Preoperative Workup
As with all major surgical procedures, a complete history and a thorough physical examination are important.
Specifically investigate dietary habits, history of weight gain or loss, and family history regarding venous problems or lymph edema. Note medical problems, especially diabetes, as well as smoking habits. Carefully document previous surgical procedures, especially gynecologic, orthopedic, vascular, or cutaneous.
In particular, be sure to inquire into the patient’s use of medications. Patients are often reluctant to volunteer information regarding certain drugs they are taking (eg, prescription or nonprescription [homeopathic, over-the-counter] weight loss drugs, drugs that can promote obesity), so question them carefully and document the answers meticulously.
The physical examination should be thorough. In particular, be alert for signs of peripheral vascular disease and lymphatic disease.
Examine the patient without clothing in the standing position. Note the location of any previous surgical scars and the presence of multiple skin folds and rolls. Assess the elasticity of the skin. Carefully measure both lower extremities and note any significant discrepancies between them. Determine the circumference and record the patient’s weight on the weighing scales in the clinic. Self-reported weights are not accurate.
If possible, a full-length mirror should be available. Draw the planned excisions and locations of the scars on the patient while the patient observes. Patients should be told to look straight ahead during the placement of the marks. Otherwise, they are likely to twist their body to the left to watch you place the marks on the left side of their body. When they turn to the right side to observe your marks, they may turn a lesser amount. This can give rise to asymmetric marks, which, in turn, can lead to an asymmetric result.
Perform a complete laboratory workup. Obtain a complete blood count, a complete metabolic panel, and an electrocardiogram (ECG). Carefully investigate any abnormal value before surgery.
Conduct detailed discussions with the patient regarding areas of concern and the patient’s aesthetic goals. Give the patient a realistic idea of whether the deformity can be treated with a local resection or whether a regional resection would be better. Spend a significant amount of time obtaining informed consent.
Patients should be aware that skin that has been stretched severely by obesity has lost much of its elasticity. Therefore, tight, smooth contours cannot be obtained with these procedures, especially if the patient gains weight or continues to lose weight, which is why the patient’s weight should remain stable for at least 18 months before surgery. Inelastic stretched skin continues to age, frequently requiring revisional or “touchup” surgery. This is true in most patients.
Impress the magnitude of this operation upon the patient. Thoroughly discuss postoperative complications. Inform the patient where scars will be located and that these scars almost assuredly will not fade into fine white lines. Discuss the presence of drains (if any) and the possibilities of hematoma, infection, wound dehiscence, and their treatment. Patients with poor skin tone are at high risk for recurrent seroma. As with thigh and buttock surgery, deep venous thrombosis and pulmonary embolism are rare but real considerations.
Discuss difficulties that the patient will have with walking and sitting for up to 3 weeks. The patient should be shown beforehand how to get out of bed and how to use the bathroom with minimal flexion of the torso.
Schedule a second and, if necessary, a third consultation to ensure that the patient understands the magnitude of this operation.
-
Trunk and lower extremity.
-
Trunk and lower extremity.
-
Batwing torsoplasty.
-
Preoperative markings, lateral view.
-
Preoperative markings, anterior and posterior views.
-
Incisions placed entirely within bathing suit line.
-
Flankoplasty and thigh lift.
-
Anatomy of the superficial fascial system in males and females.
