Massive Weight Loss Patients Research Articles

Versatility of the Superomedial Pedicle in Managing the Massive Weight Loss Breast: The Rotation-Advancement Technique

Management of the breast following massive weight loss is challenging. Specific issues include an unstable envelope (skin laxity) and an unstable mound (decent and volume loss). The evolution of a technique is presented. A retrospective review of all massive weight loss patients who underwent superomedial pedicle mastopexy techniques was performed. The current procedure involves incorporating the lower pole of the breast and rotating it superiorly. The lateral breast flap is then advanced medially and plicated. This essentially (1) autoaugments the upper pole, (2) narrows the wide breast, (3) provides an internal sling, and (4) redefines and secures the inframammary fold. Thirty-five patients were included in the series. The average body mass index was 26.5, and the average weight loss was 121 pounds. Six patients (17 percent) had mastopexy augmentation. Wise pattern skin takeout was performed in 89 percent of patients. The revision rate for the series was 11 percent. The average follow-up was 1.7 years. The superomedial pedicle is a versatile, well-vascularized pedicle that allows for glandular plication of the lower pole and autoaugmentation of the upper pole once rotated. Parenchymal shaping through plication and suspension of the breast mound should improve breast shape over time, theoretically reducing the incidence of recurrent ptosis as breast shape relies less on the often inelastic skin envelope. It applies a familiar and reliable technique, with certain modifications, to improve results and maintain shape in the long, deflated, massive weight loss breast.

Body Contouring of the Arms and Brachioplasty

Massive weight loss patients suffer severe arm deformity, extending through the axilla and onto the chest. We found current operations inadequate, often with conspicuous scars. The L-brachioplasty was evolved to treat the entire deformity through the excision of two right angle unequal ellipses, leaving natural contours and an unobtrusive L-shaped scar. The upper body deformity consists of loose upper arm skin, oversized axilla, descent of the posterior axillary fold, flattening and elongation of the anterior axillary fold, and lateral chest rolls of skin. By tissue gathering and pinching, a hemi-ellipse is drawn over the lower half of the inner arm, sweeping up to the deltopectoral groove. Then a shorter ellipse is extended through the axilla onto the chest. These ellipses are connected by an inverted V-resection through the axilla. After skin resection the wound margins are closed with a triangular flap advancement of the posterior axillary fold. The result is a properly contoured reduced arm, axilla, and lateral chest with a sweeping inverted L-scar coursing upward along the lower medial arm to cross the dome of the axilla and then drop vertically along the mid lateral chest. Over the past four years more than fifty weight loss patients have been treated with aesthetic reshaping of the upper arm leaving inconspicuous scars and only minor complications. There have been 8 scar revisions, including two Z-plasties for contracture. The rationale and results compare favorably with contemporary techniques. L-brachioplasty is our procedure of choice for the massive weight loss patient and can be selectively applied to the aging arm.

Modified Vertical Abdominoplasty in the Massive Weight Loss Patient

Patients with massive weight loss following bariatric surgery are now presenting in large numbers for body contouring. To achieve optimum cosmetic results in these patients, a comprehensive circumferential approach is usually required that includes the lateral thighs and buttocks. For a number of reasons, many patients are not candidates for these comprehensive procedures. Some patients view the circumferential procedures as too extensive or aggressive. Others have large hernias or other medical conditions that necessitate a more limited approach. Still others do not have sufficient resources to treat multiple areas. A 2-year review of patients presenting with a chief complaint of anterior lower abdominal tissue excess as a consequence of massive weight loss following bariatric procedures was conducted. In 64 cases, patients opted for anterior-only treatment of the lower trunk. Average operative time in patients undergoing modified abdominoplasty alone was 2.5 hours. The mean mass of the excised panniculectomy specimens was 3.8 kg (range, 1.1 to 10.0 kg). The most common complication was wound dehiscence at the T-junction (27 percent), which was treated successfully with local wound care in all cases and did not require reoperation to achieve wound closure. There were no known thromboembolic events. Not all massive weight loss patients are suitable candidates for comprehensive circumferential body contouring procedures, and many patients desire a limited anterior approach to the frontal abdomen. The modified vertical abdominoplasty should be considered as an option in these patients.

