Operation Guide: Belt Lipectomy Surgery After Weight Loss

After massive weight loss, patients often have excess skin on the abdomen, hips, lower back, and buttocks. A belt lipectomy is a circumferential operation that tightens the skin on these areas. As an added benefit, the procedure also has a mons pubis and thigh-lifting effect.

A belt lipectomy is a complex operation. This article describes how to perform a liposuction-assisted belt lipectomy from start to finish. Various techniques and tips are discussed, as well as advice regarding patient selection, tissue excision, operating room equipment, closing the incision, and more.

Patient selection

The goal of a belt lipectomy is to tighten loose skin on the abdomen, flanks, lower back, buttocks, and to a degree, the thighs. This life-changing surgery has many benefits for post-weight loss patients, but not everyone is a candidate.

What areas benefit from a belt lipectomy?

Patient selection is critical for a good result. After substantial weight loss, some patients have sagging skin 360 degrees around their midsection. In this case, they may be a good candidate for a belt lipectomy.

Lax skin should be present on the front, back, and sides of the patient’s body. Some of the key areas that improve with a belt lipectomy are the following:

  • Abdominal apron
  • Flanks
  • Buttocks
  • Lateral thighs
  • Medial thighs
  • Mons pubis
  • Rectus abdominal muscles

If the patient only has abdominal skin laxity, they do not need a belt lipectomy. Abdominoplasty procedures, such as a Fleur-de-lis, full, or extended tummy tuck may be performed instead. If lax skin is isolated to the thigh area, then a thighplasty may be the right choice.

Who is a good candidate for a belt lipectomy?

A belt lipectomy is a cosmetic skin tightening procedure that is performed after a patient has reached their goal body weight. The patient should maintain a healthy weight for at least six months before undergoing skin reduction procedures.

A belt lipectomy tightens and lifts skin around the entire midsection. It helps to lift sagging lateral and medial thigh skin to an extent. Therefore, if the patient is also considering a thighplasty, then a belt lipectomy should be performed first. As it is a major operation, the procedures should be spaced several months apart to allow for proper healing.

Limitations

When determining if a patient is a good candidate for a belt lipectomy, the surgeon must consider several factors:

A belt lipectomy mainly addresses the vertical extent of weight loss

The abdominal tissue needs to remain straight during a belt lipectomy, and that can limit the result. It cannot be pulled to the side as in other abdominal skin reduction procedures.

After weight loss, some patients need a vertical skin excision. A Fleur-de-lis abdominoplasty addresses both the vertical and horizontal vectors. In a full abdominoplasty, the tissue can be pushed to the side a bit. Neither is possible during a belt lipectomy.

The surgeon must carefully evaluate the patient during the consultation to determine which skin reduction procedure will provide the most benefit.

A belt lipectomy tightens a sagging buttocks, but it does not add volume

Many post-weight loss patients have significant volume loss in the buttocks area. One of the benefits of a belt lipectomy is that it lifts a sagging buttocks. While it tightens the gluteal tissue nicely, it will not restore volume.

It is important to manage patient expectations during the consultation and be clear about what a buttocks lift can and cannot do. For example, patients who are seeking a rounded, curvy bottom may be disappointed with a belt lipectomy’s bum lifting effects. That is, unless they already have adequate gluteal muscle or fat, or are interested in pursuing buttocks enhancements.

Buttocks fat transfer is growing in popularity, although it can be risky. The mortality rate for the ‘Brazilian Buttocks Lift’ is high compared to other elective surgeries. Buttocks implants are another option, but implant movement is a frequent complaint.

Glute exercises are a more reliable and safe way to enhance the buttocks. If the patient’s main concern is skin laxity on the buttocks region, then a belt lipectomy will provide the results they are seeking. Worth noting is that a buttocks lift may make it easier to see the gluteal musculature if the patient chooses to engage in glute workouts.

A belt lipectomy improves thigh laxity, but only to an extent

Thigh skin tightening is no easy task, even for the experienced surgeon. A belt lipectomy helps to tighten the lateral and medial thighs prior to undergoing a thighplasty. However, the procedure’s thigh tightening effects are limited.

If the patient continues to have extensive looseness in the thigh area after a belt lipectomy, a thighplasty can be considered as a second procedure. Performing both procedures separately provides a “one-two punch” for a common trouble spot that is hard to treat.

