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Circumferential Contouring of the Lower Trunk:
Indications, Operative Techniques, and Outcomes-A
Systematic Review
Raphael Carloni, Antoine de Runz, Benoit Chaput, Christian Herlin, Paul
Girard, Eric Watier, Nicolas Bertheuil
To cite this version:
Raphael Carloni, Antoine de Runz, Benoit Chaput, Christian Herlin, Paul Girard, et al.. Circumferen-tial Contouring of the Lower Trunk: Indications, Operative Techniques, and Outcomes-A Systematic Review. Aesthetic Plastic Surgery, Springer Verlag, 2016, 40 (5), pp.652–668. �10.1007/s00266-016-0660-7�. �hal-01392032�
Circumferential contouring of the lower trunk. Indications,
Operative techniques and Outcomes. A Systematic Review.
INTRODUCTI ON
The i ncreasing preval ence of obesit y[ 1] and the development of bariat ri c
surger y[2] have l ed t o the gradual development of skin redraping t echniques.
Among them , circumferenti al bod y contouring allows t he correcti on of redundant s kin on the l ower t runk aft er m assi ve wei ght l oss .
Several t echniques have em erged since "circu m ferential dermoli pect om y" was fi rst descri bed in 1940[3]. In t he 1960 s, Gonz al ez -Ulloa[4] and
Vill ain[5] des cribed "bel t lipectom y" and "circular li pectom y ," im pl ying
circular res ection perform ed up to the m uscular aponeurosis at depth , wit h a post erior s car located at the belt li ne . In 1993, Lockwood[6] des cribed the
"l ower bod y li ft , " which merged t he m edial t hi gh l ift[7] wit h the t rans vers e
thi gh -buttock li ft[8] and incorpor at ed two maj or innovati ons: a res ect ion that
pres erved t he s uperfici al fas ci a and a lower -sit ed s car to hel p li ft the lat eral thi gh and butt ocks.
Carwell[9] and Van Geertru yden[10] des cribed " circumferenti al
tors opl ast y, " derived from belt li pectom y[4], and Lockwood improved his
ori ginal t echni que[11].
The m ain innovati ons were hi gh superi or[12] and hi gh l at eral t ens ion[13]
abdominopl ast y, but tock -aut ologous augment ati on with[14] or without[15–
17] a fl ap, and li pogl uteopl ast y[17, 18].
Accepted manuscript
Raphael Carloni, Antoine De Runz, Benoit Chaput, Christian Herlin, Paul Girard, Eric Watier, Nicolas Bertheuil
Different t echniques have been des cribed under di fferent nam es (“mid -bod y lift”[19], “circumferential body lift”[20] , “central body lift”[21], “circumferential abdominoplasty” [22], “circular lipectomy”[23]); all deri ve from belt l ipectom y or the lower bod y l ift , dependi ng on t he l evel of post erior res ection.
No s ys t ematic revi ew of the lit erat ure on ci rcum ferenti al contouring of the lower t runk has been conduct ed to date. The ai m of this revi ew was to summ ariz e the i ndi cations for, procedures and out comes of, and pati ent satis faction wi th t hese t echniques .
MATE RI ALS AND ME THO DS
We undertook t his revi ew in J une 2015 in accordance wit h the Preferred
Reporti ng Items for S yst em ati c R evi ews and M et a -Anal ys is (PR ISM A)
stat em ent[24, 25] .
Our protocol was AMSTAR (Assessi ng the M ethodol ogi cal Qualit y of
S ys temati c R evi ews) – compl iant and is avail able online at:
www.crd. york.ac.uk/ PROSPERO/d is pla y_ record.asp? ID=CRD42015020680 .
Eligibili ty cri teria
The inclusi on criteri a were: publ ished report s (ori ginal art icl es, randomized
controlled t ri als, controll ed cli ni cal t rials, ret ros pecti ve or prospective
observat ional st udi es, case reports, l et t ers to the edit or, and t echnical
Accepted
des cripti ons ) that included pat ients undergoi ng circum ferenti al contouri ng of
the lower t runk, perform ed as si ngl e -step surger y.
The exclusi on criteri a were: two -step s urger y, ci rcum ferenti al contouring of
the upper trunk, isol ated abdomi nopl ast y or butt ock l ift , and
circumferenti al li pos ucti on without skin resecti on. W e excluded all studies
lacking ori gi nal dat a and st udi es i n an y language other t han English or
French.
Search s trategy
Eli gible studies were identi fi ed fro m the P ubM ed and C ochrane Li brar y
dat abas es usi ng the following ke ywords combi ned wit h Boolean operators:
«bod yl i ft » OR «body li ft » OR «ci rcumferenti al bod y c ontouri ng» OR
«ci rcum ferenti al abdominoplast y» OR «l ower bod y li ft » OR «bod yl ifti ng»
OR «ci rcum fer enti al contouri ng» OR «b elt lipectom y» OR «ci rcum ferenti al
dermoli pect om y» O R «t runcal bod ycontouring » OR «ci rcumferenti al belt
lipectom y» OR «circular li pect om y». R eference li sts of s elect ed arti cl es were
also ex amined to i dentif y addi tional pot ential l y eli gibl e articl es.
Data col lection
Dat a were extract ed independent l y b y two res earchers (RC, ADR ) , and
disagreem ents were resol ved b y a t hird s enior author (NB).
Dat a were coll ected on: authors, publi cat ion dat e, count r y, t ype of s tud y and
level of evi dence, number of pati ents, i ndi cati ons, demographi c data (bod y
Accepted
mass index [ BM I] , wei ght l oss before surger y, m edi cal histor y), peri operati v e
care, operati ve t echnique, out com es and compli cations .
Statis tical analysis
Statist ical anal ysi s was performed us i ng P rism 5 (GraphP ad Soft ware, La
J olla, CA, US A). A des cripti ve anal ysi s of all dat a was carri ed out and
results were express ed either in m edi ans with inter -quartil e-range ( IQR ) or i n
means wit h 95% confidence intervals .
RESULTS
Among the 3,424 artic l es i niti all y i denti fied b y the s earch, 42 were fi nall y
sel ected (Fi g. 1). Published bet ween Jul y 1960 and M arch 2015, t he y
incl uded 1,748 pat ients. Most had a l ow l evel of evi dence (Tabl e 1). The
publi cations ori ginat ed mai nl y from West ern count ries (Tabl e 2, Fi g. 2). Patients’ characteristics, indications, and operative techniques are summ ariz ed in Tabl es 3 and 4.