Components Separation Combined with Abdominal Wall Plication for Repair of Large Abdominal Wall Hernias following Bariatric Surgery

Abdominal wall hernias frequently occur after open bariatric surgical procedures. Standard repair with synthetic mesh may be suboptimal, with a recurrence rate as high as 50 percent. Patients often seek hernia repair in conjunction with abdominal body contouring procedures following substantial weight loss. In 66 consecutive patients undergoing abdominal surgery after open bariatric surgery, abdominal wall hernias of some size were found in 50 patients. In 65 of these patients, panniculectomy was performed simultaneously. The majority of these hernias could be closed primarily in conjunction with abdominal wall plication [38 of 50 (76 percent)]. In 12 patients (24 percent of hernias), the defects were too large (median, 10.8 cm) or located too close to the xiphoid to permit primary closure without undue tension. Using a components separation technique, primary fascial closure was achieved in all 12 patients. The technique was modified to include abdominal wall plication above and below the repaired hernia defect and the use of an absorbable mesh onlay. Although these patients had a high rate (50 percent) of minor or major superficial wound complications, all wounds closed subsequently without additional operative procedures. Despite the high-risk nature of this group, ventral hernia recurred in only one of 12 patients (8.3 percent) after a median follow-up of 16 months. The single recurrence occurred in one of the two patients with the largest diameter (15 cm) hernias in the series. The components separation technique combined with abdominal wall plication was assessed as the preferred technique for the repair of large hernias not amenable to primary repair in the massive weight loss patient following open bariatric procedures. Because this technique avoids placement of permanent mesh, it is particularly advantageous in the post-bariatric surgery patient at high risk for wound dehiscence and infection.

Factors Impacting Thromboembolism after Bariatric Body Contouring Surgery

The purpose of this study was to define the risk of venous thromboembolism within the massive weight loss population undergoing body contouring procedures. Retrospective analysis of massive weight loss patients who had body contouring operations between March of 1998 and September of 2004 was performed. Patient factors studied included age, gender, medical comorbidities including history of thromboembolic complications, depression, tobacco use, preoperative/postoperative body mass index, surgery, and transfusion. There were 138 cases, and the female-to-male ratio was 5:1. Procedures were often combined: 128 patients had abdominal surgery, 36 had a back lift, 41 had brachioplasty, 29 had chest surgery, and 47 had a thigh lift. The most common complications were related to healing (n = 28) and seroma (n = 18). Three patients had postoperative deep venous thrombosis requiring anticoagulation, and one had a fatal pulmonary embolism, making the overall venous thromboembolism risk 2.9 percent. The mean body mass index at contour was 48.5 for patients with venous thromboembolism versus 31.8 for patients who did not develop venous thromboembolism (p = 0.01). Looking at this subgroup of 45 patients, the risk of venous thromboembolism was 8.9 percent, with no risk found in patients with a body mass index less than 35 (p = 0.01). The risk of venous thromboembolism with contouring surgery for massive weight loss is comparable to that for gastric bypass surgery. Body mass index in the obese range appears to be a leading risk factor. The authors' data support routine prophylaxis against venous thromboembolism. Recommendations for high-risk patients are discussed.

LIFESTYLE OUTCOME STUDY FOLLOWING BODY CONTOURING IN MASSIVE WEIGHT LOSS PATIENTS.