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Benefits of liposculpture during a belt lipectomy

A belt lipectomy can be performed with or without liposculpture. For patients with loose skin and stubborn fat pockets on the midsection, adding liposuction to the procedure enhances the final result. Yet the latest liposculpting technology, such as VASER fat melting, can also benefit patients with minimal body fat. Some of those benefits include:

A more shapely physique

While dramatic weight loss may be accomplished with a healthy diet, exercise, or weight-loss surgery, it is difficult to achieve a model-worthy figure by natural means alone. Liposculpture is ideal for sculpting the abdomen, sides, and back during a belt lipectomy. It can eliminate abdominal rolls, love handles, and lower back fat that resist diet and exercise efforts.

Easier tissue dissection

VASER provides discontinuous tissue dissection. As the VASER probe passes through the tissue to melt fat, it creates small holes. This makes it easier to excise redundant skin during a belt lipectomy with fewer cuts for the surgeon.

A safer recovery

VASER’s discontinuous dissection minimises tissue trauma during the belt lipectomy. Therefore, there is less risk of nerve damage, hematoma, seroma and necrosis. VASER is also gentler on the tissues than standard liposuction. It liquifies fat cells with ultrasound energy, so low-pressure suction is all that is needed for fat removal. Traditional liposuction attempts to remove solid masses of fat. It requires the surgeon to aggressively break apart the fat with special tools, which can be traumatic. Likewise, the high-power suction that is needed to remove solid fat causes more damage to the tissues.

Better muscle definition

VASER liposculpture does more than remove fat. A surgeon can use it to artistically shape and sculpt the patient’s abdomen, back, and sides. Fat melting helps to define curves and highlight existing musculature. Nearly all patients can benefit from VASER, even those who are fairly slim.

How to perform a VASER liposuction-assisted belt lipectomy

This surgery training guide explains how to perform a belt lipectomy operation with VASER liposculpture step by step.

PHASE 1: SURGICAL PREPARATION

Patient questions

The pre-operative appointment is a good time to go over any last-minute questions or concerns the patient might have before heading into surgery.

Surgical markings

Incision lines and pockets of unwanted fat and skin should be clearly marked prior to surgery. Once the patient lies down on the operating table, gravity changes everything. The patient is alert and stands upright while the surgeon draws the markings. This provides a visual plan for a successful operation.

Belt Lipectomy Surgical Markings by Dr Bernard Beldholm

Spirit level

Using a spirit level helps to produce a neat, straight incision line. Keep in mind that gravity will distort the tissues once the patient lies down on the operating table. The best thing a surgeon can do is trust the markings they drew before surgery.

Scar placement

Scar placement is important. Patient preferences and clothing styles should always be considered when planning the incisions. It is best to discuss incision placement with the patient during the consultation process, and once again during the pre-operative appointment. Managing patient expectations is perhaps the simplest way to maintain a high patient satisfaction rating.

Operating table selection and body positioning

A belt lipectomy is a circumferential operation. The patient is turned over during the operation. The issue with lying prone for a long period of time is a risk of compression on the vena cava. This can result in brain pressure problems and stroke. Choosing the right operating table may reduce these risks.

The Jackson table

The Jackson table frees up the abdomen so there is no compression on the vena cava in the prone position. It also allows the operating room staff to turn the patient over in a safe, controlled manner. There is less risk of an accident or slippage than manual turning. The table is complex, however, and it takes up to one hour to turn and re-strap the patient. A team of people must take part in the turning process to ensure everything goes smoothly.

Belt Lipectomy Positioning you on the operating table by Dr Bernard Beldholm

A belt lipectomy starts with the patient lying prone on the Jackson table. The ASIS is placed on the hip pad. The bottom ribs are placed on the chest pad. The neck is clear. The eyes are clear in the face foam block.

A drawback of the Jackson table is that it limits access to the sides since the ASIS is placed on a post. Thus, it is imperative to follow the pre-operative markings in order to tighten the lateral thighs successfully. Tighter is better when it comes to the lateral thighs. When the patient is turned over to address the front, the lateral thighs tend to loosen up.

Four-post operating table

A four-post is a platform that attaches to an operating table with straps. Like a Jackson table, it frees up the abdomen in the prone position to alleviate compression on the vena cava. It provides no benefit for turning the patient during a belt lipectomy, however.

General anesthesia

A belt lipectomy is performed under general anesthesia. Sedative drugs are administered intravenously. Once the patient is safely sedated, the surgery can begin.

PHASE 2: POSTERIOR LIPOSCULPTURE

Surgical fat reduction provides a more shapely figure, and it also helps to dissect the tissues.

VASER liposculpture of the posterior flanks and buttocks

Special equipment called VASER liposculpture is used to melt fat in preparation for liposuction. VASER is a cutting-edge technology that liquefies fat cells with ultrasonic energy. Liquid fat is easier to remove with liposuction than solid fat. This not only provides a slimmer physique, it also helps to define existing musculature.