Indication s
The fi rst des cri bed t echni ques[4, 5, 26– 28] were indi cat ed for obes e wom en
with redundant pannicul us at the wa i stli ne foll owi ng pregnanc y or di eting.
Accepted
pati ent s wit h s oft -ti s sue l axit y of t he lower t runk and thi ghs. Carwell[9] was
the fi rst to include post -bari at ric pati ent s ( n = 6).
The most frequentl y report ed i ndi cation was m assi ve wei ght loss[10, 15, 19,
20, 22, 27, 30 –45] secondar y to bari at ric s urger y or dieti ng, whi ch creat ed
excess ci rcumferenti al s kin of t he lower trunk. P ost eri orl y, belt lipectom y and derived techniques better treat ed hips and back rolls , wh ereas l ower bod y
lifts bett er treated buttocks and l at eral t hi gh pt osis[33]. Belt lipectom y could
also treat excess fat localiz ed i n the fl anks in overwei ght or obese pati ents[4,
23, 31, 46].
Tobacco us e was contraindicat ed i n four st udi es[6, 15, 30, 37] . C ont raril y,
surger y on smokers was reported in 10 studi es [10, 27, 31, 35, 39, 41 –43, 47,
48]. Four s tudi es each i ncl uded surger y on pati ents wi th hi gh bl ood
press ure[21, 35, 39, 43] and di abeti c pati ents[21, 35, 43, 47] .
Preop erative ass ess men t
Preoperati ve ass ess ment s were reported on in ei ght publ ications[19, 20, 32,
39, 40, 42, 44, 48]. Ass es sments i ncluded preoperati ve correction of
anemi a[14, 39, 40, 42, 44]; m easurem ent of t otal protei n[40, 44], prealbumin
and albumin[44] , gl ucos e[44] , iron[44] , cal ci um [44] , magnes ium [44] ,
thiam ine[44], com plet e cell count [ 44] , blood urea nit rogen [44] ,
creatini ne[44], el ectrol yt es [19, 44, 48] , and li ver function [44] ; and
urinal ys is[44]. Onl y two authors recom mended foll ow up by a di eti ci an[20]
or nut ritionist[42].
Accepted
Operative techniqu e
Operati ve m arkin gs
No di fference in m arking between m en and wom en was report ed. M arki ngs
were usuall y made whil e patients were st anding[4, 33, 36 –38, 43] and
com plet ed i n the supine position [34, 35, 47] . “Pinch t est s”[4, 21, 27, 42, 43,
46, 47] were us ed t o esti mat e t he am ount of t issue t o be res ected . Anteri orl y,
stret ching forces proceeded from top to bottom, and pos teriorl y the y were
inverse[48] . Techni ques deri ved from belt lipectom y result ed in s car s
situated at t he waist line, wh ereas l ower bod y li ft s l eft s car s situat ed at the bikini line (Fi g. 3).
For bel t lipectom y, t he upper resecti on l i ne was drawn fi rst posteri orl y , and
ideall y was pl aced at t he superi or m argi n of the fl ank rol ls [19]. Then, a
horizont al inferior line was drawn that cross ed the int erspi nal l ine
approxim at el y 5 cm above the i nt erglut eal groove [23].
For l ower bod y l ift , the lower resecti on line crossing the i nterspinal line
inside or at the t op of t he glut eal cleft [48] was m arked fi rst. The upper
resecti on l ine was us uall y 5 cm inferi or t o L5 [36] .
For both t echni ques, the upper res ection line was us uall y V -shaped[20, 26,
27, 36] t o pres erve the glut eal aestheti c unit and decrease tension i n t he
middl e line. The upper li ne j oined t he central point to t he posterior superior
iliac spi ne[36, 43] . The hei ght of tiss ue resect ed post eri orl y ranged from 5 t o
7 cm in the m iddl e [23] and 10 to 15 cm l at erall y[21]. A grid patt ern could be
Accepted
marked to facilit at e clo s ure[37] . The butt ock fl ap was m arked, if operat ed on,
and ended lat erall y at the l at eral limit of the inferior glut eal fold [14] .
Lat eral l y, the s car had to be locat ed at the l eve l of the anterior s uperi or iliac spi ne[37]. On t he mi d -axillar y l ine, the hei ght of resecti on range d from
10 to 25 cm [11],[23],[48]. A tri angul ar l ateral excision to correc t transversal
lat eral thi gh excess was perform ed in some cas es [49] .
Ant eri orl y, the patt ern j oined the abdomi nopl ast y s car, wi th a lower point of resecti on pl aced in t he abdomi nal fold or 7 cm from the vulvar commi ssure or the bas e of the peni s[48]. Ass oci at ed m e dial t hi gh l ift with a horizont al s car
was report ed b y two authors[6, 39]. Gonzalez -Ull oa[4] ass ociat ed “triangl es of compensation” anteriorly and posteriorly to correct the transversal excess and to di minis h the promi nence of t he m ons Venus , when necess ar y.
Li pos uction areas were m arked preoperat i vel y.
Pati ent positi oning
Three possi biliti es for posit ioni ng were report ed:
- t wo -st ep positioning in the supine posi ti on fi rst, then prone[ 4, 5, 19, 27, 33,
40, 46] ;
- two-st ep positi oni ng in the prone position fi rst , then supine (t he most
comm onl y reported t echni que)[9, 10, 14, 15, 20 – 22, 36 –39, 42, 43, 48]; and
- t hree-st ep positioning, with the pati ent supine and in t wo l at eral decubit us positi ons[6, 23, 26, 34, 35, 47, 49, 50]. This inst all ati on was chos en for
bett er control of t he lateral thi gh l ift and when lateral t hi gh res ection was
requi red[49], and was used in t he US A [6, 23, 26, 34, 35, 49, 50] and UK[47] .
Accepted
We des cribe the different s urgical techniques using the most comm on
positi oning s equence.
