Belt Lipectomy

Anatomy and Physiology

Understanding the blood supply to the abdominal wall skin and subcutaneous tissue is crucial for minimizing the risk of wound healing complications. Huger identified 3 zones of perfusion that divide the abdominal wall:

• Zone 1: The first zone covers the central tissue overlying the rectus abdominis muscles and is primarily supplied by the superior and inferior epigastric artery system perforators.
• Zone 2: The second zone extends inferiorly from a horizontal line connecting the anterior superior iliac spines and is predominantly supplied by the superficial inferior epigastric and superficial circumflex iliac systems.
• Zone 3: The third zone includes the lateral aspects, including the flanks, and receives blood from intercostal, subcostal, and lumbar perforating vessels.

When making a lower abdominal transverse incision, the blood supply to the abdominal wall in zone 2 is disrupted. Similarly, during the central abdominal flap undermining to the level of the xiphoid for diastasis plication and downward mobility, the blood supply in zone 1 is mainly divided. However, the transition between zones 1 and 3 requires more cautious undermining, with a perforator-sparing approach employed as necessary. When liposuction is incorporated into the procedure, surgeons must maintain a similar level of caution and awareness regarding the anatomy of perforators to minimize the risk of compromising the blood supply to the abdominal wall.[4][5] Proper layered closure of the abdominal incision emphasizing the SFS can off-load tension from the skin, close down dead space, and enhance healing. The SFS comprises loose, vaguely defined Camper fascia superficially and denser, more obvious Scarpa fascia below.[6] 

Indications

Belt lipectomy is typically considered in the following situations:

• Significant weight loss
  • Patients who have lost a substantial amount of weight, either through bariatric surgery or other means, with resultant excess skin and fat in the lower trunk area can be considered for this procedure.
  • Loose, sagging skin and excess fat in the abdominal area (pannus), flanks (love handles), hips, and buttocks may cause functional limitations, hygiene issues, skin conditions, and aesthetic concerns.
• Desire for body contouring
  • Patients experience loss of waist contour due to excess skin and fat deposits around the lower trunk and seek improvement in body contour and silhouette, wanting to achieve a more toned and proportionate appearance.

Regardless of why they want the procedure, patients considering belt lipectomy must undergo a thorough evaluation by a qualified plastic surgeon to determine if they are suitable candidates and discuss the potential risks, benefits, and expected outcomes based on their individual circumstances.

Contraindications

While belt lipectomy can be highly beneficial for many individuals, specific contraindications may make the procedure inappropriate or risky for certain patients. Some common contraindications include:

• Unstable medical conditions
  • Patients with uncontrolled hypertension, diabetes, heart disease, compromised immune systems, or other serious health issues may not be suitable candidates for surgery due to increased risks of complications.
• Bleeding or clotting problems
  • These issues can cause increased risks of intraoperative bleeding, postoperative hematoma formation, and thromboembolic complications. Patients with these conditions require careful evaluation to develop appropriate perioperative management strategies.
• Severe obesity
  • Belt lipectomy may not be recommended for individuals with severe obesity who have not yet achieved a stable weight, as significant weight loss following the procedure could lead to further skin laxity and potentially require additional surgeries.
  • Dr Nemerosfsky et al found a higher complication profile in body lift procedures commiserate with body mass index (BMI) increases, starting with patients with a BMI of more than 32 suffering an increased complication rate as high as 50%.[7]
• Unrealistic expectations
  • Patients with unrealistic expectations and goals regarding the outcomes of belt lipectomy may not be suitable candidates. Patients must clearly understand what the procedure can and cannot achieve.
• Active smoking
  • Smoking can impair wound healing and increase the risk of complications during and after surgery. Patients should quit smoking before undergoing belt lipectomy to reduce these risks.
• Psychological factors
  • Individuals with untreated psychological issues such as body dysmorphia or severe mental illness are not good candidates for this procedure. A thorough psychological assessment may be necessary before proceeding with surgery.
• Planned future pregnancies
  • Performing belt lipectomy in a patient who plans to have future pregnancies after the procedure may lead to premature reaccumulation of skin excess.
• Presence of abdominal hernias, especially umbilical
  • Suppose a moderately sized umbilical hernia is detected preoperatively. In that case, the conservative approach is to have it repaired by a hernia surgery team 6 months to 1 year before any procedure requiring umbilical relocation, eg, belt lipectomy or abdominoplasty. 
  • A laparoscopic or robotic approach to hernia repair can be tried to leave the umbilical stalk intact to preserve its blood supply and withstand a subsequent relocation. Open umbilical hernia repair often results in a divided umbilical stalk, which may cause umbilical necrosis if islanding the tissue is tried later.
  • Another possible scenario is that an umbilical hernia is encountered during surgery. In this case, as long as the hernia is reducible, the surgery could be completed, leaving the hernia for a later laparoscopic or robotic repair after the patient is fully healed. 

