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On the Multiple-Procedure Approach to Body Contouring in the Massive Weight Loss Patient

Agostini, Tommaso M.D.; Quercioli, Fabio M.D.; Mori, Andrea M.D.; Dini, Mario M.D., Ph.D.

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Plastic and Reconstructive Surgery: August 2010 - Volume 126 - Issue 2 - p 682-683
doi: 10.1097/PRS.0b013e3181df653f
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It was with interest that we read the article by Coon et al. entitled “Multiple Procedures and Staging in the Massive Weight Loss Population” published in the February issue of the Journal. The authors fairly emphasize the fact that, unlike conventional patients, massive weight loss patients are candidates for multiple operations in several areas to be treated, thus reducing costs and recovery time, and enhancing body contour. We fully agree that a multiple-procedure approach requires careful preoperative evaluation and influences operative times and costs. Undoubtedly, abdomen, upper limbs, and breasts followed by lateral/medial thigh represent the most frequent areas to be treated as confirmed by the personal case records presented by Coon et al.1

Our approach to the massive weight loss population provides multiple procedures to the abdomen (abdominoplasty/liposuction/panniculectomy), upper limbs (brachioplasty), and lower limbs (lateral/medial thigh lift) as preferred, similar to Coon et al., who performed multiple procedures on 269 patients (40.7 percent) on a total of 661 cases. Undoubtedly, the intraoperative time is proportional to the number of procedures performed; indeed, the authors' operative time varies from 6.2 hours (two procedures) to 9.2 hours (three procedures). The multiple-procedure approach increases blood loss and hospital stay but does not impact major complications such as thromboembolic events.1 As a consequence, the operative time seems to play a key role on minor complications as previously published by Gusenoff et al., who noticed patients undergoing operations longer than 8 hours having a greater number of complications worsen by an almost constant comorbidity (hypertension and diabetes).2

The ideal multiple-procedure approach to the massive weight loss patient would require a two-team approach to minimize the intraoperative time and minor complications. To facilitate a two-team approach, we would like to take the opportunity to illustrate our approach to the massive weight loss population. We usually perform abdominoplasty associated with brachioplasty as follows: starting with brachioplasty, once excised, the skin and the subcutaneous layer with the arms are placed in a comfortable position at 90 degrees from the chest wall and the elbow is mildly bent according to Aly et al.3; some key stitches temporarily close the wound, and the arms are positioned cranially with the elbows standing just above the head to complete the suture (Fig. 1). We do think this is particularly useful because it allows a second team to approach the abdomen, thus saving time and improving safety with shorter operative time. We adopted this technique on 15 patients undergoing surgery after massive weight loss and obtained shorter operative times (range, 1 to 2 hours saved) with local complications (e.g., seroma, edema, and dehiscence) overlapping with the single-procedure approach as supported by the common experience of the authors, who report no significant increase in abdominoplasty complications when performed alone compared with in combination with other procedures.1 Indeed, the complexity of the procedures performed would not predict complications as previously published,4,5 and even if staging procedures are common in bariatric surgery, it seems that the total complication rate would not be reduced anyway for selected patients.1 As Gusenoff et al. observed, the minor complication rate would be sensitive to the intraoperative time.2

Fig. 1.
Fig. 1.:
Once the skin and subcutaneous tissue are excised, we suture the wound in key points and then move the patient's arms cranially with hemiflexed elbows standing just above the head. This position allows a second team to approach other areas (abdomen/thighs).

As a consequence, we do recommend the presented procedure as a safer and faster procedure for selected patients with low comorbidity undergoing contemporary abdominoplasty (abdominoplasty/liposuction/panniculectomy) and brachioplasty or lateral/medial thigh lift and brachioplasty as well.


The authors have no commercial associations that may pose or create a conflict of interest with information presented in this communication.

Tommaso Agostini, M.D.

Fabio Quercioli, M.D.

Department of Plastic and Reconstructive Surgery


University of Florence

Faculty of Medicine and Surgery

Andrea Mori, M.D.

Department of Plastic and Reconstructive Surgery

University of Florence

Mario Dini, M.D., Ph.D.

Department of Plastic and Reconstructive Surgery


University of Florence

Faculty of Medicine and Surgery

Florence, Italy


1. Coon D, Michaels JV, Gusenoff JA, Purnell C, Friedman T, Rubin JP. Multiple procedures and staging in the massive weight loss population. Plast Reconstr Surg. 2010;125:691–698.
2. Gusenoff JA, Coon D, Rubin JP. Brachioplasty and concomitant procedures after massive weight loss: A statistical analysis from a prospective registry. Plast Reconstr Surg. 2008;122:595–603.
3. Aly A, Pace D, Cram A. Brachioplasty in the patient with massive weight loss. Aesthet Surg J. 2006;26:76–84.
4. Stevens WG, Vath SD, Stoker DA. “Extreme” cosmetic surgery: A retrospective study of morbidity in patients undergoing combined procedures. Aesthet Surg J. 2004;24:314–318.
5. Gmür RU, Banic A, Erni D. Is it safe to combine abdominoplasty with other dermolipectomy procedures to correct skin excess after weight loss? Ann Plast Surg. 2003;51:353–357.

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