Post eri or R es ection
The depth of res ecti on varied am ong studies (Fi g. 4). Belt li pectom y– derived
techni ques us ed res ection deep t o the mus cul ar fasci a[4, 5] or to the
superfi ci al fascia[19, 21]. The resection depth for the l ower bod y li ft was
also t o the mus cul ar fasci a[26, 35, 37, 38, 40, 43] or the s uperfi ci al fasci a[6,
11, 15, 39, 47]. Lo ckwood[6] was the first t o report the associated use of
lipos ucti on.
In 2002, the fi rst buttock auto -augm ent ation with a flap[14] was report ed
(Fi g. 5). The fl ap m easured approximat el y 10 25 cm and extended laterall y
to t he end o f the buttock fol d. Ot her derived fl aps were described: a l at eral
perforator -bas ed deepithelized derm al fat fl ap[34], a random medi all y bas ed
flap[33], the "m oust ache fla p "[20], and a s uperi or gl uteal arter y perforat or
flap[36]. Augm ent ati on flaps were report ed in 9 of 42 publicati ons .
The t echnique of b uttock augm ent ation without fl ap i ncl uded s utures i n an out er– inner di rection[15, 17, 33] (Fig. 6) or a “purse string” suture [16].
Finall y, t he most conservati ve techni que for post erior resecti on was lipogl ut eopl ast y, which involved skin -onl y resecti on aft er li posucti on under the zone to be resect ed[18].
Anteri or res ection
Accepted
This approach cons isted of abdominoplast y as sociated wit h rect us fas ci a
plicature, where a di ast asis existed, and t ranspositi on of t he umbili cus . It was
com bined i n som e cas es with l ipos uction [21, 37, 38, 48] and a hi gh superior
tension[42] or hi gh l at eral t ensi on t echni que [14, 40] . Ass ociated perform ance
of m ons pl ast y to treat mons Venus ptos is was also report ed [40] .
Thigh li ft
Lockwood’s[6] lower body lift no. 1 provided a medial thigh lift with a horizont al s car in t he ingui nal fol d and an anchor t o the Colles fas ci a.
Kitzinger[39] also report ed the associated performance of a m edial thi gh li ft .
The lat eral thi gh li ft , as des cribed i n Lockwood’s[11] lower bod y li ft no. 2,
was us ed much more frequentl y[10, 23, 26, 31, 34, 35]. It consist ed of
liposucti on and minimal undermi ning of the trochant eri c regi on to li ft the lat eral t hi gh. Suspension point s were eventua ll y added[14, 48]. Davison[49]
perform ed t riangular res ection of the lat eral thi gh t o correct excess ski n i n this area.
Outcomes and comp lication s
All m ain dat a were summ arized i n Tabl e 5. The m edi an percent age of
pati ent s who had a compl icati on was 36,55[26 ,63 -45,65] %. The m edian revisi on rat e for a non -aest hetic purpos e (wound dehis cence, abs cess, skin necrosis, fat necrosi s, serom a evacuation, hem at oma) was 3,5 [0,25-6]%. The
medi an revi sion rate for aestheti c purpose (scar revisi on, secondar y
Accepted
liposucti on or fat inj ection and correcti on of om bli c) was 0[0 -5,75] %. In t he
post erior st ep, 6 cases of glut eal fat necrosis were report ed i n 4 s eri es [20, 33,
34, 36] and 48 cases of glut eal h ypoesthesia were report ed in two studi es[32,
48].
Antibi oti c p rophylaxis
Antibioti c proph yl axis was not well codifi ed (Tabl e 6). Som e authors
recommended i nt raoperative proph yl axis[10, 22, 23, 42]; others
recommended anti bi otherap y for 24 hours[38], 48 hours[14, 32], 3 da ys[ 39] ,
or 5 da ys[ 47] post operativel y. M an y teams treat ed thei r pati ent s until
rem oval of drai ns[11, 19, 20, 26, 29, 35, 36, 46]. All antibiotics used were
first- o r s econd -generati on cephalospori ns . Fi rst -generat ion cephalospori ns incl uded cephalexin[6, 29] , cephal othi n[22, 23], and cefazolin[19, 42], al l
admi nist ered at a dose o f 1–2 g peri operativel y, then 1 g t hree ti mes per da y
if continued[38]. The s econd -generation cephalos porin was cefuroxime ,
whi ch was pres cribed at a dos e of 1.5 –2 g[39], [47] peri operativel y, then 2 g
twi ce a da y[39] i f continued.
Thrombop rophyl axi s
Most aut hors recom mended earl y ambul ation[5, 10, 19, 20, 23, 30 –32, 35 –37,
42, 44, 47, 48] and t he us e of compressi on stocki ngs[10, 14, 22, 26, 30, 37,
39, 42, 47]. Proph yl actic anticoagul ati on[10, 19, 21 –23, 32, 38 –40, 42, 48]
Accepted
were not ed in s everal publi cations (Table 7). When thromboproph yl axis was
des cribed , it was performed with low-molecul ar -wei ght enoxaparin (3000 UI twi ce a da y[21], 4000 U I per da y[38, 42, 51], or 5000 U I[ 23] per da y) or
unfractionat ed heparin (5000 U I per da y[40]). The us e of fondapari nux was
menti oned in onl y one publi cation[20] .
Anti coagulants were fi rst admini st ered 1 hour before surger y[21] or 4 hours
aft er surger y[19]. The durati on of throm boproph yl axis vari ed among s tudi es:
for 2 da ys after s urger y[ 40], until hospit al dis charge[19],[21], and for 1
week[48], 2 weeks[42], and 6 weeks[39] aft er di scharge . Nem erofsk y[ 35]
perform ed Doppler ul tras ound before dis charge to eliminat e thromboembolism .
Patien t s atisfacti on and quali ty of life
Onl y one prospective st ud y[52] ass essed qualit y of li fe ( QOL) and pati ent
satis faction in 27 patient s after ci rcum ferenti al bod y li ft of t he lower trunk using a validat ed questi onnai re ( WHOQOL-BREF surve y for QOL and FbeK for pati ent satis faction). Operat ed pat ient s showed a hi ghl y si gni fi cant increase in global QOL, ph ys ical and ps ychologi cal health, s ocial rel ati onships , and environm ent ( WHOQOL-BREF; all p < 0.01). The FbeK results s howed s i gni ficant l ower s core s on t he “ins ecurit y a nd uneasiness ” scal e after bod yli fti ng ( p < 0.01) and a greater attractiveness and s el f -confidence scores aft er surger y ( p < 0.001).