Equipment

A belt lipectomy requires specific equipment and instruments to ensure a safe and effective surgical procedure. Here's an overview of the equipment typically needed for a belt lipectomy:

• Surgical instruments: Various surgical instruments, including scalpels, scissors, forceps, retractors, and needle holders, are required to perform the procedure. A Lockwood underminer dissector can be helpful.

• Electrocautery: Monopolar and bipolar cautery devices may both be utilized during different stages of the procedure.

• Suction system: A suction system is essential to provide a clear field of view for the surgeon and reduce the risk of postoperative complications such as hematoma formation.

• Liposuction equipment and tumescent solution: Depending on the preoperative discussion with the patient, these may be required in some cases.

• Anesthesia equipment: This includes monitoring devices, anesthesia delivery systems, and medications necessary to ensure patient comfort and safety.

• Operating table and positioning aids: An adjustable operating table that can flex at the patient's hips is essential. Positioning aids such as a vacuum bean bag immobilizer, extra pillows, foam wedges, gel pads, and an axillary roll can be used. 

• Drains: Surgical drains are often placed in the surgical site to evacuate any accumulated blood and fluid postoperatively. This reduces the risk of seroma formation and promotes wound healing. Depending on the surgeon's preference, closed suction drains or passive drains may be used.

• Skin marking pens and rulers: Precision is crucial in marking the incision lines and areas for tissue excision. Skin marking pens and rulers are used to accurately outline the planned incisions and areas of tissue removal based on preoperative markings and surgical planning.

• Sterile drapes and surgical attire: Using sterile materials reduces the risk of contamination and surgical site infections. 

• Wound closure materials: Various types of sutures, staples, and adhesive skin closures are used to close wounds following tissue excision and contouring. Absorbable and nonabsorbable sutures may be used depending on the specific surgical technique and patient factors.

• Postoperative dressings and compression garments: Dressings and compression garments are applied to the surgical site following wound closure to support tissue healing, minimize swelling, and contour the newly shaped body. These garments are typically worn postoperatively for several weeks to months to optimize surgical outcomes.

Personnel

In addition to the operating surgeon, having a first assistant and additional moving help for belt lipectomy cases can benefit intraoperative positional changes, retraction help, and expedient closure of long incisions. An anesthesiologist and circulating nurse are also needed. 

Preparation

Given that belt lipectomy is an elective procedure, it's essential to conduct a thorough preoperative evaluation to ensure patient safety and optimize surgical outcomes. The patient's medical team should address any cardiopulmonary or medical issues before surgery. As previously discussed, severe or unstable medical comorbidities such as cirrhosis, uncontrolled diabetes, renal failure, unstable coronary artery disease, and heart failure are considered contraindications to belt lipectomy due to the increased risk of complications.

Smoking is often regarded as an absolute contraindication by many plastic surgeons, as it can impair wound healing and increase the risk of surgical complications. Patients are typically advised to stop smoking at least 1 month before the scheduled surgery to minimize these risks. Bariatric surgery patients may have nutritional deficiencies due to malabsorption, which should be corrected before undergoing belt lipectomy. Proper nutritional management helps optimize wound healing and reduce the risk of postoperative complications.

When obtaining the patient's history concerning their weight loss journey, it's essential to gather information about their highest weight, lowest weight, and the duration of their current weight. Additionally, discussing the patient's further weight loss goals is crucial. Performing a belt lipectomy on a patient still losing weight may result in premature reaccumulation of skin excess. Similarly, if a patient is planning to have more children, undergoing a belt lipectomy before completing their family may lead to the recurrence of skin laxity. In such cases, waiting until childbearing is over and the patient's weight loss goals have been achieved and maintained for at least 6 months to 1 year before considering a belt lipectomy is advisable. This waiting period stabilizes the patient's weight and body contours, reducing the risk of additional surgeries due to further weight loss or changes in body shape. This also ensures optimal long-term outcomes and patient satisfaction with the procedure's results.

