Body Contouring in the
Postbariatric Surgery Patient
Loren J Borud, MD, Anne G Warren, BA
Obesity has become a national and worldwide epidemic,
with nearly two-thirds of the US population classified as
overweight or obese.1 The numerous comorbidities as-
sociated with obesity include hypertension, hyperlipid-
emia, noninsulin-dependent diabetes mellitus, cardiovas-
cular disease, obstructive sleep apnea, asthma, and
degenerative joint disease. Although dietary and lifestyle
modifications have traditionally been the mainstay of
treatment for obesity, their lack of success at longterm
weight reduction and the paucity of effective pharmaco-
logic agents led to a comprehensive evaluation of surgi-
cal management by the National Institutes of Health
Consensus Conference in 1991.2 Guidelines established
at that time recommend bariatric operation for mor-
bidly obese patients, defined as those with a body mass
index (BMI) ⱖ 40 or patients with a BMI ⱖ 35 who
have associated comorbidities.
Attempts to bypass part of the intestinal tract to create
a malabsorptive state date to 1954, when Kremen and
colleagues3 published a case report of jejunoileostomy
for weight loss. Over the past decade, advances in surgi-
cal technique and anesthetic management have permit-
ted evolution of the burgeoning field of bariatric surgery.
In recent years, the number of bariatric procedures per-
formed has skyrocketed, with an estimated 140,000
weight-reduction procedures performed in 2004 alone
(American Society of Bariatric Surgery estimate). Bari-
atric surgery has been proved in both individual trials4-7
and large meta-analyses8 to produce sustained weight
loss and marked improvement in comorbid conditions.
Postoperatively, patients experience rapid weight reduc-
tion, typically peaking in the first 18 to 24 months, and
Competing Interests Declared: None.
Received December 9, 2005; Revised January 20, 2006; Accepted January 27,
2006.
From Department of Surgery, Harvard Medical School (Borud, Warren), and
the Division of Plastic Surgery, Beth Israel Deaconess Medical Center
(Borud), Boston, MA.
Correspondence address: Loren J Borud, MD, Division of Plastic Surgery,
Beth Israel Deaconess Medical Center, 110 Francis St, #5A, Boston, MA
02215. email: lborud@bidmc.harvard.edu
© 2006 by the American College of Surgeons
Published by Elsevier Inc.
gain heightened self-confidence and mood, in addition
to substantial medical benefits.
Despite considerable improvement in their health af-
ter massive weight loss (MWL), patients are discouraged
by the large amounts of excess skin that remain in vari-
ous regions of their body as they lose weight. They find
that they are unable to minimize the skin laxity through
activity or targeted exercise, and many of these patients
subsequently seek plastic surgery consultation for alter-
native management options. This review will describe
the analysis and treatment of body-contour deformities
present in the MWL patient.
PATIENT EVALUATION
Evaluation of most body-contour deformities consists of
determining two factors: degree and quality of skin ex-
cess or deficiency, and degree of fat excess or deficiency.
The typical “cosmetic surgery” patient without a history
of substantial weight loss has areas of moderate fat excess
with minimal skin excess, and is adequately treated with
minimally invasive procedures, such as liposuction, al-
lowing the elastic properties of skin to resolve the resid-
ual minor skin excess. In contrast, areas of major skin
excess, such as those seen in the MWL patient, do not
contract adequately to achieve a reasonable cosmetic re-
sult with minimally invasive methods, necessitating ex-
cisional procedures. Areas of major skin excess result
from expansion followed by deflation of underlying
structures. Factors such as pregnancy can result in a
tissue-expander effect on the abdominal wall and skin
and on the breast. In the MWL patient, subcutaneous
(SC) fat before bariatric operation has expanded the skin
far beyond its elastic modulus, and major skin excess is
usually present in several locations.
The pattern of skin excess in the MWL patient is
fairly characteristic, although can be quite variable from
patient to patient. Anatomic studies by Lockwood9 have
defined a layer of SC fascia, known as the superficial
fascial system, analogous to Scarpa’s layer, that provides
strength and support in the SC layers throughout the
body (Fig. 1). In some “zones of adherence,” the super-
ISSN 1072-7515/06/$32.00
82 doi:10.1016/j.jamcollsurg.2006.01.015
Vol. 203, No. 1, July 2006 Borud and Warren Body Contouring and Postbariatric Surgery 83

