, pleasing results.
Patients with BMIs less than 30
Overall this group of patients tend to have the best results and the least complications.
Patients with BMI 30 to 35
Note that these patients have less aesthetically pleasing results, as a group, than the previous group of patients, 30 and below BMIs.
Note the definition of the buttocks, waist and lower back.
Patients with BMI Greater than 35
Note that these patients have less aesthetically-pleasing results as a group, than the last group of patients, 30 to 35 BMIs.
This patient presented after an abdominoplasty, (above), and after a belt lipectomy, (below). Abdominoplasty or tummy tucks are often not appropriate after massive weight loss.
Non-Massive Weight Loss Patients: 30-40 Pounds Over Weight Patients
Non-Massive Weight Loss Patients: Normal Weight Patients
For our patients that do not live locally or are from out of the country, we ask that they fill out a medical questionnaire that helps us, along with photographs that they supply, to do an initial evaluation prior to traveling to the Southern California area.
To learn more about belt lipectomy / body lift surgery in Orange County, please call (949)-999-2411 to inquire about a consultation. You can also email us at our southern California plastic surgery office.