Patients who have undergone massive weight loss may present with various types of skin and fat excess, including vertical, horizontal, or a combination of both, sometimes accompanied by intraabdominal fat accumulation that remains unaddressed by certain procedures. Vertical skin excess can result in panniculus formation, mons pubis ptosis, and rolls around the sides and back, while horizontal excess can contribute to a loss of waist contour. During the physical examination, assessing for rectus diastasis and the presence of hernias is essential. Additionally, buttock deflation, thigh laxity, and lipodystrophy should be noted, as they can also be addressed during belt lipectomy.

When planning a belt lipectomy procedure, careful consideration must be given to the positioning and potential impact of existing scars, particularly those over the abdomen and back. Scars from previous surgeries, such as Kocher or chevron subcostal incisions, can affect the vascularity of the abdominal skin flap, which is critical for successful wound healing and flap viability. Midline scars may also present challenges and may require revision at the time of belt lipectomy, with consideration given to converting them to a fleur-de-lis type excision to optimize aesthetic outcomes and minimize tension on the wound closure. By addressing existing scars proactively and optimizing incision placement during belt lipectomy, surgeons can mitigate potential complications and optimize the overall aesthetic result for the patient.

Belt lipectomy is often performed in the outpatient setting. The anesthesia team may administer a transversus abdominis or erector spinae plane block to enhance patient comfort and facilitate recovery. These regional anesthesia techniques can reduce intraoperative and postoperative narcotic use while improving pain scores after surgery.[8] A single dose of preoperative low-molecular-weight heparin is typically administered as a precaution against thromboembolic events. Additionally, preoperative antibiotics are given to reduce the risk of surgical site infections. Tranexamic acid (TXA), an antifibrinolytic agent, may be considered to minimize blood loss during liposuction and body contouring procedures associated with belt lipectomy. TXA can be applied topically, infiltrated into tissues, or administered systemically before, during, or after surgery. However, further research is needed to establish the optimal protocol for TXA use in these procedures.[9]

The crux of the case is the marking of the belt lipectomy patient. This begins in the preoperative area, where the patient stands and slightly flexes at the waist to tension the eventual back closure appropriately. This moment also offers an opportunity to review patient expectations and ensure clarity regarding the areas to be addressed and the location of scars.

The marking process notes vital landmarks such as the midline from the xiphoid to the pubis and the anterior superior iliac spines. Anterior markings involve pulling down the mobile panniculus to estimate the excise amount at the proposed lower incision. However, the final decision on the extent of excision is made intraoperatively after confirming that closure is feasible without excessive tension. Conversely, the marking strategy for the posterior aspect is different. The upper incision is marked first as the static area, followed by pulling the excess buttock and lateral thigh skin upward to approximate and mark the extent of the excision. This method ensures the markings accurately reflect the planned excision and contouring of the back and lateral thigh areas.

Technique or Treatment

General anesthesia is induced with the patient in the supine position. A Foley catheter is inserted, and sequential compression devices are applied to prevent deep vein thrombosis. Pubic hair is removed with clippers, and the patient's hips are positioned at the level of the bed articulation to facilitate later flexion. Belt lipectomy often requires 3 position changes throughout the procedure to effectively access different areas of the body. First, the patient is positioned in lateral decubitus on a beanbag with proper padding and skin preparation using chlorhexidine. Second, the patient is moved to the opposite lateral decubitus position, and the preparation process is repeated. Finally, the case concludes with the patient in the supine position, prepared and draped for the final stages of the surgery. Depending on surgeon preference, patient positioning may vary, including an awake standing skin preparation circumferentially before induction. These variations aim to optimize access to the surgical site and ensure the best possible outcomes.

After the patient is positioned supine and anesthesia is induced, the operator stands to the patient's right and retracts the panniculus using the left forearm. Markings are made approximately 5 to 10 cm above the pubis within the hair-bearing area. The left side and then the right side of the lower abdominal pannus are retracted, with the left forearm pulling up the thigh skin. Equal tension is applied to each side to mark the proposed lower incision static area, extending just over the anterior superior iliac spine (ASIS) and laterally connecting with the flank incisions. Symmetry is ensured in the proposed incision. The upper incision may be remarked but is finalized after undermining to provide a minimally tensioned closure.