VASER ring-size selection

The VASER handpiece comes in various ring sizes. Selecting the appropriate ring depends on how much fat must be removed. The five-ring hand piece is ideal for removing large quantities of fat. The one-ring hand pieces is best for working through scar tissue, such as during a revision surgery. For a belt lipectomy, the five-ring hand piece is suitable for most applications.

VASER process

Eliminating fat with VASER technology is a three-step process.

Tumescent fluid application

Belt Lipectomy VASER liposculpture Fat Melting by Dr Bernard Beldholm

First, a tumescent solution is injected. A moderate amount of fluid is best for a belt lipectomy. A general rule of thumb is two-to-three litres of tumescent fluid per one-to-two litres of fat removed. The solution consists of one ampoule of adrenaline per litre, and 400 milligrammes of lignocaine per litre as well. The fluid expands the tissues to promote hydrodissection. Adrenaline also constricts the blood vessels to minimise bleeding. Patients can expect good pain relief for 12 to 18 hours after the operation.

Fat melting

Prior to liposuction, it is helpful to melt the fat first. This makes aspiration easier. VASER liquefies the targeted adipose cells with ultrasound energy transmitted through a handheld probe.

Fat aspiration

Once the adipose tissue is melted to the consistency of hot butter,  it is time to remove it with machine-assisted suction. Gentle, low-power aspiration is all that is needed to remove the fat once it has been liquefied by the VASER. A gentle approach to liposuction reduces damage to the interconnected blood vessels, particularly those located close the skin surface.

Belt Lipectomy VASER liposculpture Fat Removal by Dr Bernard Beldholm

Typically, a four-millimetre cannula works best for liposuction on the average post-weight loss patient. A Candy Cane cannula removes a large amount of fat in each pass. Thin patients may require a Mercedes cannula.

PHASE 3: BACK, BUTTOCKS, & THIGH LIFTING

This stage involves tightening lax skin on the posterior flanks, lower back, buttocks, and lateral thighs.

Incision

The surgeon makes a horizontal incision on the lower back, following the surgical markings from earlier. During a belt lipectomy, it is best to excise loose skin as far forward as possible while the patient lies prone. This will leave a big dog ear on the sides, which will be removed once the patient is turned over to address the abdomen.

Belt Lipectomy Tightening of Loose Skin by Dr Bernard Beldholm

Determining the extent of skin removal

Surgical markings placed on the skin prior to surgery are useful, but they should be confirmed before resecting any skin. There are several ways to identify how much skin to remove:

Method 1: A surgeon can make segmental cuts, then do a vertical incision, and then match it to the lower section of skin.

Method 2: A simpler method involves placing Allis forceps along the edge of the lower skin, then pushing that up with one hand while an assistant pulls the upper skin downward over the lower skin. Using this technique, the surgeon can feel where the Allis forceps are located, then use that as a guide to mark out the excess skin.

Method 3: Another technique is to mark out the incision line and then measure in order to match up both sides of the skin symmetrically. Pre-operative markings and a spirit level ensure those two lines are even.

Posterior skin excision

Belt Lipectomy Sealing the Blood Vessels

Tissue removal must not be rushed. Working on small areas at a time is the best approach. Care should be taken to remove just the right amount of skin (not too much, nor too little). The goal is to provide adequate tightness, keeping in mind the tissue will loosen up to a degree as the patient heals. However, removing too much tissue can pose a problem when it comes time to close the incision. Experience is the best teacher when it comes to striking the perfect balance.

Sealing the blood vessels

The surgeon should seal each blood vessel as they proceed with excision. This is important for haemostasis. It is time consuming to close up each individual blood vessel, but it is best for patient safety. Doing so minimises the risk of bleeding and hematoma after surgery. This is particularly important during a belt lipectomy since there is a massive amount of space the blood can pool into. Worth noting is that the tumescent fluid from the liposuction that took place earlier also has a haemostatic effect.

Closing the incision

Belt Lipectomy Closing the Back Incision by Dr Bernard Beldholm

As the posterior incision is sutured closed, the buttocks and thighs are elevated. The closure should be tight initially, but not so tight that it causes bunching. The incision is closed in layers. Permanent sutures are placed into the deep tissues. Ethibond or Tricron sutures are an excellent choice. Barbed V-Loc sutures are applied in three layers, working upward toward the skin surface. ARTISS tissue glue is a sprayable, medical-grade glue that also helps to seal the tissue layers. Glue minimises the risk of seroma, or fluid buildup. It is also thought to reduce bruising.