Introduction Body contouring operations following massive weight loss are being performed at an exponentially increasing rate. Although highly effective for reshaping the body, these operations are associated with a high cost incurred by the patient. Traditionally, body contouring procedures have been considered an aesthetic procedure. However, due to disproportionate excess skin distribution, massive weight loss (MWL) patients often have a functional disability, which adversely affects their quality of life. Whereas some insurance companies are reimbursing for these procedures, most continue to consider body contouring as strictly cosmetic and ineligible as a covered benefit. The purpose of our study was to analyze the outcome benefit in patients undergoing body contouring following massive weight loss. Methods This single-center, multisurgeon body contouring outcome study was designed to assess the overall outcome and life-changing events that took place following the surgery. Twenty-five consecutive patients with an average age of 38 years (range 18-65 years) who underwent body contouring surgery were followed for 8 months. Postoperative evaluations were standardized and quantified with a validated series of short questionnaires (30 questions) that assessed measures in an objective and subjective manner. Questionnaires were designed to address specific lifestyle benefits attributed to body contouring. Results Of 25 patients who completed the survey, 84% were female. The mean BMI was 45. The majority of patients experienced positive lifestyle outcomes as a result of having had the procedure: 100% reported increases confidence and noted an increase in self-esteem; 100% felt more comfortable in clothes. A number of patients had changed careers and increased their annual income. In addition, 100% of patients indicated that their overall health had improved due to their ability to be more involved in society, improved ability to ambulate, and exercise. Discussion These data provide an assessment of some outcomes associated with weight loss procedures commonly performed in the United States. Although most health care insurance companies are hesitant to recognize body contouring as an essential procedure for MWL patients, we believe that our study demonstrates both objective and subjective improvements in quality of life and health. Body contouring in MWL patients represents the final stage in the surgical transformation of obese patients. There is little doubt that these procedures are invaluable and should be made more readily available to those patients who cannot afford the out-of-pocket expense.

Considerations for Body Contouring After Massive Weight Loss

This article examines the problem of redundant and excess skin and associated with massive weight loss. Included in the review is the damage to skin following excessive weight gain and subsequent weight loss; patient selection and criteria for body contouring; psychological considerations; and body contouring options. This will be the first in a series of articles looking at the current status of body contouring procedures for the massive weight loss patient.

Mastopexy With Autologous Augmentation After Massive Weight Loss

The reconstruction of breast and upper-body deformities in massive weight loss (MWL) patients presents specific challenges to the plastic surgeon. In addition to significant breast ptosis and loss of breast volume, bariatric patients also have excessive lateral axillary and posterior truncal tissue that may require dermolipectomy for correction. A wise-pattern mastopexy was designed with a pedicled fasciocutaneous flap based on the intercostal artery perforators (ICAP) to correct breast ptosis, to restore breast volume, and to eliminate redundant upper truncal tissue. Five MWL patients underwent mastopexy with ICAP flap augmentation. All patients had stable and esthetically pleasing results 1, 3, and 6 months postoperatively. There were no complications of infection, wound dehiscence, seroma, or hematoma. Furthermore, there was no evidence of flap loss or tissue necrosis. Mastopexy with autologous augmentation using the ICAP flap was found to be a reliable method of breast reconstruction in the MWL patient.

An Outcomes Analysis of Patients Undergoing Body Contouring Surgery after Massive Weight Loss

Although published reports about technical management of massive weight loss patients are beginning to appear, risk factors for complications following body contouring operations are not known. A retrospective analysis of massive weight loss patients who had body contouring operations between March of 1998 and October of 2004 was performed. Demographic and surgical factors were analyzed. Outcome measures included seroma, wound dehiscence, thromboembolic complications, blood transfusion after surgery, and extended lengths of stay (>2 days). A total of 139 patients were analyzed; 82.7 percent of them were female; mean age was 41 years. On multiple logistic regression, male gender was associated with significant risks for wound dehiscence (odds ratio, 6.4; p = 0.01). There were also trends toward increased risk for wound dehiscence with hypothyroidism (odds ratio, 4.3; p = 0.06) and Ehlers-Danlos syndrome (odds ratio, 18.7; p = 0.05). In terms of risk of blood transfusion, asthma and having three or more procedures were the two variables that emerged with significant association (odds ratio, 16.8 and 13.7, respectively; both p < 0.01). Increased length of stay to greater than 2 days was also significantly associated with having three or more procedures (odds ratio, 4.72; p < 0.01). Male gender, hypothyroidism, and Ehlers-Danlos syndrome may be risk factors for wound dehiscence following body contour operations for massive weight loss. Asthma may be a marker of poor general health status, and asthmatic patients are at increased risk for requiring blood transfusions. Having three or more procedures is associated with an increased risk of blood transfusion and increased length of stay.