Abbreviations and Acronyms

BMI ⫽ body mass index
MWL ⫽ massive weight loss
SC ⫽ subcutaneous

ficial fascial system is firmly invested with the underly-

ing musculoaponeurotic tissue. Fatty deposits and skin
expansion occur outside these zones of adherence, and
the resulting skin excess after weight loss “sags” around
the zones of adherence. The expanded abdominal pan-
nus hangs over the mons, and the expanded breast tissue
hangs over the adherent inframammary fold. The great-
est areas of skin excess are generally along the lateral
lower trunk, where fat deposits frequently occur and
where skin is not adherent to underlying structures.
These principles govern the patterns of skin excess ob-
served in the neck, arms, upper body, breast, trunk, and
thighs.
Clinical evaluation of the MWL patient begins with
history and physical examination. The patient’s maxi-
mum BMI and current BMI should be calculated, and
body-contouring operation should not be contemplated
until the patient’s weight has achieved a plateau.10 If the
patient is still obese, additional diet and weight loss
should be encouraged before body-contouring opera-
tion to minimize surgical complications11,12 and ensure
optimal aesthetic outcomes. Smoking causes small vessel
vasoconstriction and is associated with higher complica-
tions in body-contouring operation, where vascular sup-
ply to the skin can already be compromised. Many plas-
tic surgeons refuse to perform body-contouring procedures
on smokers. Nutritional assessment should ensure ade-
quate nutritional status, as malnourished patients have
much higher wound healing complication rates. In par-
ticular, protein intake of ⬎ 50 g per day is essential. The
patient must also be psychologically stable and have a
reasonably accurate perception of his or her body to
properly understand the anticipated risks and benefits of
body-contouring operation. The patient must be an ad-
equate medical risk for anesthesia, as for any surgical
procedure. Sometimes the proposed body-contouring
procedure can be greater in magnitude physiologically in
terms of blood loss, fluid shifts, and overall stress than
the bariatric procedure.
The history should focus on the patient’s chief com-
plaint after their bariatric operation and subsequent
Figure 1. Anatomic zones of adherence of superficial fascial system
(red bands, most adherent; yellow zones, least adherent).
weight loss. Generally, weight loss plateaus at 12 to 24
months after the bariatric operation. It is vital to estab-
lish that the patient has reached a stable plateau before
any body-contouring procedure is performed. Note
should be made of chronic rashes or intertrigo associated
with excess skin folds and how these conditions have
been treated. Clothing size and comments about how
clothing fits should be recorded. Photographs taken
from several views should be done as part of the physical
examination. Particular attention should be directed to-
ward evaluation for the presence and location of earlier
scars and detection of incisional hernia. We have found
it useful to classify overall skin excess by calculating the
percentage of excess body surface area. Additionally, the
patient’s priorities for their body-contouring procedure
must be enumerated in order of importance. Patients’
specific concerns about their physical appearance vary
widely, and the identical degree of skin excess in a par-
ticular region can be of major concern to one patient and
no concern at all to another. Commonly performed
body-contouring procedures are listed in Table 1.
Criteria for insurance coverage for body-contouring
procedures after MWL vary tremendously from region
to region and from carrier to carrier. Almost all insurance
84 Borud and Warren Body Contouring and Postbariatric Surgery J Am Coll Surg

