Following significant weight loss after dieting or Bariatric Surgery the body subcutaneous fat and surrounding skin hangs in folds. This is uncomfortable and interferes with normal activity. It can also be embarrassing. The areas affected are similar in each patient – abdominal overhang, breasts and buttocks empty and droopy, inner thigh and inner arm excess, and back folds. The correction of these unwanted skin/fat folds involves staged procedures usually six months apart. Four or more operations are sometimes needed to optimize body shape. The operations remove excess skin, unwanted scars, stretch marks, fat and can tighten the stomach muscles. The different procedures are tailored to your particular problem(s). It is important to have a stable weight, and be feeling well before undergoing any surgery.

Most patients wish to have the excess abdominal tissue removed first. These patients usually require a belt lipectomy which involves removal of tissue from around the lower trunk. This operation removes the overhanging belly , lifts the mons, removes folds from the lower back and lifts the buttocks. Sometimes it is possible to use the tissue to be discarded to augment the buttocks. If this is something you would desire please mention it to me. A belt lipectomy operation is performed under general anaesthesia and usually requires hospitalisation of 3- 4 days. The operation starts with you in the prone position (facing down) and the excess tissue is removed from your lower back. While still asleep you are turned over so that I can perform the abdominoplasty component of the surgery on the front of your tummy. An incision is made from hip to hip connecting with the back incision, and around the belly button. A large wedge of skin and fat is excised from the belly button to just above the pubic hair. Some areas may be treated with liposuction and the muscles above and below the belly button can be tightened. Although this operation does leave the biggest scar, it does provide the greatest degree of improvement in shape. Patients still planning pregnancies should wait until completion of their family.
Subsequent operations involve lifting and filling empty breasts, arm and thigh tucks, and adjunctive liposuction. These can all be discussed with me when the time is right.

What can be expected at the initial consultation?
At the initial consultation you will be assessed as to whether you are a good candidate for belt lipectomy. Your abdomen will be carefully examined to assess the skin quality, the quantity of fat and the muscle tone. Your general fitness for the procedure will be evaluated and the potential for problems sought. It is important to know about previous abdominal surgery, pregnancies, medication that you are on, previous leg or lung clots and whether or not you smoke.
Your reasons for wanting the procedure will also be discussed. It is important that your expectations concerning the outcome of the procedure are realistic. If they are, you can expect to be happier with the result.

Once you have been fully assessed, an operative plan tailored to your individual needs will be formulated. The incision to be used, the amount of skin and fat to be excised, whether muscle tightening and navel repositioning is to be performed, and whether liposuction will be used as an adjunct will be discussed with you.

Do not be hesitant to ask questions, now or at any other time.

Medical aids or health insurance companies do not usually provide cover for this kind of surgery although occasionally a motivation can be done especially if you have lost large amounts of weight, or have a hernia.

Preparing for surgery

Ideally surgery is performed when you are fit and healthy. No special diet or exercise program is required. It is a good idea to have a good fluid intake for a few days before your operation. You should not have been on a long-haul flight for 2 weeks prior to surgery.

It is advisable to stop smoking at least six weeks prior to surgery and not to smoke until your wounds have healed - usually about two to three weeks after the operation. It is well known that there is a higher frequency of complications in patients who smoke.

On the morning of surgery you should wash well. Do not shave your pubic hair specifically. Prior to surgery, the incision lines will be marked with a pen in your room. Mr Soldin usually takes photographs for your records immediately before surgery.

The Surgery

Surgery will be performed in an operating theatre under general anaesthesia. You will need a urinary catheter to monitor fluid balance, and may need blood during or after the operation. A belt lipectomy takes between three to five hours depending on what will be done.
Following surgery the wounds are closed with dissolving sutures, and drains may well be left in place for a few days. Dressings and an elasticised garment will be applied.