Five studi es assessed pati ent satisfaction usi ng non -validat ed questionnaires[27, 36, 41 –43]. P ati ent satisfact ion with aest heti c out com e s
Accepted
aft er belt li p ect om y was evaluat ed b y a 1 –10 vis ual analog s cal e and s howed
improved results [27] . Baca[41] showed an average overall i mprovement to
scores of 9.4/ 10. A simil ar result was obs erved aft er lower bod y li ft with
aut ologous augm ent ation , wit h ass ess ment us ing a 1 –5 s cal e (4.35 ±
0.63)[36] . De Runz [42] evaluat ed overall s atis fac t ion (55.8% excell ent
results ), abdom en s atisfaction (55.8% excellent res ults ), butt ocks satis facti on
(32.7% excell ent results ), and QO L (i mproved in 73.1% of pati ent s ). No
difference in satis faction was found bet ween butt ock aut o -augm ent ation and
non -augm ent ati on[43]. The authors of 10 studi es[9, 10, 14, 21, 22, 30, 34, 35,
40, 48] report ed hi gh or ve r y hi gh sat isfaction from all pati ents , wit hout
explanat ion of the evaluation m ethod.
DISCUSSIO N
Circum ferenti al contouring of the lower trunk procedures were i niti all y
creat ed to treat circum ferenti al excess skin of t he lower trunk in non
-bari atri c pat i ent s[4– 6], and progressed t o the t reatm ent of pati ents who had
undergone m as sive wei ght loss [9]. Massi ve wei ght loss, defined in t he
literature as a l oss of 50% of excess wei ght [53] , i s t he most appropri at e
indi cat ion.
In this cas e, excess (redundant) circum ferential s kin is pres ent and cannot
be correct ed b y abdominoplast y or s imple liposucti on [30] . Exces s posteri or
skin requires belt lipectom y or l ower body li ft, dependi ng on the deform ati on.
Accepted
This revi ew provides the fi rst overvi ew of circum ferenti al bod y cont ouring
of the l ower trunk, and the various techni ques, indi cat ions , and com pli cations,
with anal ysi s of fi ndings i n 1,748 operated pati en ts. The majorit y of
publi shed s eries were Ameri can and European, i n connection wit h the
preval ence of obesit y on thes e continent s.
Patien ts eli gibl e for operati on
Pati ents shoul d have st abl e wei ght for at leas t 6[30] or 12[ 39, 44] m ont hs
before surger y, ideal l y wi th BMI < 35 kg/m2[35, 39] . Mor e w omen than m en
underwent surger y, probabl y for three main reasons: t he gl obal prevalences
of obesit y and overwei ght are hi gher in wom en than in m en (13.7% vs. 9.3%
and 37.3% vs. 35.9%, res pecti vel y) [ 1]; more bari atri c surger i es are
perform ed on wom en [2]; and wom en are m ore concerned about t hei r
appearance[54].
Opti mal p reop erati ve ass ess ment
Anemi a s creeni ng and nutrit ional ass es s ment are ver y important . Surger y is
oft en hem orrhagic , and anemia should be det ect ed and correct ed
preoperativel y[14, 42] t o avoid hi gh t ransfusi on rat es [ 6]. Colwell [36]
recommended a bas eline hemoglobi n concent rati on of 12 g/ dl.
Post-bari at ric pati ents often present nut ritional defi ciencies (iron, ferrit in,
hem oglobin, thiam i ne, 25 -OH vi tami n D, vi tam in A, vi t amin B12, zi nc,
sel eni um, and folat e) [55], aggravat ed b y low com pli ance (60%) with vit amin
Accepted
and mineral s upplem ent ation. Such defi ci enci es are m axima l i n the fi rst year
foll owi ng bariatri c surger y[56] and should be corrected preoperativel y t o
reduce s urgi cal com plicati ons , es peci all y wo und probl em s [57] . Fis cher[58]
dem onst rated t hat preoperativ e al bum in l evels and m al nutrition were
associ at ed wit h increased odds of minor wound complicati ons i n all bod y
contouring procedures. Nutri tional defi ci enci es creat e biom echanical changes
in the skin[59, 60] that del a y wound heali ng.
Austi n[61] dem ons t rat ed t he positi ve impact of prot ein nut ritional
suppl em ent ati on on abdominopl ast y, wit h a decreas e in wound dehis cence.
We bel ieve t hat the sam e preoperati ve assess ment should be perform ed for
circumferenti al body contouring. Nutri tion should be cont roll ed not onl y
preoperativel y, but also after s urger y wi t h prot ein suppl em ent ation [62] .
Current trends in techniqu e
Belt lipectom y was t he fi rst t echnique described in the lit erat ure[4], wh ereas
lower bod y li ft [6, 11, 29] is most popul ar. A glut eal augmentati on fl ap [14],
suppl ied b y perforat ors from the superior gl uteal art er y, l at eral s acral art eries,
and lumbar art er y[14, 20, 33] , can be added to correct i nsuffi ci ent butt ock
proj ection. C olwell [ 36] showed t hat m aj or perforat ors are generall y s ituat ed
6–9 cm from t he mi dline, wh ereas Noji ma[63] pl aced them 10 –12 cm from
the midli ne .
Despit e the effect on glut eal projecti on, t hese t echni ques ma y actuall y
increase t he com pli cation rat e [43]. We noted that gluteal fat necrosis [20, 33,
Accepted
34, 36] and glut eal h ypoest hesi a [14, 48] were report ed onl y in pati ents who
were t reat ed wit h aut o-augm entation fl aps.
The most cons ervat i ve and safe procedure is probabl y “li pogl uteopl ast y” [17 ,
18], which us es a t echnique sim ilar t o t hat us ed in brachi oplasti es [64] and
medi al t hi gh lifts [65, 66] , with skin resection jus t under t he dermis with no
underm ining. It c an eventuall y be combined wit h buttock augm ent ati on
techni ques wit hout flap [15 –17]. R es ection under t he dermis after liposucti on
is even more conservati ve in t erms of t he blood and l ymphati c s ys t em s[18,
67]. When deeper res ection is perform ed, t he us e of fibrin seal ant duri ng
surger y[33] and quilt ing s utures [20] m a y reduce dead spaces .
