CHAPTER TWO CREATION OF TOTAL body LIFT™ SURGERY
TOTAL body LIFT™ REPRESENTS A PARADIGM SHIFT IN BODY CONTOURING SURGERY; AN ORIGINAL AND BOLDLY COMPREHENSIVE CORRECTION OF SKIN SAGGING, DEMANDING INSIGHT, ARTISTRY, SKILL, STAMINA, AND TEAM WORK.
The Total Body Lift combines Lower body Lifts, Upper body Lifts, and circumferential abdominoplasty. Liposuction with ultrasound assisted lipoplasty may play a prominent role. Upper and vertical medial thighplasty and brachioplasties are often concomitant. When staged, the Upper Lift follows a prior circumferential abdominoplasty and Lower body Lift. If immediate, Upper Lift planning considers the patient positioning, operative sequencing, tissue tensions and blood supply inherent in the first part of the operation. The basic principle is to leave as few scars as possible; however, the further the skin from the line of closure, the less effective is on the correction of laxity and contour deformity, especially if there are intervening lines of adherence between the dermis and muscular fascia.
Accurate markings for the Total Body Lift are time consuming but crucial. With experience one can map out the precise lines for tissue excision with little modification during the operation. Once the decision is made to use the prone and supine positions, one has to be confident that the lateral extent of the resection will be appropriate after the patient is turned to the supine position. With gravity as an aid and good judgment when employing folding and gathering of the skin, the surgeon can preoperatively accurately judge skin resection.
The markings for the circumferential abdominoplasty, modified lower body lift and a medial thighplasty are drawn first with the patient reclined and standing. Drawing for the upper body lift begins with sighting the IMF beneath the breasts. The invariably descended IMF's are positioned upwards and extensions of the new IMF'S are sighted over the sternum. She is standing and lifting her breast, as the surgeon gathers excess epigastric skin upward and laterally to plan the breath of skin excision entirely inferior to her repositioned breast. Unless the breast reduction pattern takes us there, these reverse abdominoplasty incisions do not cross anterior midline, even though some midline laxity remains. The breath and orientation of back skin resection is dictated by the redundancy.
As the patient turns from side to back the mid torso fold is gathered from lateral breast towards mid back along the brassiere line. For the most redundant skin problem, an oblique elliptical excision, similar to the Latisimis Dorsi myocutaneous donor site for breast reconstruction is draw to gather excess skin in both the transverse and vertical dimensions.
A Wise pattern breast reduction is drawn to remove enough loose skin and raise the nipple for reshaping that may include lateral chest wall deepithelialized flap or silicone implant augmentation. A Wise pattern skin excision is centered over the nipple, which often needs to be moved one to two centimeters medialy. The Wise pattern is chosen because the design maximizes skin removal as the remaining skin is unable to contract. Moreover, the incision along the IMF is incorporated into the reverse abdominoplasty.
The Upper body Lift begins in the prone position with removal of mid back excess skin after closure of the bikini line excision of the lower lift. With minimal undermining, the subcutaneous fascia is closed with large braided absorbable sutures, and nylon in the dermis. Upon completion in the prone position portion of the operation, the patient is wrapped in a surgeon's gown and turned supine onto a second operating room table. The abdominoplasty is completed with minimal lateral undermining.
After the abdominoplasty, the estimated upper abdominal skin resection is rechecked by gathering and pinching tissues. After the upper abdominal skin incisions are made, the skin flap is undermined over the Rectus Abdominis fascia to the coastal margins. The skin island between these incisions and inferior breast is excised or deepithelialized for a superior flap breast auto augmentation. The inferior based abdominal flap is advanced to about the sixth rib. After a half dozen #0 braided polyester sutures are placed in the flap subcutaneous fascia and along the rib periosteum, all the sutures are pulled superiorly and the abdominal flap is secured upward to the rib, temporarily dimpling the skin.
A Wise pattern breast reduction includes a deepithelialized nipple pedicle of the surgeon's choice (superior, lateral or medial pedicle to the nipples). The marked tissue laxity negates the need for pedicle undermining. The body roll immediately lateral to the breast is deepithelialized for rotation and advancement into a tunnel under the superior breast for auto augmentation.
In males the objective is to obliterate the inframammary fold, while sub totally excising gynecomastia and redundant skin. In one patient (35 year old) only ultrasonic assisted lipoplasty was necessary. In another (25 year old) limited lateral breast skin excisions were added. For the other three, redundant inelastic skin was removed through long obliquely oriented anteriolateral chest wall excisions in the form of a boomerang above the nipple. In contrast to females, the male Upper body Lift is usually combined with the Lower body Lift and circumferential abdominoplasty.
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