Table 1. Body Contouring Procedures by Anatomic Region Table 2. Complications after Body-Contouring Procedures
Region Procedure Common
Face/neck Face/neck lift Seroma
Back Upper body lift Hematoma
Arm Brachioplasty Minor wound dehiscence
Breast Mastopexy, reduction, augmentation Prolonged edema
Trunk (anterior) Panniculectomy, abdominoplasty Pathologic scarring: scar hypertrophy, keloid formation
Trunk (posterior) Buttock lift, lateral thigh lift Rare
Trunk (circumferential) Belt lipectomy, lower body lift Lymphatic injury: lymphedema, lymphocele
Thigh (medial) Medial thigh lift Major wound dehiscence
Thromboembolic events: deep venous thrombosis, pulmonary
embolus
carriers specifically exclude coverage of aesthetic surgery,
and have developed criteria for assessing “medical neces-
sity” in this patient population. The most commonly anterior abdomen. The term pannus is used to describe
covered procedure in our area is panniculectomy, other the excess hanging skin that is characteristically present
procedures are rarely covered. Presence of intertrigo re- below the umbilicus. Irritation of the undersurface of
fractory to over-the-counter medication is, in our expe- the pannus can result from chronic moisture retention,
rience, the most common grounds for establishing med- poor hygiene, and skin-to-skin abrasion. Chronic inter-
ical necessity for panniculectomy. Other criteria can trigo can occur in these skin folds, and is treated by
include descent of the pannus over the genitalia on an- topical antifungal agents, topical corticosteroids, and
terior view, or descent of the pannus to contact the thigh
on lateral view. In our experience, other surgical prob-
lems, such as ventral hernia, are considered separately by
most insurance companies and do not influence deter-
mination of benefits with regard to panniculectomy or
other body-contouring procedures.
The final key step in the consultation is providing
extensive information to the patient, which is of partic-
ular importance, given that a major information gap
frequently exists. Some patients are extremely sophisti-
cated about body contouring, although others do not
appreciate the limitations of what is possible, and the
fact that body contouring is a “real” operation with as-
sociated complications (Table 2). An extensive informed
consent should take place, with particular attention to
outlining realistic outcomes expectations.

BODY-CONTOURING PROCEDURES
Lower body
Deformity of the lower body in the MWL patient con-
sists of circumferential truncal skin excess in the vertical
dimension; circumferential truncal skin excess in the
horizontal dimension; gravitational descent of impor-
tant soft tissue landmarks with respect to the bony skel-
eton, including the lateral thighs, buttocks, and anterior
abdomen; and distal sagging and sometimes circumfer-
ential skin excess in the medial thigh.
The area of greatest concern to most patients is the Figure 2. Simple panniculectomy skin excision.
Vol. 203, No. 1, July 2006 Borud and Warren Body Contouring and Postbariatric Surgery 85

Figure 3. This 30-year-old woman who presented 9 mo after gastric bypass operation and conse-
quent weight loss of 170 pounds, decreasing her body mass index from a maximum of 58.8 to 34
kg/m2. She reported considerable activity limitation and lower back pain secondary to her large
pannus and chronic intertrigo. She underwent panniculectomy, ventral hernia repair, component
separation, bilateral brachioplasty, and bilateral mastopexy augmentation. Although her pannus and
overall body contour were notably improved, skin excess was still present in the lateral trunk. (Top)
Preoperative view; (bottom) postoperative view.