We ident ifi ed no s tud y of fat grafti ng int o buttocks. This sit uat ion is
probabl y due to the risk of reduced graft survival, as the pat ient li es on the
graft ed fat during t he postoperative course [20].
Comp lications
Since the 50% com plicati on rat e described b y Lockwood [6], the
com plicati ons rate has decreas ed among publ is hed reports , with a mean of
37%. This rat e is comparabl e t o t hat for abdominopl asti es (between 18% [68]
to 40%[69] ) and brachi opl asti es (from 20% [70, 71] to 56%[ 64] ). It rem ains
lower t han m edial t hi gh li fts (43 –74%[72, 73] ). M ajor complicati ons are
uncommon and the most frequent com plications are m inor: serom a, wound
dehiscence, and s car irregul arities. Wound dehis cences m a y be prevent ed b y
stop sm oki ng and suppl em enti ng nutriti onal carencies before surger y [ 57];
serom as b y the use of fi bri n seal ant during surger y [ 33]; qui lting sut ures to
Accepted
reduce dead space [20] ; wearing a compressi on garment for 6 weeks [42] . The
usuall y reported i dea i s t hat preserving superfici al fas ci a is ess enti al to
diminish s erom as. Maki ng a res ecti on under the derm is after a li pos uction
seems even more conservati ve towards t he bl ood and l ym phati c s ys tem [18,
67] .Glut eal h ypoest hesi a and glut eal fat necrosi s onl y occurred in pati ent s
who had a glut eal augm entat ion wit h fl ap.
Post bariatri c pat ients were associ at ed with a hi gher complicati ons rat e
duri ng abdomi nopl as ties , especial l y heali ng problem s [74] ,[75] . This was not
report ed during ci rcumferential proced ures[38, 42] . However this surger y
was int ented for m as sive wei ght l oss pati ents , creating a s el ection bias.
Our revi ew confirmed t hat , when combining di fferent bod y contouri ng
techni ques such as lower bod y lift and m edi al t hi ghpl ast y [6, 39] ,
com plicati on rat e increas es [76, 77] .
Although mi nor com plicati ons are frequent, c i rcum ferenti al contouri ng of the
lower trunk should be propos ed whenever it is i ndi cated, because the qual it y
of life is i mproved [ 52] . In this surger y, the benefit to pat ient s is m ainl y
functi onal, not esthetic.
Antibi oti c p rophylaxis
The i nfection rat e after circumferenti al contouring of t he lower trunk wa s
similar t o that foll owi ng abdominopl ast y (7%[68] –8%[78] ). For
abdominopl ast y, antibioti c proph yl axis was recom mended [79, 80] . For
circumferenti al cont ouri ng, further specifi c studi es are necessar y to assess
Accepted
Thrombop rophyl axi s
Pati ents undergoing ci rcum ferent ial procedures of the lower t runk should
alwa ys be considered t o be at hi gh risk of throm boem bolism [81, 82] .
Hat ef[51] found that enoxaparin admi nistrati on was associ ated with a
decrease in deep venous t hrombosis in pati ent s un dergoing circumferenti al
abdominopl ast y. For all bod y contouring procedures, he reported BM I > 30
kg/m2, hormone therap y, and ci rcum ferential abdominopl ast y as ris k fact ors
for t hromboem boli s m and recom mended s yst em ati c t hrom boproph yl axis i n
these cases [51]. Sim ilar results [83] were reported among pati ent s undergoing
procedures aft er bari atric surger y with BMI s > 35 kg/m2.
Bas ed on this revi ew, we st rongl y recommend chem oprop hyl axis associ at ed
with earl y am bul at ion and the use of compression stockings (st andard
pati ent s) or pneumat ic stockings (hi gh -ri sk patients ). The ris k of phlebitis is
sli ghtl y hi gher [51] t han for abdominopl ast y, but it can be reduced b y t hese
simpl e m easures.
The ti ming of administration of t he fi rst dos e vari ed among s tudi es, with no
difference in int raoperative bl ood loss, pos toperat ive bleeding, or
thromboembolism [51]. Independent l y of the timi ng, chem ical
thromboproph yl axis was ass oci at ed with increased rate s of h ematom a[39] and
postoperative bl eedi ng [51]. Thi s sit uation expl ains wh y som e authors did not
admi nist er heparin [35]. In our opini on, phl ebitis pos es a greater ris k t han
does hem atom a.
Accepted
Method ological is su es
Our revi ew was lim ited i n that the m aj orit y of studies incl uded were l ow
-evi dence st udi es , e.g. , retrospective series. Onl y two studies were
prospect ive[39, 52] . Dat a concerning pati ent charact eri stics , operative
techni ques, and out comes were reasonabl y wel l report ed, even i f means were
oft en preferred t o raw dat a; dat a concerning wei ght loss before surger y,
preoperative ass es s ment , use of l ipos ucti on, antibioti c proph yl axis, and
thromboproph yl axis were poor. P opul ati ons wer e fairl y het erogeneous , wit h
differen ces i n pati ent charact eristi cs and operative t echniques among studies.
Further prospective studi es shoul d be desi gned usi ng det ail ed dat a report ing
and more st ri ct i ncl usion crit eri a.
Onl y t wo st udi es were excluded beca use of l anguage [84, 85] , whi ch reduced
the language bi as and render ed our revi ew reas onabl y comprehensi ve. Other
bias es included publ ication bi as and det ection bi as , as m ost s tud y data were
anal yz ed retrospecti vel y.
CONCLUS ION
To dat e, no cl ear gui deli nes exist for circumferential lower t runk contouring
indi cat ions and cont rai ndi cations. The popul arit y of thes e procedures will
increase over t he next few years, in parall el with the worldwi de preval ence of
obesit y. Great er accurac y is requ i red concerning preoperati ve ass essm ent of
pati ent s, sel ected BMI ranges, and preoperative risk evaluat ion. To achi eve
Accepted
anal yz e pati ent characterist ics and outcomes. Future work wi ll evolve in t wo
directions: m ore hi ghl y defi ned i ndi cat ions establis hed b y ph ys i cians and
improved i nform ati on regardi ng surgi cal risks for pati ent s.
