Correcting the Saddlebag Deformity in the Massive Weight Loss Patient

Abstract

Skin redundancy of the trunk and thigh is treated by a circumferential abdominoplasty and a lower body lift. Despite preservation and tight approximation of the subcutaneous facial system, the authors have failed to adequately correct severe saddlebag deformity and midthigh laxity in the massive weight loss patient. The technique used in the last nine of the senior author's 43 lower body lifts was modified by fully abducting each operated thigh on a side utility table, before closure in the prone position. This maneuver permits an increase in width of skin excision and causes the lateral thigh skin to be taut upon leg adduction. This is a retrospective review of the senior surgeon's experience over a 3-year period. Postoperative follow-up of the nine-patient cohort ranged from 8 to 12 months. A standardized set of six-view preoperative and postoperative photographs was available for each patient. A regional grading system was developed to assign points for deformity seen in preoperative and postoperative photographs. To compare the effect of the new technique on the correction of hip/lateral thigh deformities, the authors used this same grading system to analyze 10 other lower body lift patients treated by the same surgeon without full thigh abduction who had six sets of standardized photographs. A deformity severity score was determined for each anatomic region by four trained observers blinded to the surgical technique. The nonparametric Mann-Whitney U test using exact p values was used to compare preoperative and percentage change in deformity severity score from preoperative to postoperative scores relative to preoperative scores for each anatomical region among subjects in each treatment group. The nonparametric Wilcoxon signed rank test using exact p values was used to evaluate the change in deformity severity score from preoperative to postoperative values. The change in technique resulted in an observable symmetrical correction of the severe saddlebag deformity and better contour to the distal lateral thighs. All evaluated patients were satisfied with the lateral thigh skin contour. The grading system revealed that patients treated with or without intraoperative thigh abduction had similar preoperative deformity severity scores for each anatomic region (p > 0.05). Postoperatively, all subjects showed improvement in scores for all treated regions. However, patients closed during full thigh abduction had significantly lower deformity severity scores for the hip/thigh complex when compared with patients treated without full thigh abduction (p < 0.05). Complications in these 19 patients consisted of one 6-cm superficial skin layer dehiscence due to a broken polyester suture that healed spontaneously. There were three seromas that responded to a short series of aspirations or catheter drainage. There were no infections. Distal abdominal flap tip skin necrosis in four patients responded to outpatient débridement and healed secondarily. A new grading system for body contour deformities was successfully utilized to judge differences in the quality of trunk and thigh deformity and outcome in 19 patients with adequate photographic records. Tight suture closure in full thigh abduction in the prone position results in improved treatment of significant saddlebag deformity and midthigh skin laxity in the massive weight loss patient. The essential principles are meticulous planning, careful isolation, tight closure of the lateral trunk and thigh subcutaneous fascial system, and artistic contouring of remaining tissues. Dehiscence, undesirable scarring, and seromas were minor issues in the entire group of 43 patients.