dressings or clothing to minimize skin-fold contact. Any
rash in this area must be resolved before undertaking
surgical procedures in this area.
The most basic procedure to address the medical con-
ditions resulting from skin-fold irritation is panniculec-
tomy. The term panniculectomy refers to excision of the
excess hanging skin inferior to the umbilicus (Fig. 2).
Only a minimal degree of undermining is performed,
and closure is performed over closed suction drains. It is
vital, as in all body-contouring procedures, to use per-
manent or long-lasting sutures in the Scarpa’s fascia or
superficial fascial system. Skin is generally closed in two
additional layers of absorbable suture. Although the pro-
cedure can treat chronic skin irritation, it does not achieve
86 Borud and Warren Body Contouring and Postbariatric Surgery
Figure 4. Modified abdominoplasty skin excision.
aesthetically pleasing results because it incompletely ad-
dresses vertical skin excess. Additionally, it does not address
abdominal wall laxity, horizontal skin excess, or the proper
positioning of the umbilicus relative to the abdominal skin
(Fig. 3).
Abdominoplasty addresses some, but not all, of the
limitations of panniculectomy. Abdominoplasty be-
gins with an incision and dissection of the umbilical
stalk, which is preserved. The skin and SC tissue are
then undermined to some degree in a cephalad direc-
tion (Fig. 4), which permits a more aggressive skin
resection than is possible with simple panniculectomy
(Fig. 5). Most surgeons elevate the abdominoplasty
flap cephalad to the xiphoid process and costal mar-
gins.13 Plication of the abdominal wall is then per-
formed from the xiphoid to the pubis, tightening the
stretched abdominal wall in the transverse dimension.
Some authors also perform oblique plications to obtain a
degree of vertical reduction.
J Am Coll Surg
Before abdominal wall plication, ventral hernia re-
pair can be addressed when necessary. Although the
current trend toward minimally invasive bariatric
procedures14,15 has led to decreasing rates of incisional
hernias,16-18 development of ventral hernia, particu-
larly in the first years after the operation,19 is common
after open procedures,20-22 with some studies describing
rates as high as 35%.23 In most patients, the abdominal
wall defect can be closed primarily; more extensive de-
fects can require component separation to ensure ade-
quate repair.24
Although abdominoplasty can be sufficient for
some patients presenting primarily with anterior ab-
domen contour deformity, the procedure does not
address circumferential truncal excess, and can, in
fact, accentuate lateral excess.25,26 To achieve im-
proved waist and flank contour, a belt lipectomy
(which is also known as torsoplasty or circumferential
lipectomy) can be performed.27-29 The procedure begins
similarly to a traditional abdominoplasty, with elevation
of the abdominal flap to the xiphoid and costal margins,
but lateral elevation of the abdominal flap is then per-
formed to allow for greater lateral resection. After verti-
cal midline rectus sheath plication and umbilicoplasty
are completed, the incision is closed over several closed
suction drains. The patient is then turned to the lateral
decubitus position, prepared, and redraped, and resec-
tion from the anterior axillary line to the midline of the
back is performed. Subsequent elevation and resection
of an inferiorly based skin and SC tissue flap eliminates
upper and midback rolls. Although in the lateral posi-
tion, suction-assisted lipectomy and discontinuous un-
dermining of the lateral thigh are performed; closure
again involves placement of a suction drain to drain the
back and flank. Patients are then turned to their opposite
side for completion of the operation.
A more extensive approach to circumferential ex-
cess that also corrects saddlebag deformities of the
lateral thigh and buttock ptosis is the lower body lift
(Figs. 6A, 6B). The operation combines circumferen-
tial abdominoplasty with a lateral thigh and buttock
lift and is the preferred treatment for the lower torso
in our institution.30 The procedure begins with the
patient in the prone position, where inferior and su-
perior back and hip incisions are made and skin flaps
are subsequently undermined, with direct undermin-
ing extending laterally to the greater trochanter and
discontinuous undermining to just above the knees.
Vol. 203, No. 1, July 2006 Borud and Warren Body Contouring and Postbariatric Surgery 87

Figure 5. This 28-year-old woman who underwent gastric bypass operation 12 mo before
presentation. Her current body mass index (BMI) was 30 after a weight loss of 100 pounds and
an earlier maximum BMI of 49. She reported abdominal skin excess and thigh and upper arm
excess and breast ptosis. Although the best possible cosmetic outcomes would have been
obtained with a circumferential lower body lift, the patient opted for a front-only procedure. A
fleur-delis abdominoplasty was performed. (Top) Preoperative view; (bottom) postoperative view.
Note the improved lateral contour when compared with simple panniculectomy.

Suction-assisted lipectomy is used as needed for flap
mobilization and excess fat removal. To avoid flatten-
ing of the buttock, we frequently develop flaps based
on the superior gluteal artery and use this otherwise
discarded tissue for autologous augmentation. But-
tock lift can be performed in conjunction with this
type of autologous tissue augmentation, given the
considerable soft-tissue volume loss of the region seen
in some of these patients (Fig. 7). The midback is
closed without tension over a closed suction drain,
and the flank and lateral thighs are closed under max-
imal tension by fully abducting the leg. The patient is
then turned supine and circumferential abdomino-
plasty is performed as described. At this time, correc-
88 Borud and Warren Body Contouring and Postbariatric Surgery
Figure 6. Lower body lift excision.
tion of the ptotic mons pubis affecting many patients
after MWL can then be achieved with excisional li-
pectomy and liposuction through pubic “monsplasty”
as described by Hurwitz and colleagues.31 Although
this series of procedures constituting the lower body
lift can be quite extensive, with careful planning and
preoperative marking, the large incision can be well-
concealed in the bikini line (Fig. 8).
Excessive redundant skin and localized fat deposi-
tion of the medial thigh is common after bariatric
operation and is particularly resistant to correction
through exercise.32,33 A medial thigh lift, especially in
combination with a lower body lift, can provide no-
table improvement in the contour of the area.34 The
skin excess can be viewed as being comprised of two
components, vertical and circumferential. If the ex-
cess is mainly thought to be vertically oriented, a
standard medial thigh lift can be performed, wherein
J Am Coll Surg
a crescentic area of skin and SC fat is excised from the
upper medial thigh. The procedure is usually begun in
the prone position, and can be completed with the
patient in the supine position, which obviates the
need for additional preparing and draping of the pa-
tient in cases where the patient is undergoing concur-
rent abdominoplasty. After resection, the thigh
wound is closed without tension over closed suction
drains. For patients in whom a considerable circum-
ferential aspect to the excess is present, a vertical me-
dial thigh lift is necessary.35 This requires extending
the traditional thigh lift incision to include a vertical
incision down the medial thigh to end at the knee.
Upper body
Upper extremity skin and fat excess is typically treated
through brachioplasty, although some patients with only
minimal skin redundancy can achieve good results with
Vol. 203, No. 1, July 2006 Borud and Warren Body Contouring and Postbariatric Surgery 89