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Accepted
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Accepted
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Accepted
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Accepted
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79. Sevin A, S enen D, S evi n K, et al. (2007) Ant ibiotic use in
Accepted
80. Hurvitz KA, Ol a ya WA, Ngu yen A, W ells J H (2014) Evi dence -bas ed medi cine: Abdomi noplas t y. Plast R econs t r Surg 133:1214 – 1221.
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Accepted
FI GURE LE GENDS
Figu re 1. Pri sma flow chart of t he s ystema ti c revi ew.
Accepted
Figu re 2. Obes it y preval ence
(gamapserver .who.int/gho/i nt eracti ve_charts/ncd/ris k_f actors /obesit y/atl as.html )
and geographical dis tribution of publi cati ons.
Accepted
Figu re 3. Skin patt erns of bel t lipectom y (red m arkings) and l ower bod y l ift (blue
markings). For belt l ipectom y: pat tern is hi gher; s uperi or res ection li ne is
drawn first at t he superior m argin of t he flank rolls. For lower bod y li ft: patt ern
is lower; inferior resection line i s drawn first either i nside or at t he superior
Accepted
Figu re 4. Di fferent res ection dept hs duri ng post erior st ep: (1) to t he mus cular
fasci a, (2) to the s uperfi ci al fascia or (3) under the dermis foll owing
lipos ucti on of both s uperfi cial and deep fat.
Accepted
Figu re 5. Techni que of butt ock augm entat i on with fl ap. An aut ologous derm al fat
flap i s di ss ect ed and moved down t o the gluteal fold, aft er an underm ine over the gluteus maximus muscle creating thus a “gluteal pocket”.
Accepted
Figu re 6. Techni que of butt ock augm entat ion without fl ap. a) Point B, locat e d at
the lat eral end of t he glut eal fol d on the i nferi or res ection li ne, is sutured to
point A, locat ed 5 cm mediall y to point B on the superi or res ection line. b)
gl ut eal augm entati on b y suturing point B to point A.
Accepted
T a b l e 1
Presentation of included articles, with level of evidence
Article Country Study design Evidence level
Number of included patients
Gonzalez-Ulloa [4] Spain Technical
description V 2 Vilain and Dubousset
[5] France
Retrospective
cohort III 150 Lockwood [6] United States Case Series IV 10 Lockwood [29] United States Technical
description V 1 Hunstad [46] United States Technical
description V 1 Carwell and Horton [9] United States Case Series IV 7 Van Geertruyden [10] Belgium Retrospective
cohort III 30 Hamra [26] United States Retrospective
cohort III 40 Lockwood [11] United States Technical
description V 2 Heddens [30] United States Retrospective
cohort III 32 Pascal and Le Louarn
[14] France
Retrospective
cohort III 40 Modolin et al. [22] Brazil Retrospective
cohort III 12 Morales Gracia [23] Mexico Retrospective
cohort III 39 Aly et al. [31] United States Retrospective
cohort III 32 Pascal and Le Louarn
[32] France Retrospective cohort III 100 Cormenzana and Samprón [28] Spain Retrospective cohort III 20 Rohde and Gerut [33] United States Retrospective
cohort III 62 Van Huizum et al. [27] Netherlands Retrospective
cohort III 21 Sozer et al. [34] United States Retrospective
cohort III 20 Centeno [20] United States Retrospective III 21
Accepted
Article Country Study design Evidence level
Number of included patients
cohort
Rohrich et al. [21] United States Retrospective
cohort III 151 Strauch et al. [19] United States Retrospective
cohort III 75 Colwell and Borud
[36] United States
Retrospective
cohort III 18 Davison et al. [49] United States Case Series IV 3 Aly et al. [50] United States Technical
description V 0 Hatef et al. [51] United States Retrospective
cohort III 65 Shermak et al. [45] United States Retrospective
cohort III 57 Jones and Toft [47] United
Kingdom
Retrospective
cohort III 16 Dini et al. [48] Italy Retrospective
cohort III 41 Kolker and Lampert
[37] United States
Retrospective
cohort III 24 Vico et al. [38] Belgium Retrospective
cohort III 80 Koller and Hintringer
[15] Austria
Retrospective
cohort III 50 Koller and Hintringer
[16] Austria
Letter to the
editor V 1
Koller et al. [52] Austria Prospective
cohort II 27
Kitzinger et al. [39] Austria Prospective
cohort II 50
Buchanan et al. [40] United States Retrospective
cohort III 35 Baca et al. [41] United States Retrospective
cohort III 59 Aly et al. [44] United States Technical
description V 1 De Runz et al. [42, 64] France Retrospective
cohort III 55 Koller [18] Austria Letter to the
editor V 1
Srivastava et al. [43] United States Retrospective
cohort III 97
Accepted
Accepted
Accepted
T a b l e 4
Indications and operative techniques
Article Indication Patient positioning Operative technique Buttock augmentation Buttock Resection depth Liposuction Gonzalez-Ulloa [4] Post pregnancy, obese, post-diet weight loss Supine then prone Belt lipectomy No Muscular fascia No Vilain and Dubousset [5] Post-diet weight loss Supine then prone Belt lipectomy No Muscular fascia No Lockwood [6] Truncal excess (normal weight) Supine then twice lateral Lower body lift NO Superficial Fascial Yes Lockwood [29] Truncal excess (normal weight) Supine then twice lateral Lower body lift No Superficial Fascial Yes
Hunstad [46] Obese Supine then prone Belt lipectomy No Muscular fascia Yes Carwell and Horton [9] Massive weight loss (bariatric surgery or diet) Prone then supine Belt lipectomy No Muscular fascia Yes Van Geertruyden [10] Massive weight loss (bariatric surgery or diet) Prone then supine Belt lipectomy No Muscular fascia Yes Hamra [26] Post pregnancy, massive weight loss Supine then twice lateral Belt lipectomy No Muscular fascia Yes Lockwood [11] Massive weight loss Supine then twice lateral Lower body lift No Superficial Fascial Yes Heddens [30] Bariatric surgery or diet Prone then supine OR Supine then twice lateral Belt lipectomy No Muscular fascia Yes
Accepted
manuscript