Classification for indications of lipoabdominoplasty and its variations

Lipoabdominoplasty, the combination of lipoplasty with classical abdominoplasty, presents new opportunities for the treatment of abdominal lipodystrophy. The author analyzed 211 patients who underwent lipoabdominoplasty from 2000 to 2004. After the preoperative physical examination, the patients were classified into 9 different groups according to the indications for the most appropriate technique in each case. Patient groups ranged from those presenting with mild fat panniculus and good quality skin to massive weight loss patients with a high degree of flaccidity. Techniques used in treating the various patient groups included lipoplasty alone, 3 variations of lipominiabdominoplasty, 4 variations of lipoabdominoplasty, and abdominoplasty alone. The surgical principles used in the variations of lipoabdominoplasty included dissection and sculpturing of the subcutaneous deep layer and superficial layer through lipoplasty, selective undermining and plication of the anterior rectus sheath, preservation of the perforator vessels, preservation of Scarpa's fascia and deep fat, skin resection, and umbilical transposition. Two hundred eleven patients were treated between January 2000 and May 2004. Results were good, with high patient satisfaction regardless of variations in technique. There was no loss of sensibility in the suprapubic region in any patients. Among patients who underwent lipoabdominoplasty, there were low complication rates of epidermolysis (1.5%), seroma (1%), hematoma (1%), and necrosis (0.1%). There was no incidence of seroma, necrosis, or hematoma in the lipominiabdominoplasty subgroups I and II; in subgroup III, there was a 2% incidence of necrosis. Seroma was noted in 2% of patients who underwent reverse lipominiabdominoplasty. Similar low complication rates were observed in other groups. The classification of lipoabdominoplasty indications offers good options for treatment of the abdominal region. Lipoplasty, selective undermining, and maintenance of Scarpa's fascia help reduce surgical trauma that is the main factor affecting hematoma and necrosis rates. The learning curve for these classifications is fast because the described procedures are already familiar to most plastic surgeons.

Postbariatric Surgery Breast Reshaping

After massive weight loss, the breasts have poor shape, projection, and skin elasticity. Breast reshaping is recognized as difficult and may require excess nearby tissues. As the senior author's approach evolved over the past 4 years, breast reshaping with the spiral flap became integral to an upper body lift. After the weight loss has stabilized, body contouring surgery has been performed on 53 patients over a 3-year period. Six patients had mastopexy and/or augmentation only. Eighteen patients had spiral flap breast reshaping as part of an upper body lift. This lift is a reverse abdominoplasty that ends along the inframammary fold incision of the Wise pattern mastopexy and continues laterally to along the back roll. Excess tissue from the epigastrium and lateral back roll is deepithelialized and used for augmentation. These flap extensions of the central breast pedicle are spiraled around the breast for augmentation, shaping, and suspension. When more tissue is needed, saline-filled silicone implants have been used, preferably during a second stage. Follow up of this initial group ranged from 4 to 28 months with a mean of 11 months. In this initial effort, 14 of the 18 were pleased. In 3 patients, subsequent bilateral saline implants further augmented the breasts. Tip fat necrosis was evident by firmness of the tissues in 3 patients and resolved in all but 1. That 1 patient had operative debridement of the distal 50% of the flaps followed by saline-filled silicone implants. One patient was disappointed with the back scar. Two patients dislike the shape and fill of their breast and have not returned for revision. During 3 years of focused clinical activity, we have evolved the spiral flap reshaping with upper body lift into a comprehensive, effective, satisfying, and safe esthetic contouring of the breast and upper torso after massive weight loss performed with an upper body lift.

