Lower Body Lift in the Massive Weight Loss Patient

Sir: I recently read the interesting article by Schmitt et al. entitled “Lower Body Lift in the Massive Weight Loss Patient: A New Classification and Algorithm for Gluteal Augmentation.”1 In their study, the authors described outcomes and complications following gluteal augmentation performed for patients who had lost a massive amount of weight.1 The use of autologous dermal-fat rotation flaps was previously addressed by our group and published in Plastic and Reconstructive Surgery in 2006.2 In our study, we demonstrated the use of superiorly based rotation flaps based on superior gluteal perforators, corresponding to the maximum number of perforator arteries in the gluteal region.2,3 Using this technique, we also further developed and compared methods for assessing gluteal projection.4 If overall gluteal projection is the goal, as is commonly the case with the patient population in Brazil, it is essential to elevate and rotate the dermal-fat rotation flaps to gain ample fullness in the gluteal region. Preoperative demarcation is a critical initial step in ensuring a reliable and satisfactory position of the scar, to avoid vertical augmentation of the gluteal fold, and greatly reduce wound healing complications caused by excessive suture tension. Based on my personal experience, there are some important concerns to keep in mind during the preoperative marking phase that can result in a better outcome and a lower complication rate.5 First, I always initiate the marking process by placing each patient in the standing position, and begin marking immediately above the end of the gluteal fold. This technique prevents vertical augmentation of the superior gluteal fold. Second, the first marked line should be bowed toward the anterior iliac spine to create a scar that follows the bikini line. Patients routinely tend to have descent of the scar during the longitudinal follow-up, which compromises the aesthetic result. A visible scar that traverses the superior and midgluteal region is a common concern raised by our Brazilian patients. If the markings are completed while the patient is lying on the bed, there is more skin tissue that will be recruited because of the inherent skin laxity in this particular patient population. In our opinion, patient marking should always be performed with the patient in the standing position, which is the ideal position to test for the presence of excessive tension. [See Figure, Supplemental Digital Content 1, which shows (above, left) preoperative oblique view of a 42-year-old woman with excess skin and gluteal ptosis and (above, right) postoperative oblique view at 7 months after surgery and postoperative oblique views (below) at 3-year and 14-year follow-up, https://links.lww.com/PRS/D80.] Third, the size of the flap may vary depending on the amount of gluteal fullness that the patient and physician wish to achieve. Marking the excess skin with a pinch test, without also carefully determining the volume of the autologous flaps, may compromise suture tension on the skin. It is therefore better to mark less skin than that revealed by a pinch test to avoid wound healing complications. These different experiences and concerns may be directly related to unique characteristics of the Brazilian culture and the specific desires of our patients. The authors should be commended for their insight with their algorithm and for collecting extensive data on their patients. DISCLOSURE The author has no personal financial or institutional interest to declare in relation to the content of this communication. No funding was received for this work. Cassio Eduardo Raposo-Amaral, M.D., Ph.D.Institute of Plastic and Craniofacial SurgerySOBRAPAR HospitalAv. Adolpho Lutz, 1006028 CampinasSão Paulo 13084-880, Brazil[email protected]