Are FDL and Torsoplasty needed? Vertical or horizontal torsoplasty? (Photos)

I think you would have a nice result with a standard tummy tuck skin removal without the vertical scar. I can understand the concern with a circumferential scar . . . but continuing skin removal around the sides can really benefit skin laxity in the outer thigh and buttock. Thank you.

Hello, Glorious 373613. Thank you for your question regarding whether you need a Fleur-de-Lis (FDL) and torsoplasty or whether you need a vertical or horizontal torsoplasty. Thank you for your history and your pictures. Let’s analyze your body before suggesting plastic surgery. Upon examining your abdomen, we notice weakness in the abdominal muscles, along with excess abdominal skin and fat, and lower abdominal stretch marks. You have excess skin and fat above the mons (pubic region) and an overhang of excess skin and fat above the belly button. You do not have a significant amount of excess skin from the sternum to the umbilicus (or belly button). Upon analyzing your hips and outer thighs, you have excess skin and fat in the saddlebag region (or the lateral aspect of the upper 1/3 of the lateral thigh). In analyzing your buttocks, you have mild excess skin and fat in the upper 1/3 of the buttocks. Upon analyzing your back, you have two moderate skin and fat rolls: one above the bra strap and one within the bra strap area.
Now, let’s analyze what the FDL, circumferential tummy tuck, vertical torsoplasty, and horizontal torsoplasty entail. The Fleur de Lis (FDL) is a type of abdominoplasty in which an incision is made horizontally, low in the abdomen, and another vertical incision perpendicular to the aforementioned horizontal incision. The vertical incision extends from the sternum to the mons (or pubic region). The benefits of the FDL are that it addresses the excess skin and fat from the sternum to the umbilicus. The disadvantage of the Fleur de Lis is that it leaves a quite visible, sometimes non-cosmetic vertical scar in the central portion of the abdomen. This vertical scar can be very difficult to hide. Another disadvantage of the FDL is that it does not lift or reduce the buttocks or the outer thighs. In addition, the FDL will not significantly impact your back. The FDL may improve your waistline, but not as much as the vertical and horizontal torsoplasties. The 360-degree circumferential tummy tuck, or lower body lift, removes excess skin and fat from the abdomen, hips, and buttocks. In addition, the abdominal portion of the 360-degree circumferential lower body lift tightens the rectus abdominis musculature and lifts and reduces the mons. The disadvantage of the 360 circumferential lower body lift is that there is a scar that goes completely around your body. However, there is no vertical scar like the FDL. The recovery from an FDL and a body lift is about the same.
During a vertical torsoplasty, an incision is made from the armpit down your sides to the top of the hip. A large elliptical area of skin and fat is removed from each side. This procedure is often called an “hourglassing procedure” because the result can lead to a vast improvement in the shape of your torso, resulting in an hourglass shape. The horizontal torsoplasty is also called a “bra strap incision” or a “bra-plasty” because the incision goes across your back. By creating an incision across your back, a large butterfly-shaped area of skin and fat is removed from your upper back.
The disadvantage of the vertical torsoplasty is that it requires two incisions (one on each side), compared to the single incision across the back incision of the horizontal torsoplasty. However, the advantage of vertical toroplasty is that it results in more concealed scars compared to horizontal torsoplasty. The vertical scars are more concealed than the horizontal torsoplasty because when your arms are by your sides, they cover your scars. The disadvantage of the horizontal tool is that there is a more visible scar across your back.
In analyzing your body, most board-certified plastic surgeons specializing in these procedures would recommend a 360 circumferential lower body lift to address your abdomen, hips, and buttocks. Most experienced board-certified plastic surgeons would not recommend a vertical abdominoplasty or Fleur de Lis (FDL) incision because of your upper abdominal fat distribution. Since you do not have much excess skin and fat from the lower sternum to the belly button, you do not need an FDL surgery. Plastic surgeons must accurately examine and diagnose before recommending the appropriate surgery. You don’t need that extra visible middle of the abdomen scar.
Most plastic surgery experts recommend performing the lower-body lift surgery in isolation and staging the vertical toroplasty after the 360 lower body lift. Staging is important due to the blood supply because at the intersection of the vertical torsoplasty and the body lift scar, the blood supply may be jeopardized. At a later date, in your case, based on pictures provided, most plastic surgeons would suggest a vertical torsoplasty as opposed to a horizontal torsoplasty. You will achieve a better body shape with a vertical torsoplasty than a horizontal torsoplasty. If your primary focus is on reducing the skin and fat on your upper back rather than achieving a more hourglass shape, proceed with the horizontal torsoplasty or bra strap lift. However, be aware of the tension vectors. It is preferable to stage the horizontal torsoplasty and the lower body lift, as performing the horizontal torsoplasty pulls the back up. In addition, when performing the 360 circumferential lower body, lifting the butt is performed. That means there are two vectors, both pulling the upper back and the lower buttocks upwards. Therefore, it is advisable to stage the vertical and horizontal torsoplasties several months after undergoing a 360 circumferential lower body lift. If you have any more questions regarding the lower body lift, 360 circumferential lower body lift, belt lipectomy, belt abdominoplasty, belt dermolipectomy, vertical torsoplasty, horizontal torsoplasty, bra strap lift, bra plasty, upper back lift, or upper body lift, please get in touch with an experienced plastic surgeon. Since the body lift is a big procedure, please seek an experienced, board-certified plastic surgeon with significant experience performing the lower body lift. Do your research.  Ensure they have performed at least 150 circumferential lower body lift surgeries, supported by before and after pictures.  Carefully examine their before and after pictures and check their reviews on RealSelf.   If you cannot find an experienced lower body lift surgeon in your neighborhood, consider traveling out of state if necessary.
Sincerely, Dr. Katzen, MD, MBA, FACS, FICS, FASMBS (President of the American Society of Bariatric Plastic Surgeons, certified by the American Board of Plastic Surgery, Fellow of the International Society of Aesthetic Plastic Surgery, American College of Surgery, and International College of Surgery and member of the American Society of Plastic Surgery, American Academy of Cosmetic Surgery RealSelf Hall of Fame, and RealSelf Doctor Advisory Board for Medical Review and Consumer Panel.)

Based on your surgical goals, there are options to consider. From the submitted photos it appears a lower body lift with liposuction would address the abdomen, hips and lower back. If you are wanting the upper back addressed you can consider liposuction with J Plasma or a bra line lift if you are wanting a more complete result. I've included a video I hope you find helpful.