PHASE 3: TURNING THE PATIENT OVER

After completing the posterior, the patient must be turned over on the operating table in order to access the abdomen. The turning process is arguably the most challenging part of a belt lipectomy. It involves a massive amount of time and effort, as well as risk for the patient.

Turning with the Jackson table

A Jackson table is a special operating table that is designed to turn the patient over safely. Instead of the surgical staff turning the patient manually in three turns, the Jackson table does much of the work. A carbon fiber table frame is placed above the patient, sandwiching the body in place. The frame is then locked. A mechanical turn is performed by unlocking and then rotating the unit to 180 degrees.

Performed correctly, the Jackson table turns the patient in a safe, controlled manner. There is less risk of an accident or slippage if the patient is properly strapped in place compared to manual transfers.

While a Jackson table offers safer turning, it is time consuming. The typical strapping, turning, and re-strapping process takes approximately one hour. A medical journal article describes placing pads underneath the patient as a “daunting task”.

It takes a team of people to make sure everything goes smoothly. Everyone must be on the same page. Surgeons can streamline the process by adopting a standardized turning protocol along with setup checks and educational tools that are shared among the operating room team. Practice exercises go a long way toward ensuring a successful turn during a live surgery.

PHASE 5: EXTENDED LIPOABDOMINOPLASTY

With the patient now lying supine, the surgeon can address redundant skin and fat on the abdomen and sides. The technique for the front is similar to the back. The surgeon essentially performs an extended tummy tuck with liposuction.

VASER liposculpture of the abdomen and anterior flanks

All three steps of VASER liposculpture are repeated on the abdominal front and sides. Excess fat is melted and aspirated to highlight the existing curves and musculature. VASER provides excellent abdominal definition.

Extended tummy tuck

Unlike a full tummy tuck, the extended abdominoplasty has an elongated horizontal incision that extends up and over the hips. The exact placement of the incision should be discussed with the patient prior to surgery. Individual preferences, swimsuit, and preferred undergarment styles should be considered when marking out the incision.

Abdominal incision

A horizontal incision is placed low on the abdomen. The incision extends up and around the hips.

Epigastric dissection

Starting from the incision, the surgeon cuts upward, terminating at the navel. Older abdominoplasty techniques dissected all the way up to the ribs. Such extensive dissection is not necessary today. Instead, an epigastric tunnel creates a pathway from the navel toward the ribs. This method reduces seroma formation, epigastric bulging, and suprapubic necrosis. It also minimises tissue trauma and preserves blood flow. As a belt lipectomy is quite an extensive procedure, this is considered by many as the safest approach.

Abdominal muscle repair

Through the epigastric tunnel, the surgeon gains access to the rectus abdominis muscles. Diastasis recti, or abdominal muscle separation, is common among patients who were formerly obese. After losing weight, an abdominoplasty can be performed to plicate the muscles together at the midline. A belt lipectomy offers the same opportunity to repair rectus muscle separation. In addition to sutures, the surgeon may elect to use ARTISS tissue sealant to add strength to the closure. This ensures a tight seal and alleviates tension on the sutures.

Freeing the umbilicus

Belt lipectomy patients often require extensive skin removal. Removing a large amount of abdominal skin can result in a navel that is positioned too low on the abdomen. Umbilical repositioning may be necessary.

An incision is placed around the navel to free it. This can be tricky, as the skin surrounding the navel has a tendency to wobble under the scalpel. Skin hooks can be used to stabilize the skin around the navel. An assistant holds the hooks in place, keeping the skin taut as the surgeon cuts around the navel to free it.

Once the navel is freed, it is helpful to secure a small plastic marker to it with a 2/0 Silk stitch. Later in the belt lipectomy, as the skin is pulled downward and over the freed navel, the plastic bit makes it possible to feel where the navel is located. Navel repositioning will be addressed in a later step.

Skin excision on the abdomen and anterior flanks

Redundant skin is measured, marked, and excised on the abdomen and sides. The initial markings drawn on the patient during the pre-operative appointment ensure a straight, symmetrical result. The markings should be confirmed prior to making any incisions. To confirm the incision, the operating table may be placed on a slight tilt of about 15 degrees. This small gravitational change makes it easier to confirm how the skin will drape once it is removed.

There are special surgical tools to measure and mark excess skin. However, an old-school method works just as well. The surgeon may place several Allis forceps along the lower abdominal incision. Next, the upper abdominal skin is pulled downward so that it overlaps the lower abdomen. Feeling for the Allis forceps beneath the skin tells the surgeon where the incision line is located. As the skin is trimmed away, each blood vessel is sealed progressively to reduce bleeding.