Figure 7. This patient is a 33-year-old woman who presented 3 y after open gastric bypass
operation. Her body mass index decreased from 50 to 29.2 during that time. She had previously
undergone anterior skin excision, but had an inadequate result and reported considerable lateral
and posterior trunk skin excess and medial thigh excess. She underwent a buttock and lower
body lift. (Top) Preoperative view showing planned areas of excision. Some of the otherwise
discarded posterior back tissue was preserved, based on the superior gluteal artery, and used
for autologous tissue augmentation to prevent flattening of the buttocks; (bottom) postoperative
view.

liposuction alone. Brachioplasty has traditionally been
performed reluctantly because of high rates of effusions
and extensive scarring. More recent techniques have
sought to minimize these complications through use of
liposuction and superficial skin excision.36 The proce-
dure involves circumferential liposuction of the arm fol-
lowed by resection of the region of skin excess, with only
minimal undermining just under the dermal layer. A
brachial approach is used, in which a vertical incision
along the bicipital groove of the upper arm is created,
which extends from the axilla to the elbow with an L- or
T-shaped extension onto the chest wall (Fig. 9). The
wound is closed in two layers with absorbable 3-0 su-
tures and a compressive dressing is used.
90 Borud and Warren Body Contouring and Postbariatric Surgery J Am Coll Surg

Figure 8. This a 55-year-old woman who was seen 26 mo after gastric bypass operation and subsequent decrease
in body mass index to 28 from 52.4. She reported recurrent intertrigo of her abdominal pannus. On physical
examination she had considerable circumferential truncal skin excess and upper arm excess. Concurrent lower and
upper body lift were performed. Mastopexy with intercostal artery perforator flap augmentation was also performed,
avoiding the use of breast implants. (Top) Preoperative view; (bottom) postoperative view.

MWL can lead to considerable breast deformities,
which can be a source of particular distress to patients.
Deformities commonly seen include excess sagging
skin, ptosis, loss or deficiency of breast volume sec-
ondary to atrophy, and excess breast volume. Proce-
dures for correction of the deformity are centered on
the removal of redundant skin and raising of the nip-
ple though mastopexy, or breast lift. Mastopexy is
typically performed using a Wise pattern,37 or in-
verted T, skin excision, which allows for maximal skin
removal by preventing contraction of the remaining
skin.38 The procedure involves both a circumferential
incision around the nipple-areola complex and an in-
framammary incision. The skin excision and closure
allow for repositioning of the nipple, which should be
located at or above the inframammary fold. In pa-
tients lacking substantial breast volume, breast aug-
mentation can be performed at the time of mastopexy,
either with implant placement or with autologous
tissue implantation.39-41
COMBINING AND STAGING PROCEDURES
Combining multiple procedures is very appealing to
many patients, because total time off work, total re-
covery time, and total cost of treatment are reduced.
Combined procedures can involve prolonged opera-
tive times, increased blood loss, increased postopera-
tive pain, and possibly increased risk of deep venous
thrombosis, pulmonary embolus, and other compli-
cations. The approach must be individualized to each
patient and to each surgeon.42
Combination procedures should only be per-
formed by surgeons with substantial experience in
each component operation, an experienced surgical
team, adequate technical assistance, and the availabil-
ity of critical care resources. Relative contraindica-
Vol. 203, No. 1, July 2006 Borud and Warren Body Contouring and Postbariatric Surgery 91

