Surgical design for body reshaping after significant weight loss and correction of skin laxity

Patients seeking medical treatment with unrealistic expectations.

When weight loss plateaus, the fat content in the excess skin varies greatly across different areas. Extensive skin wrinkling and folding occur alongside significant weight loss. The skin is like an oversized garment, with no part of it able to support its shape horizontally or vertically. Unlike surgical treatments for trauma or congenital malformations, reshaping surgery does not require transplanting normal tissue to correct deformities because all the skin tissue is in a disordered state and requires corresponding repair.

When patients return for their second appointment, usually a few weeks before the reshaping surgery, we perform imaging examinations. We display the patient's pre-operative photos on a monitor, then use an electronic pen to draw the planned incision, marking the direction of tissue tension and the location of the final surgical scar from multiple angles.

A patient's new body contours can be roughly drawn after surgery, but no absolute guarantee can be given. The choice of surgical procedure and the surgical outcome vary depending on the patient's physical condition. People who are too large or obese cannot be transformed into a lean physique. Patients who return for follow-up visits, whether impatient, disappointed with the results, or happy with them, will realize how much they have changed when they see the before photos of their full-body transformation from various angles on the monitor.

Surgeons must consider the patient's body type, degree of physical deformity, body size, gender, patient wishes, lifestyle, and risk tolerance. Before undertaking such a complex surgery, the surgeon, surgical team, and hospital should all have a solid foundation in the field. The larger the patient, the longer the surgery, and the greater the likelihood of complications.

**Deformity after weight loss**

**Causes of Loose Skin**

The causes of sagging skin following rapid weight loss are not fully understood. Microscopic studies of the fibrous tissue in the subcutaneous and fascial regions of patients reveal the breakage of elastin fibers. Damage to elastin and collagen prevents the skin from retracting after weight loss.

We cannot prevent sagging skin on the abdomen, chest, buttocks, upper arms, and inner thighs that occurs with rapid weight loss. Using the highest quality skin for abdominal repair is crucial, typically taken from the upper abdomen. Unfortunately, after significant and rapid weight loss, patients often lack high-quality skin.

These problems are more complex in patients over 55 years of age, because even without significant weight loss, their skin has already lost a considerable amount of elasticity. Unless we can find a feasible way to reverse these complex deformities and subcutaneous lesions, we will have to remove as much skin as possible within permissible limits, then tighten the flap as much as possible before suturing it.

Following significant weight loss, changes in body shape depend on familial and sex-specific fat deposition and local skin attachment to the fascia. The most commonly affected areas are the front of the neck, upper arms, chest, lower back, flank, abdomen, mons pubis, and thighs. In men, fat accumulation is more common in the flank, abdominal tissues, and chest, while in women it is more common in the subcutaneous tissues of the abdomen, buttocks, and thighs. The pattern of body shape distortion appears to be significantly influenced by the patient's preoperative BMI and the degree of change in BMI.

Excess skin hangs from the tightly attached fibrous sites between the skin and the deep fascia. The skin on the trunk adheres tightly to the inframammary fold, running downwards along the anterior midline and the linea alba to terminate in the groin. The density of skin attachment at the rectus abdominis tendinous intersections varies, and it mostly encircles the anterior ribs, flanks, and back with the width of one or two rectus abdominis muscles.

The areas where the skin bulges and forms folds will reattach to the abdominal wall after surgery, and the local skin tension will decrease. This explains why extra skin folds often appear at the location of the first abdominal muscle after abdominoplasty.

Whether it's anterior or posterior approach surgery, we must perform a staggered dissection of excess tissue from the middle outwards. The skin of the thigh attaches below the anterior superior iliac spine, and excess skin is distributed in the middle of the lateral to the middle of the medial side, with relatively less distribution in the posterior thigh area.

Three factors contribute to postoperative skin laxity: First, the abnormality of collagen and elastin in the skin tissue; second, the skin tension decreases the further away from the suture, which I consider an objective law of skin laxity. It should also be noted that skin laxity near the suture is corrected, while laxity gradually worsens the further away from the suture; finally, adhesion between the skin and the subcutaneous fascia prevents the remaining skin from being tightened. Surgical separation of these common yet unique adhesions can yield free flaps, but given that the blood supply of perforating vessels often resides in this structure, the survival rate of the flap is affected.

Previously, there was no proven method to effectively improve the elasticity of the skin and subcutaneous tissue. I am currently researching the application of the Endermologie rehabilitation therapy device, which uses a computer to adjust the intensity of massage and suction. LPG claims that symptoms of skin laxity can be significantly reduced after 20 sessions per week using their machine. We have already implemented this treatment to improve surgical results, and the effectiveness has proven to be as advertised.

We are confident that, when performed skillfully and correctly, the Endermologie rehabilitation therapy device can accelerate the dissipation of postoperative swelling and induration, soften most hypertrophic scars, and reduce scarring pain. The U.S. Food and Drug Administration has approved this therapy for short-term treatment of subcutaneous fat deposits. We have observed that smaller skin deformities become smoother after treatment.

Experiments on experimental pigs have shown that collagen production in subcutaneous tissue begins to increase after a period of treatment. Clinical studies have not indicated a reliable improvement in facial deformities, but the treatment of subcutaneous fat deposits shows promising results and can be used as an adjunct to ultrasound therapy and traditional liposuction.

The company has incorporated the latest electronic technology into its new product, Keymodule, and believes that even better treatment results will soon emerge. In the first half of 2006, we successfully applied Thermage technology-a radiofrequency energy source-to correct small areas of postoperative skin laxity.