Hernia Repair and Abdominoplasty in Gastric Bypass Patients

Patients who sustain massive weight loss after open gastric bypass surgery are prone to incisional hernias. The authors undertook a retrospective study with two objectives: to characterize this patient population at their institution and to review their experience with treatment of incisional hernias in massive weight loss patients who had open gastric bypass surgery. With increasing prevalence of such patients, the authors aim to improve understanding and treatment of this disease entity and thereby improve patient outcomes. Operating room records and the patient database of the primary plastic surgeon treating massive weight loss patients at an academic teaching institution were retrospectively reviewed. Incisional hernia was often diagnosed before surgery but confirmed intraoperatively. Surgical management included primary repair of the hernia with plication of the abdominal wall from xiphoid to pubis and removal of redundant abdominal skin. From February of 2001 to December of 2003, 40 patients had hernia repair in combination with abdominoplasty. Average age was 42 years, and average weight loss was 152 pounds. Average body mass index at the time of plastic surgery was 35.6. Average abdominal skin resection was 9.9 pounds. Hernia recurred in one patient with a body mass index of 41.3 after heavy lifting within 1 year of hernia repair surgery. Other complications included wound-healing problems (20 percent); seroma (12.5 percent); bleeding requiring surgical take-back (2.5 percent); suture abscess requiring surgical removal of suture (7.5 percent); bleeding anastomotic ulcer requiring transfusion (2.5 percent); and fatal pulmonary embolus (2.5 percent). Of the group, 60 percent had uncomplicated healing. Hernias are safely and preferentially repaired at the time of removal of redundant abdominal panniculus after massive weight loss sustained from gastric bypass surgery. The authors present their approach to hernia repair and abdominoplasty in this patient group, with acceptable results.

Body Lift: An Account of 200 Consecutive Cases in the Massive Weight Loss Patient

The epidemic of obesity in the United States has led to a rapid increase in the number of bariatric procedures performed over the past several years. The dramatic changes to the torso following massive weight loss are only partially addressed by routine procedures such as abdominoplasty and liposuction. Circumferential body lifts or simultaneous abdominoplasty, thigh, and buttock lifts are becoming the method of choice for treating the postbariatric condition. In this article, the authors review the senior author's experience of 200 body lifts with massive weight loss individuals. The charts of 200 consecutive body lift patients were reviewed for complications and other variables. The preoperative markings, current surgical technique, and postoperative care are described. The patients were classified into three types according to their body mass index at the time of surgery. Type I individuals had a body mass index less than 28, type II individuals had a body mass index between 28 and 32, and type III individuals had a body mass index greater than 32. Type I and II patients in many instances achieved a nearly ideal body contour. Type II and III individuals also had a significant functional and aesthetic improvement but were more likely to have complications. The overall complication rate was 50.0 percent. The most frequent complications were skin dehiscence and seroma formation at 32.5 percent and 16.5 percent, respectively. The body lift very effectively addresses the functional and aesthetic concerns of the massive weight loss patient. Careful patient selection and education are essential to a good outcome.

The L Brachioplasty: An Innovative Approach to Correct Excess Tissue of the Upper Arm, Axilla, and Lateral Chest

Brachioplasty is aesthetic reshaping of the upper arm after removal of excess medial skin and fat. Massive weight loss patients evolve a severe arm deformity that extends through the axilla and onto the chest. Prevalent operations are incomplete and leave conspicuous scars along the bicipital groove that end as Ts or Zs in the axilla. The L brachioplasty starts with a long ellipse centered over the lower half of the inner arm that sweeps up to the deltopectoral groove. A shorter ellipse is connected at right angles through the axilla onto the chest. The V flap formed between the ellipses is advanced across the axilla to raise the posterior axillary fold. An improved arm, axilla, and chest have an L-shaped zigzag crossing the axilla. L brachioplasty, along with upper body lifting, was applied to 24 female weight loss patients over the last 2 years. Ultrasound-assisted lipoplasty was also performed in five patients. All patients were interviewed. Follow-up ranged from 6 to 28 months. All 22 patients were improved and pleased. One patient requested and received a limited scar revision. Three patients had delayed healing at the tip of the triangular flap. Four seromas near the elbow responded to multiple aspirations. One hypertrophic scar was improved with intense pulsed light. The L-shaped brachioplasty is an innovative, effective, reliable, aesthetic, and safe technique. Integrating the brachioplasty into the upper body lift improves the contours of the axilla, breast, and upper lateral chest, contributing to improved harmonious body contour.