Figure 9. This is a 43-year-old woman who presented after laparoscopic gastric bypass operation performed 28 mo
before evaluation. She had weighed as much as 415 pounds and had subsequently lost 245 pounds after the
procedure, with a decrease in body mass index from 75.2 to 31.1. Secondary to her large pannus, she experienced
chronic back and hip pain and persistent fungal infections of her abdominal skin folds. A two-stage procedure was
planned, with the first addressing the pannus and circumferential truncal and upper arm skin excess. The
second-stage procedure has not been performed but will include mastopexy augmentation, and thigh lift. Preop-
erative view (top); postoperative view (bottom).

tions to combined procedures include smoking his- DISCUSSION

tory; history of deep venous thrombosis or clotting
disorders; high residual BMI; or substantial medical
risk factors.
At our institution, the most common approach to
the healthy MWL patient with BMI ⬍ 34 seeking
multiple areas of treatment is to perform a circumfer-
ential lower body lift as a first stage, combined with
either brachioplasty or medial thigh lift. The second
stage consists of upper body lift with mastopexy, and
either brachioplasty or medial thigh lift. In particu-
larly healthy and motivated patients with BMI ⬍ 32
and willing to provide autologous blood donation, we
have combined all these procedures into a single stage.
Given the epidemic of obesity in the US and the boom
in bariatric surgery procedures, an increasing number of
patients are seeking plastic surgery consultation for
body-contouring evaluation after MWL. With severe
skin laxity frequently seen in these patients, the basic
goal of postbariatric procedures is to excise excess skin
and SC fat to correct functional and contour deformi-
ties. This can eliminate associated complications, such as
panniculitis or intertrigo, and considerably improve pa-
tients’ self-image. There are limitations that must be
accepted to achieve satisfaction with the procedures, on
which patients should be adequately counseled preoper-
92 Borud and Warren Body Contouring and Postbariatric Surgery
atively. First, body-contouring operations in effect trade
“skin for scar,” which is crucial to explain to the patient.
Given the nature of the long incisions needed for the
operations and the frequently suboptimal wound heal-
ing conditions seen in these patients, scars are inevitable
and can hypertrophy, particularly in difficult areas, such
as the arms and medial thighs. Although all attempts are
made to place incisions such that scars will be well-
hidden, the nature of the large dermal excisions can
make predicting the exact final location of the scar chal-
lenging. In addition, skin relaxation can be a recurrent
problem, and might not be “cured” with one procedure.
Patients can be frustrated by the return of unsightly skin
folds that they had thought had been sufficiently re-
moved, and should be well-informed of this possibility
before proceeding with body-contouring operation and
should maintain regular followup with their bariatric
and plastic surgeons.
The key to achieving successful patient outcomes is
careful evaluation and selection of surgical candidates.
Advising patients to delay body-contouring procedure
until they have reached their ideal body weight or at least
realized a plateau in their weight reduction allows for
maximal patient benefit. Patients who have reached a
plateau but are still motivated to continue losing weight
should be encouraged and counseled on dietary and ex-
ercise strategies. Given the much higher surgical compli-
cation rates seen in obese patients, performing proce-
dures on patients who have been unable to achieve
sizeable weight loss and are still considerably obese
should only be done when medically necessary because
of recurrent infection or severe functional disability. Al-
though weight reduction after successful bariatric oper-
ation frequently improves or eliminates patients’
obesity-related comorbid conditions, operative time for
body-contouring procedures can be quite lengthy and
patients should be reevaluated for comorbidities that
could heighten their surgical risks.
In conclusion, addressing patient concerns about
body contour deformities after MWL is a crucial com-
ponent to providing optimal and successful bariatric
care. Although body-contouring procedures are not rou-
tinely performed until considerable time has passed, be-
cause of the bariatric operation, early consultation about
potential future surgical procedures to correct skin laxity
can help the patient to be better informed about the
longterm course of bariatric operation and to develop
J Am Coll Surg
realistic expectations and goals about aesthetic and func-
tional outcomes.
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