Article Indication Patient positioning Operative technique Buttock augmentation Buttock Resection depth Liposuction Modolin et al. [22] Massive weight loss (bariatric surgery) Prone then supine Belt lipectomy No Muscular fascia NR Morales Gracia [23] Overweight (0–35 kg) Twice lateral then supine Belt lipectomy No Muscular fascia Yes Aly et al. [31] Massive weight loss, normal weight, overweight or obese Prone then supine OR Supine then twice lateral Belt lipectomy No Muscular fascia Yes Pascal and Le Louarn [32] Massive weight loss Prone then supine Lower body lift Autologous flap Muscular fascia yes Cormenzana and Samprón [28] Post pregnancy, obese or massive weight loss NR Belt lipectomy No NR Yes Rohde and Gerut [33] Massive weight loss (bariatric surgery) Supine then prone Lower body lift Autologous flap Muscular fascia NR Van Huizum et al. [27] Post pregnancy or massive weight loss Supine then prone Belt lipectomy No Muscular fascia NR Sozer et al. [34] Massive weight loss (bariatric surgery or diet) Twice lateral then supine Lower body lift Autologous flap Muscular fascia Yes Centeno [20] Massive weight loss Prone then supine Lower body lift Autologous flap Muscular fascia NR Nemerofsky et al. [35] Massive weight loss (bariatric surgery or diet) Supine then twice lateral Lower body lift No Muscular fascia Yes Rohrich et al. [21] Massive weight loss or truncal Prone then supine Belt lipectomy No Muscular fascia Yes
Accepted
manuscript
Article Indication Patient positioning Operative technique Buttock augmentation Buttock Resection depth Liposuction excess (normal weight) Strauch et al. [19] Massive weight loss (bariatric surgery) Supine then prone Belt lipectomy No Superficial Fascia NR Colwell and Borud [36] Massive weight loss (bariatric surgery) Prone then supine Lower body lift Autologous flap Muscular fascia NR Davison et al. [49] Massive weight loss (bariatric surgery or diet) Supine then twice lateral Belt lipectomy No Muscular fascia NR Aly et al. [50] NR Supine then twice lateral Belt lipectomy No Superficial or muscular fascia Yes Hatef et al. [51] NR NR Lower body lift or belt Lipectomy NR NR NR Shermak et al. [45] Massive weight loss NR Lower body lift NR NR NR Jones and Toft [47] Massive weight loss (bariatric surgery or diet) Twice lateral then supine Lower body lift No Superficial Fascia Yes Dini et al. [48] Massive weight loss (bariatric surgery or diet) Prone then supine Lower body lift Autologous flap Muscular fascia Yes Kolker and Lampert [37] Massive weight loss (bariatric surgery or diet) Prone then supine Lower body lift No Muscular fascia Yes
Vico et al. Massive Prone then Lower Muscular
Accepted
Article Indication Patient positioning Operative technique Buttock augmentation Buttock Resection depth Liposuction surgery or diet) Koller and Hintringer [15] Massive weight loss (bariatric surgery or diet) Prone then supine Lower
bodylift Without flap
Superficial Fascia NR Koller and Hintringer [16] NR Prone then supine Lower
body lift Without flap
Superficial Fascia NR Koller et al. [52] Massive weight loss (bariatric surgery) Prone then supine Lower body lift NR Superficial Fascia NR Kitzinger et al. [39] Massive weight loss (bariatric surgery or diet) Prone then supine Lower body lift No Superficial Fascia NR Buchanan et al. [40] Massive weight loss (bariatric surgery or diet) Supine then prone Lower body lift No Muscular fascia Yes Baca et al. [41] Non post-bariatric surgery NR Lower
body lift NR NR Yes
Aly et al. [44] massive weight loss; normal weight or overweight Supine then twice lateral Belt lipectomy No Superficial or muscular fascia Yes De Runz et al. [42, 64] Massive weight loss (bariatric surgery or diet) Prone then supine Lower body lift Autologous flap Muscular fascia Yes Koller [18] Massive weight loss Prone then supine Lower body lift No Skin-only resection Yes Srivastava et al. [43] Massive weight loss (bariatric surgery or diet) Prone then supine Lower body lift ±Autologous flap Muscular fascia NR
Accepted
manuscript
NR not reported
Operative technique: techniques were classified as «Lower body lift» when the scar was situated at the bikini-line, as «Belt lipectomy» when the scar was situated at the waistline
Accepted
Table 5
Outcomes and complications
Articles including data (n) Median [IQR] Mean ± 95 % CI Min Max Outcomes Resection weight (kg) 10 3.76 [3.45– 4.45] 3.89 ± 0.7 0.69 15 Lipoaspirate volume (L) 7 1.68 [1.27– 2.04] 1.87 ± 0.79 0.45 8.45 Operative time (min) 14 261 [222.5–
306] 261.73 ± 31.72 79 654 Blood loss (L) 5 0.49 [0.46–
0.63] 0.56 ± 0.24 0.2 1.9 Patients transfused (%) 15 13.75 [0–22] 21 ± 14 12.5 100 Length of stay (days) 11 3.5 [2.1–7.4] 4.73 ± 1.97 0 32
Complications
Overall complications (%) 17 36.55 [26.63–
45.65] 35.01 ± 7.66 70 Overall Revision rate (%) 22 6.25 [3.2–
13.9] 10.42 ± 4.33 33 Revision rate for aesthetic
purpose (%) 21 0 [0–5.75] 4.34 ± 3.22 30 Revision rate for non-aesthetic
purpose (%) 21 3.5 [0.25–6] 5.82 ± 3.47 17 Wound dehiscence (%) 27 13.51 [9.38– 22.5] 19.54 ± 6.81 68 Skin necrosis (%) 27 0 [0–2] 1.51 ± 0.88 10 Infection/abcess (%) 27 1.82 [0–8] 7.41 ± 5.59 60 Hematoma (%) 27 0 [0–2] 1.42 ± 0.88 10 Seroma (%) 28 9.45 [4.76– 24.01] 14.46 ± 4.78 46 Scar irregularities (%) 12 11.42 [3.01– 17.59] 12.59 ± 6.95 41 Thromboembolism (%) 28 0 [0–1.70] 1.53 ± 1.20 13
IQR inter-quartile range, CI confidence interval
Accepted
T a b l e 6 Antibiotic prophylaxis Article Antibiotic prophylaxis Pre-operative Intra-operative
Post-operative Molecule Posology
Gonzalez-Ulloa [4] NR NR NR NR NR NR Vilain and
Dubousset [5] Yes No No Yes Penicillin NR Lockwood [6] Yes NR NR NR Cephalexin
(C1G) NR Lockwood
[29] Yes NR NR Yes
Cephalexin (C1G) NR Hunstad [46] Yes NR NR Yes NR NR Carwell and Horton [9] NR NR NR NR NR NR Van Geertruyden [10] Yes No Yes No NR NR
Hamra [26] Yes NR NR Yes NR NR Lockwood
[11] Yes Yes Yes Yes NR NR
Heddens [30] NR NR NR NR NR NR Pascal and Le
Louarn [14] Yes No Yes Yes NR NR Modolin et al. [22] Yes No Yes No Cephalothin (C1G) 2 g intra-operatively Morales
Gracia [23] Yes No Yes No
Cephalothin (C1G) 1 g intra-operatively Aly et al. [31] NR NR NR NR NR NR Pascal and Le
Louarn [32] Yes No Yes Yes NR NR Cormenzana and Samprón [28] NR NR NR NR NR NR Rohde and Gerut [33] NR NR NR NR NR NR Van Huizum et al. [27] NR NR NR NR NR NR Sozer et al. [34] NR NR NR NR NR NR
Centeno [20] Yes No Yes Yes NR NR
Accepted
Article Antibiotic prophylaxis Pre-operative Intra-operative
Post-operative Molecule Posology
Rohrich et al.