Optimizing Body Contour in Massive Weight Loss Patients: The Modified Vertical Abdominoplasty

Optimizing Body Contour in Massive Weight Loss Patients: The Modified Vertical Abdominoplasty

Optimizing Body Contour in Massive Weight Loss Patients: The Modified Vertical Abdominoplasty

Optimizing Body Contour in Massive Weight Loss Patients: The Modified Vertical Abdominoplasty

Abdominal contour surgery for the massive weight loss patient: the fleur-de-lis approach

Massive weight loss patients often have significant upper midline abdominal fullness that contributes to the overall abdominal girth. This region frequently is not adequately treated with conventional abdominoplasty techniques. The author used a fleur-de-lis pattern when performing a full abdominoplasty or circumferential abdominoplasty. The technical refinements of this procedure for massive weight-loss patients are presented, as well as considerations of the technique's safety. A full abdominoplasty pattern was marked, and the inferior incision was lowered along the midline to adjust for mons pubis ptosis as necessary. The vertical component of the abdominoplasty was marked as an inverted "V" or triangle to decrease the abdominal girth, and the cephalic portion was "rounded off" to create an inverted "U." It was important to lower the final incision of the superior margin of the original abdominal pannus resection approximately 2 to 3 cm to allow for minimal tension at the lower abdominal midline closure. The back and flanks were marked for those patients undergoing a circumferential procedure using a gull-wing type incision, joining it with the anterior abdominal marks. The mid-axillary line was marked bilaterally. Vertical reference lines were also drawn along the back to aid in aligning the upper and lower back incisions. The back was treated first for those patients undergoing a circumferential procedure, and then the patient was repositioned supine for treatment of the abdomen and flanks. Ten patients whose average weight loss was 137 pounds after gastric bypass surgery underwent abdominal contour surgery incorporating a fleur-de-lis pattern. Two men and 8 women with ages ranging from 17 to 53 years (average, 39 years) were treated. Seven underwent a circumferential procedure whereas 3 underwent an isolated abdominoplasty. The follow-up period ranged from 1 month to 26 months, with an average follow-up of 9.5 months. Five patients had a hernia repair performed in conjunction with the abdominal contour surgery. There was no flap loss or wound dehiscence at the inverted "T" closure for any patient. Use of a fleur-de-lis pattern in abdominal body contouring is a safe and effective technique for properly selected massive weight-loss patients. It is particularly appropriate for those patients with significant upper midline abdominal fullness.

Optimizing Body Contour in Massive Weight Loss Patients: The Modified Vertical Abdominoplasty

In morbid obesity, contour deformities of the abdomen are common after bariatric surgery and radical weight loss. Traditional abdominoplasty techniques often fail to maximally improve body contour in these cases because adjacent sites such as the hip rolls and flanks are not treated, leaving the patient with large lateral tissue redundancies and dog-ears. In an attempt to solve these challenging problems, the authors present the modified vertical abdominoplasty technique, a single-stage procedure that involves a combined vertical and transverse approach in which an "en bloc" resection of the redundant tissues is performed without undermining, drainage, or reinforcement of the abdominal wall. The latter is only carried out when diastasis and/or hernias are present, and Marlex mesh may be utilized when indicated. In patients with simultaneous large umbilical hernias and/or excessively long stalks, neoumbilicoplasty is recommended. A significant improvement of abdominal contour was obtained in the vast majority of patients because the resection design offers simultaneous treatment of both vertical and transverse tissue redundancies in the abdomen and neighboring regions, with more harmonic results when compared with purely vertical or transverse approaches. The modified vertical abdominoplasty technique is an easy, fast, and reliable alternative for treating these patients, with less intraoperative bleeding, reduced overall cost, and low morbidity rates. In selected cases, the technique is capable of offering excellent results in terms of contouring and maximizes the overall outcome of treatment protocols for these patients, who can then be integrated into normal life with heightened self-esteem, happiness, and productivity.

Discussion: Optimizing Body Contour in Massive Weight Loss Patients: The Modified Vertical Abdominoplasty

Discussion: Optimizing Body Contour in Massive Weight Loss Patients: The Modified Vertical Abdominoplasty

Correcting the Saddlebag Deformity in the Massive Weight Loss Patient

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.