What can be expected after the operation?
Following the operation you should be relatively pain free although you may feel some discomfort with movement. Post-operatively, you will be given strong painkillers (such as opiates) and patient controlled analgesia (PCA) can be arranged for in-patients. With PCA you control the amount of painkiller that you receive - it is effective and safe.
You will be allowed to eat and drink once you are awake. As an in-patient, you will be well looked after in hospital and gentle mobilisation will be started as soon as you are awake. Daily showers are encouraged. Once the drains have dried up, they are removed and you can go home. Someone will need to drive you home and look after you. I advise that you have homecare for the first week to two, and that you have stocked up on all essentials before surgery. You will be given painkillers to take home with you. At home you should mobilize gently and rest frequently. On the first day after surgery, you should try to get up into a comfortable chair and would be encouraged to walk around within the house. Following the first week of gentle mobilisation, you could get around a bit more – walks in the park and to the local shops are fine.

How long does it take to get back to normal?

Healing is a variable process and it may take you a month/six weeks to feel like your old self again. People vary enormously in their recovery period.

The scars are healed by the end of the first week, but continue to mature for up to a year, by which stage they should be thin, fine, inconspicuous lines. Massage of the scars with an aqueous cream helps, but should only be started after 1 month.
Bruising take about 2 weeks to settle. Swelling can take up to 12 weeks to settle. To help diminish swelling and bruising abdominal support should be worn for 24 hours a day and arnica, a homeopathic preparation, can be started from about day 2 post-op.
You will find that contrary to what you expect, your mood will be down following surgery and you may feel depressed, even tearful. You will also feel tired. This is a normal occurrence and as the swelling and bruising subside and your body heals, so your mood will elevate and improve.

Mobilisation should be gentle, but begun early. Immediately after surgery you should start with wiggling your toes and ankle and knee movements to help prevent leg clots. Avoid crossing your legs in bed. On the first post-perative day you should mobilise to a chair, walk to the bathroom and a little around your room. Thereafter mobilisation should progress so that gentle exercises can be begun about one month after surgery. Vigorous exercise should be avoided for six weeks, until you feel comfortable – your body will tell you if you are pushing it too hard.

At home you need to take it easy but do not take to your bed. You will need help if you have small children for 2 weeks. Gradually increase your walking day by day. Do not drive until you really feel well – usually 2 weeks. Shower daily to stay clean. If your tubigrip becomes blood-stained, wash and dry it before reapplying it.

Return to work is usually after one month to six weeks depending on your job.

What are the risks?

When performed by a qualified plastic surgeon, belt lipectomy is normally safe and the results predictable. Nevertheless, as with any surgery, there is always a possibility of complications, including the following:

• Sensory alterations in the area - numbness below the belly button occurs in nearly all patients but is usually transient. Can take up to two years to resolve.
• Bleeding (early or late) which can lead to fluid collections. These may require drainage with a syringe or, rarely, repeat open operation.
• Infection at the operative site or elsewhere (e.g., pneumonia) Deep breathing and coughing is encouraged immediately after surgery to help prevent lung problems.
• Loss of tissue (necrosis), especially low down, near the scar or of the belly button can occur as the operation interferes with the blood supply of the tissues. If this occurs it is usually small and treated with dressings.
• Unsatisfactory scarring - usually not keloid, but scars can stretch or become raised and red.
• Asymmetries or irregularities in contour, the commonest being dog-ears at the ends of the scars. These may require simple revision under local anaesthesia.
• Clots in the legs which can migrate to the lungs. The early mobilisation helps to minimise the risks of this.
• Problems with anaesthesia, drugs, fluid balance, urine output, etc. These should be rare and the risks will be explained to you by your anaesthetist.

Will the new look last?

Belt lipectomy produces excellent results for patients following massive weight loss. In most cases the results are long lasting, especially if after the operation you avoid weight gain, follow a balanced diet and exercise regularly. Remember that realistic expectations are important.

Checklist before coming into hospital

• Bring all your usual medication, toiletries and pyjamas.
• No smoking (six weeks), and no aspirin (2 weeks) before the operation

If you are worried post-operatively

• Telephone the ward of the hospital from which you have been discharged.

• Telephone my secretary during office hours – 07780 785186

• In an emergency (and you have failed to contact me by the above two methods) then please telephone St George’s Hospital (020 8672 1255) and ask them to either bleep me or the Resident Plastic Surgery House Officer on call (Bleep 7050).