The multiple body contouring surgeries frequently necessitated by massive weight loss should be sequenced in a logical fashion that maximizes patient safety and outcome, while optimizing recovery. We prefer to perform a lower body lift first, as this achieves the goals of abdominoplasty, lateral thigh lift and buttock lift with a single procedure. As this is the biggest single surgery of the sequence, we perform it first, and without any concomitant procedures to minimize operative time.
Next, we will perform the breast surgery, which is usually a mastopexy with implant to replace lost breast volume, and usually pair this with a bilateral brachioplasty. This makes sense anatomically, as massive weight loss patients frequently have excess skin at the lateral aspect of the breasts as well as in the axillae, and the contiguity of these two areas allows us to deal with them as an anatomic unit in the same surgery.
Following this we will next perform a bilateral medial thigh lift as the third stage. Although this surgery is a bit shorter in duration than the previous two surgical sessions, the inconvenient position of the incisions, and the higher risk of post-operative infection militate that we perform this as an isolated procedure.
Lastly, although you do not mention it, the majority of our post-bariatric patients do undergo some form of aesthetic facial surgery, usually a facelift, to address the excess skin and soft tissues in the face and, especially, the neck. For many of our massive weight loss patients, this is often the most significant post-bariatric surgery they undergo, for the simple reason that all of the other areas can be camouflaged by clothes to varying degrees, but the face cannot be. We save it for last in our staging for surgical and logistical reasons, but in this position in our operative sequence it is the final coda that brings this surgical symphony to a close, and marks the beginning of an exciting new stage of life for our patients.