The procedure typically starts in the lateral decubitus position with the leg abducted. One flank and side of the back are completed, ensuring that skin from the thigh and gluteal region reaches the proposed static point of the lower back before transection. Minimal posterior undermining is performed to preserve blood flow and minimize dead space. Additional mobility may be achieved using the Lockwood elevator. Gluteal auto-augmentation and liposuction are considered if necessary.

After closure and dressing of the surgical site, the patient is repositioned to the opposite lateral decubitus position for a repeat procedure, followed by supine positioning. Liposuction and cautious flap thinning may be performed if needed. The umbilicus is incised and isolated to the fascia/linea alba level. The lower incision is made, and the abdominal flap is raised, working superiorly and centrally within Huger perfusion zone 1, protecting the umbilicus and preserving perforators when possible. This dissection proceeds to the level of the xiphoid.

With the patient flexed to about 30 degrees, the abdominal flap is stretched inferiorly to remark the upper extent of transection before removal. Diastasis is marked out and plicated with buried figure-of-8 0 ethibond sutures. The abdomen is stapled closed, and the neoumbilical site is marked at the level of the ASIS. The abdominal flap is quilted with progressive tension to the underlying fascia to close down dead space and off-load the eventual skin closure using 2 double-armed 0 polydioxanone (PDS) knotless control sutures. The umbilicus is brought out through the marked area and sutured. The flap can be thinned, and the umbilical stalk can be plicated to reduce height, creating a naturally-appearing umbilical depression. Drains may be used but are optional with progressive tension suturing.[10] Layered closure, including the SFS, is carried out carefully. Skin adhesive may be used over the incisions for added strength and waterproofing. An abdominal binder is helpful postoperatively, and early ambulation is encouraged while in a beach chair position in bed.

Complications

A meta-analysis from 2016 included 28 studies and 1380 patients undergoing belt lipectomy and found an overall complication rate of 37%. The most common complications included seroma (13%) and wound dehiscence (17%). Other notable complications included infection (5%), skin necrosis (4%), hematoma (3%), and deep vein thrombosis/pulmonary embolus (3%).[11]

Clinical Significance

The psychological benefits of body contouring procedures in appropriate patient populations have been extensively documented. Effective expectation management and thorough informed consent are essential in ensuring patient satisfaction. Research indicates that individuals who have undergone body contouring surgery following significant weight loss experience substantial improvements in health-related quality of life and satisfaction with their appearance over a 10-year follow-up period compared to those who did not.[12] 

However, it's important to note that weight regain is a common issue in this patient population, regardless of whether they have undergone bariatric surgery. A study tracking body contouring patients over 12 years revealed an average weight regain of 11.8% among those who underwent bariatric surgery and 7.6% among those who did not.[13] This underscores the importance of ongoing support and strategies for weight maintenance following body contouring procedures.

Enhancing Healthcare Team Outcomes

The healthcare team caring for a belt lipectomy case encompasses various professionals, each crucial in ensuring comprehensive care and optimal outcomes. The primary care provider, including advanced practitioners, serves as a central figure, assisting with preoperative medical clearance and optimizing medical conditions, such as glycemic control, to minimize surgical risks. Surgeons are crucial in performing the surgical procedure with precision and skill, ensuring that patient expectations are managed and informed consent is obtained. Anesthesiologists contribute through preoperative evaluations to ascertain the patient's fitness for general anesthesia and determine the appropriateness of regional blocks, ensuring safe anesthesia administration during surgery. Nurses are instrumental in preoperative assessment, patient education, and postoperative care, closely monitoring patients for any signs of complications and providing support throughout the recovery process.

Pharmacists contribute by ensuring the appropriate selection and administration of medications, including preoperative antibiotics and pain management regimens, to enhance patient comfort and safety. A nutritionist collaborates with the team to address potential nutritional deficiencies in postbariatric surgery patients, ensuring they maintain a healthy lifestyle through proper diet and exercise. Psychiatric or therapy follow-up is essential to assess and stabilize mental health conditions, providing necessary emotional support perioperatively. Professional communication among team members facilitates seamless care coordination, allowing for the timely exchange of information and collaborative decision-making. By fostering a culture of teamwork and open communication, healthcare professionals can collectively optimize patient-centered care, achieve favorable outcomes, prioritize patient safety, and enhance overall team performance in the context of belt lipectomy procedures.