Approach to the upper body after massive weight loss

Upper and lower body lifts are key concepts in re-shaping the body after massive weight loss. Because of their mutual interaction, the whole body should be examined and evaluated before any contouring operation. Upper body contouring covers the arms, thoracic flanks, male or female breast and back. Before the operation, the excess tissue is determined by pinching and then marking the skin. These lines are supplemented by perpendicular orientation lines to help the surgeon to recognise corresponding wound edges and join them after resection of the skin. As the skin excess on the upper arms is often overestimated, the actual resection line is usually well within the line determined by the pinch test. After the fatty tissue is suctioned off, the deep subcutaneous layer is left undisturbed to protect lymphatic vessels and the nerves, and the excess skin is removed from the superficial subcutaneous layer. On the lateral thoracic wall, the skin is firmed up from the back and upper abdomen to the breast fold. The latter must be secured topographically in its typical position with sutures to the ribs, rib periosteum or fascia so that the breast is not skewed. Contouring operations on the breast always require pre-operative imaging studies. Besides breast lift and reduction, breast enlargement to correct involution is not uncommon. Pedicled, de-epithelialized subcutaneous flaps from the thoracic flank and upper abdomen are more suitable than implants. If needed, breast volume may be further enhanced with secondary lipofilling. The combination of a thoracic flank and lower body lift usually avoids separate lifts and scars on the back. If necessary, however, any folds or bulges are removed from their base after liposuction. The optical result correlates directly with the body mass index at the time of surgery. As almost all the patients are above the BMI norms, there are limits to what can be expected. The majority of the patients under consideration here considered the optical result of the upper body lift to be good to very good and were well satisfied.