[21] Yes Yes NR NR NR NR
Strauch et al.
[19] Yes No Yes Yes
Cefazolin (C1G)
1 g intra-operatively Colwell and
Borud [36] Yes No Yes Yes NR NR Davison et al. [49] NR NR NR NR NR NR Aly et al. [50] NR NR NR NR NR NR Hatef et al. [51] NR NR NR NR NR NR Shermak et al. [45] NR NR NR NR NR NR Jones and
Toft [47] Yes No Yes Yes
Cefuroxime (C2G)
1,5 g intra-operatively Dini et al.
[48] Yes No Yes Yes NR NR
Kolker and
Lampert [37] NR NR NR NR NR NR
Vico et al.
[38] Yes No Yes Yes
Cefazolin (C1G) 1 g intra-operatively, 1 g ×3/day during 24 h after surgery Koller and Hintringer [15] NR NR NR NR NR NR Koller and Hintringer [16] NR NR NR NR NR NR Koller et al. [52] NR NR NR NR NR NR Kitzinger et
al. [39] Yes No Yes Yes
Cefuroxime (C2G) 2 g intra-operatively, 2g × 2/day during 3 days after surgery Buchanan et al. [40] NR NR NR NR NR NR Baca et al. [41] NR NR NR NR NR NR Aly et al. [44] NR NR NR NR NR NR De Runz et al.
Yes No Yes No Cefazolin NR
Accepted
Article Antibiotic prophylaxis Pre-operative Intra-operative
Post-operative Molecule Posology
Koller [18] NR NR NR NR NR NR Srivastava et
al. [43] NR NR NR NR NR NR
NR not reported, C1G first-generation cephalosporin, C2G second-generation cephalosporin
Accepted
T a b l e 7 Thrombo-prophylaxis Article Early deambulation Compression stockings Pneumatic
stockings Chemioprophylaxis Molecule
Gonzalez-Ulloa [4] NR NR NR NR Vilain and Dubousset [5] Yes NR NR NR Lockwood [6] NR NR NR NR Lockwood [29] NR NR NR NR Hunstad [46] NR NR NR NR Carwell and Horton [9] NR No Yes No Van Geertruyden [10]
Yes Yes No Yes LMWH
Hamra [26] NR Yes No No Lockwood [11] NR NR NR NR Heddens [30] Yes Yes No No Pascal and Le Louarn [14]
Yes Yes No Yes LMWH
Modolin et
al. [22] NR Yes No Yes LMWH
Morales
Gracia [23] Yes NR NR Yes
UH (5000UI/day) Aly et al. [31] Yes No Yes ± UH Pascal and Le Louarn [32]
Yes Yes No Yes LMWH
Cormenzana and Samprón [28] NR NR NR NR Rohde and Gerut [33] NR NR NR NR Van Huizum NR NR NR NR
Accepted
manuscript
Article Early deambulation
Compression stockings
Pneumatic
stockings Chemioprophylaxis Molecule
et al. [27] Sozer et al. [34] NR NR NR NR Centeno [20] Yes No Yes ± LMWH or Fondaparinux Nemerofsky
et al. [35] Yes No Yes No
Rohrich et
al. [21] Yes No Yes Yes
LMWH (Enoxaparin 3000UIx2/day) until hospital discharge Strauch et
al. [19] Yes No Yes Yes
LMWH until hospital discharge Colwell and
Borud [36] Yes No Yes No Davison et al. [49] NR NR NR NR Aly et al. [50] NR NR NR NR Hatef et al. [51] NR NR NR ± LMWH Shermak et al. [45] NR NR NR NR Jones and
Toft [47] Yes No Yes No
Dini et al. [48] Yes NR NR Yes LMWH for 1 week after hospital discharge Kolker and Lampert [37] Yes Yes No No Vico et al. [38] NR NR NR Yes LMWH (Enoxaparin 4000UI/day) Koller and Hintringer [15] NR NR NR NR Koller and Hintringer NR NR NR NR
Accepted
manuscript
Article Early deambulation
Compression stockings
Pneumatic
stockings Chemioprophylaxis Molecule
[52]
Kitzinger et
al. [39] NR Yes No Yes
LMWH for 6 weeks after hospital discharge
Buchanan et
al. [40] NR No Yes Yes
UH (5000 UI/day) or LMWH (Enoxaparin 4000 UI/day) for 2 days Baca et al. [41] NR NR NR NR Aly et al. [44] Yes NR NR NR De Runz et
al. [42, 64] Yes Yes No Yes
LMWH (Enoxaparin 4000 UI/day) for 2 weeks after hospital discharge Koller [18] NR NR NR NR Srivastava et al. [43] NR NR NR NR
NR not reported, LMWH low molecular weight heparin, UH unfractionated heparin
