This month, Springer.com publishes Comprehensive Body Contouring: Theory and Practice. The 230-page, 190-image compendium highlights the 16-year clinical experience of innovative University of Pittsburgh plastic surgeon Dennis Hurwitz, MD, in treating dysmorphia after massive weight loss, pregnancy and aging.
The manuscript — whose cover is Impressionistic yellow and red on brilliant cobalt blue — recounts a personal odyssey of improving numerous patients’ self-esteem through converting loose skin and sagging surface body parts to a normal and even super-attractive appearance.
The companion electronic version, with 10 procedural videos, allows for enlarging images and hypertext. Both versions, with two free copies of the successful 2005 patient education book Total Body Lift1, can be purchased during November for $90 (a 30 percent discount) by emailing firstname.lastname@example.org.
Comprehensive Body Contouring is both an instructional manual and surgical atlas. By its very nature, body-contouring surgery is comprehensive. This new subspecialty of plastic surgery is characterized by extensive operations of contiguous regions. Traditional teaching in aesthetic plastic surgery is by location, such as breast, abdomen, arms or thighs. Until recently, little to no attention was placed on neighboring anatomy and the impact of contiguous procedures. In the past and, for some plastic surgeons, still today, aesthetic operations are planned and executed individually. This text focuses on the design, integration and execution of individual operations for optimal gender-specific appearance. All physicians guiding patients who are distraught about sagging skin will learn what is possible and how to achieve it. Plastic surgeons will revel in the details of an instructional guide to surgery on patients seeking body-contouring surgery. General surgeons, especially specialists in bariatric surgery, will better relate state-of-the-art treatment to their patients. Some of these surgeons will be empowered to expand their body-contouring repertoire.
From the initial supportive relationship with minimally invasive bariatric surgery pioneer and leader Philip Schauer, MD, now at the Cleveland Clinic, to a new mentorship/partnership with Sheetal Nijhawan, MD, of Sharon Regional Health System, the author has nurtured an intense personal appreciation of the expanding roles of talented bariatric surgeons. In addition to giving two instructional courses and serving as a panelist on body-contouring surgery topics at this year’s annual meeting of the American Society of Plastic Surgeons in Boston, the author lectured on Oct. 7 at the American College of Surgeons’ annual meeting in Chicago.
After losing 100 pounds, this 48-year-old woman underwent a single-stage Total Body Lift. At left, oblique views with surgical markings show her brachioplasties, mastopexies, upper-body lift with spiral flap reshaping of the breasts, abdominoplasty continued above the buttocks as a lower-body lift, and finally, limited vertical medial thighplasties. Six years later (right), the same oblique views show feminine contours with reasonable scars, as well as an absence of loose skin.
Total Body Lift (TBL) surgery was conceived as the coordinated artistic surgical effort to correct complex weight-loss deformity in as few stages as safely possible (Figure 1). The initial experience was shared in multiple scientific forums and published2, followed by an analysis of the first 75 cases3. There were 59 single-staged, 15 two-staged and one three-staged TBLs, involving 605 separate procedures, for an average of 8.2 per patient. Patient satisfaction and analysis of photographic results demonstrated excellent reduction in deformity and comparable rates of complications regardless of staging. While the 66 percent minor complication rate per patient encounter was concerning, it distilled down to a reasonable 11 percent per procedure. Since then, improvements in patient selection and preparation, technique, and technology have reduced complications.
The majority of TBL transformations are now mostly performed in two to three integrated stages. With the abdominoplasty being the keystone procedure, typically the lower body, buttocks and thighs are corrected first. At a second stage, the upper body, breasts and arms are approached. Body-contouring surgery in the male, especially in the chest and waist, has unique musculoskeletal challenges. The occasional facial rejuvenation requires fat augmentation, considerable skin excision, and a reproducibly secure barbed suture fascial and platysma imbrication. The severity of deformity after massive weight loss leads to acceptance of extensive scars for pleasing contours. Nevertheless, techniques for minimizing scars are introduced. A coordinated, well-planned, bold approach best preserves adequate excess tissue for recycling. Recontouring is becoming more sophisticated through new patterns of excision, concomitant liposuction, lipoaugmentation, selective retention of tissues and shaping with neighboring flaps (Figure 2).
At left are posterior oblique views of presurgical markings on a 58-year-old woman preparing to undergo a new procedure of abdominoplasty that extends obliquely over her bulging flanks, as well as liposuction of her torso and lipoaugmentation of her buttocks with the assistance of VASERlipo. The resulting, pleasing feminine contours are seen five months later (right).
After introductory Chapter 1, Chapter 2 presents relevant gender-specific aesthetics and perioperative care. Chapter 3 explains surgical principles and general technique. Interrelated operations demand complex aesthetic analysis, fine technical skills, organized and efficient teamwork, and attentive perioperative care. Chapter 4 addresses the shaping of females. After a detailed presentation of the lower-body lift, the two major variations of the upper-body lift are presented. Then there are Mommy Makeovers (MD News, June/July 2015). Chapter 5 addresses surgery on males. First there are cases involving gynecomastia and then skin tightening for the entire torso. Chapter 6 details efficient and effective facelift surgery for both full and deflated faces.
The advantage of this single-author book is efficiency and consistency. Representative cases are fully presented. There is a consistent pattern of photography presentation. Cases that demonstrate technique start with a series of photos without surgical markings for the reader surgeon to examine the deformity and consider treatment options. The next set of photos shows preoperative markings. Intraoperative photos and drawings usually follow. The results photographs are taken months to years later. Brief case presentations make salient points. Relevant criticism and contrary views are presented. The objectives are:
- Recognize the applied surgical art of body-contouring surgery.
- Learn the basic principles of evaluation, preparation, care, organization and surgical technique.
- Understand and implement gender-specific surgery.
- Learn the expanding role of third-generation ultrasound-assisted lipoplasty.
- Understand the organization and staging of operations.
- Learn the current status of single-stage TBL.
A new technique is only as good as the ability of others to successfully replicate it. Evidence-based medicine gurus have challenged this author to clearly and fully present his techniques so others can faithfully replicate. With this text, future clinical studies of these techniques by other surgeons will have a proper road map.
Submitted by Dennis Hurwitz, MD
- Hurwitz, DJ, Total Body Lift Surgery, Reshaping the Breasts, chest, arms thighs, hips, back, waist, abdomen and knees after weight loss, aging, and pregnancies, MDPublish, 2005, NY, New York.
- Hurwitz, DJ, Single Stage Total Body Lift after massive weight loss, Ann of Plast Surg. 2004 52:5;435-441.
- Hurwitz DJ, Agha-Mohammedi S, Ota K, Unadkat J, A Clinical Review of Total Body Lift, Aesth. Surg. J. 2008; 28:3; 294-304.