Umbilicus repositioning

If necessary, the navel is moved upward. The goal is to avoid a navel that sits too low on the abdomen once the abdominal skin is tightened.

Creating a new hole for the navel

The surgeon feels for the plastic bit that was stitched to the umbilicus earlier. A new hole is created for the navel, which is then pulled through the hole and sutured in place.

Belly button aesthetics

A navel may be small, but it makes a big difference in terms of aesthetics. During abdominoplasty procedures, an oval or irregular navel tends to work best. A navel that is too round is not often seen in nature. Rounded navels also have a tendency to cause skin to retract excessively. In severe cases, the navel opening may close up entirely. An oval or slightly imperfect navel shape avoids this defect.

Navel-shaping techniques

The navel should match the patient’s anatomy. In post-weight loss patients with a massive amount of skin and a long navel stalk, the surgeon may need to amputate the stalk slightly and then make a vertical incision. Post-pregnancy patients may see a better result by creating a small flap and pulling the navel through that.

Ensuring the navel looks natural

It is important not to rush through the navel. A surgeon can artistically shape the belly button according to the patient’s preferences and body type. Another trick the surgeon can employ to create a natural-looking navel is to remove a small cylinder of fat beneath it with liposuction. This gives the umbilicus a natural depression, similar to the look seen in swimwear models. A small hood can also be added to the uppermost part of the navel, which is another feature often seen in photographs depicting the abdomens of both men and women.

Umbilicus closure

Four dissolving 2-0 PDS sutures are placed around the umbilical stalk, incorporating the top skin of the umbilicus. The sutures are pulled downward so that they are neatly hidden in the folds of the umbilicus as much as possible. Sprayable ARTISS tissue sealant may be used as well for a tighter seal.

Abdominal closure

The abdominal tissue is closed in four layers. Deep permanent sutures (Ethibond or Tricron) and absorbable barbed V-Loc 180 and V-Loc 90 sutures are placed, starting on the scarpa’s fascia, and working upward toward the skin surface. The 90 refers to 90 days of absorption and 180 days of absorption, respectively.

The scarpa’s fascia can withstand a lot of tension. This allows for maximum tightness during suture application. This helps to keep tension off the skin, which protects the integrity of the incision in the early stages of healing.

In addition to sutures, ARTISS tissue glue creates a tight seal and reduces seroma formation. For the first few months of recovery, the abdomen needs that extra support for proper healing.

As the abdominal incision is sutured closed, it also has a mons pubis lifting effect. The abdomen should like taut and flat at this stage.

Wound dressings

Selecting the right wound dressings is important. Bandages provide a barrier to stop bacteria from entering the wound site. They also provide cushioning and reduce irritation. Basic surgical bandages are fine, but PICO negative pressure dressings offer more benefits to the patient. This high-tech, battery-operated wound dressing creates constant gentle pressure on the wound to promote healing. According to the manufacturer, it promotes blood circulation at the wound site and minimises swelling.

PICO’s advanced inner layer is made of super absorbent material with AIRLOCKTM technology. It helps to keep bacteria out and keeps the wound dry. Studies from the manufacturer show it prevents up to 99.9% of bacteria from entering. The soft PICO bandage is worn for approximately seven days.

Compression garments

Compression garments reduce swelling and minimise tension on the wound as it heals. They may also lower the risk of seroma after surgery.

The belt lipectomy is now complete.

How long does a belt lipectomy take to perform?

This operation takes approximately six to seven hours. It can be split up into two stages if desired, addressing the abdominal front and flanks first, and then performing the buttocks lift later as a second procedure.

Summary

A belt lipectomy is an extensive 360-degree operation. It requires the skill of an experienced surgeon. There are many factors that make circumferential operations a challenge. During a belt lipectomy, turning the patient, shaping the umbilicus, and making sure all the incisions match up are the biggest challenges. It is also important to avoid taking too much or too little skin. Experience is your ally when it comes to this surgery.

Patient selection is another component for success. A belt lipectomy is not right for everyone.

There are various liposculpture devices on the market. Each has pros and cons. VASER liposculpture has numerous benefits during a belt lipectomy. When performed correctly, it eliminates fat pockets and promotes better definition while minimizing tissue trauma compared to traditional liposuction methods. The added benefit of discontinuous dissection also makes it easier to excise tissue during skin reduction procedures such as a belt lipectomy. It is worth learning about VASER technology, as it may greatly improve the cosmetic outcome of surgery.