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Modern body lifting is an exciting frontier for patients and the plastic surgery team. Aesthetic body contour deformities often involve multiple areas of the trunk and thighs. Surgery must take into account the effect on the overall aesthetic balance of the body. While the results can be dramatic and fulfilling, the surgeries are labor-intensive and challenging, and the recovery requires patient commitment and compliance.

Modern abdominoplasty techniques were developed in the 1960s. The advent of liposuction has reduced the need for classic abdominoplasty and allowed more aesthetic sculpting of the entire trunk. However, the combination of significant truncal liposuction and classic abdominoplasty is not recommended due to the increased risk of complications. Although the surgical principles of classic abdominoplasty certainly have stood the test of time, they are based on two theoretical assumptions that may be proved to be inaccurate. The first assumption is that wide direct undermining to costal margins is essential for abdominal flap advancement. In fact, discontinuous undermining allows effective loosening of the abdominal flap while preserving vascular perforators. The second inaccurate assumption is that with aging and weight fluctuations (including pregnancy), abdominal skin relaxation occurs primarily in the vertical direction from the xiphoid to the pubis. This is true in the lower abdomen, but in most patients a strong superficial fascial system adherence to the linea alba in the epigastrium limits vertical descent. Epigastric laxity frequently results from a progressive horizontal loosening due to relaxation of the tissue along the lateral trunk. Experience with the lower-body lift procedure has shown that significant lateral truncal skin resection results in epigastric tightening. In these patients, the ideal abdominoplasty pattern would resect as much or more laterally than centrally, leading to more natural abdominal contours. Fifty patients who underwent high-lateral-tension abdominoplasty with and without significant truncal liposuction and other aesthetic procedures were followed for 4 to 16 months. The primary indication for surgery was moderate to severe laxity of abdominal skin and muscle with or without truncal fat deposits. Complication rates were equal to or less than those of historical controls and did not increase with significant adjunctive liposuction. The key technical elements of this procedure include direct undermining limited to the paramedian area, discontinuous undermining to costal margins and flanks as needed, skin resection pattern with significant lateral resection and highest-tension wound closure placed laterally, superficial fascial system repair with permanent sutures along the entire incision, and liberal use of adjunctive liposuction in the upper abdomen and the lateral and posterior trunk.

Although significant innovations in brachioplasty occurred in the 1970s, it remains an unpopular procedure. Current brachioplasty techniques are somewhat unpredictable and are commonly associated with significant untoward results. Recent anatomic studies demonstrate that in youth the posteromedial arm soft tissues are firmly suspended to a tough yet dynamic fascial system sling that ultimately gains its strength from the clavicular periosteum by means of the clavipectoral and axillary fasciae. Loosening of the connections of the arm superficial fascial system to the axillary fascia, as well as relaxation of the axillary fascia itself, with age, weight fluctuations, and gravitational pull yields a "loose hammock" effect, resulting in significant ptosis of the posteromedial arm. On the basis of this anatomic concept, the brachioplasty procedure was modified to provide secure anchoring of the arm flap to the axillary fascia along with strong superficial fascial system repair of incisions, reducing the risk of widening or migration of scars and unnatural contours. Five patients having brachioplasty with or without liposuction were followed for 6 to 12 months. The primary indication for surgery is moderate to severe skin laxity of the arms with or without associated arm fat deposits. Results were consistent, and complications were limited.

Multiple body contour deformities of the trunk and thighs are commonly treated in separate stages to limit postoperative complications and disability. Recent advances in the surgical design of the medial thigh lift and the lateral thigh/buttock lift along with an understanding of the functional anatomy of the superficial fascial system have significantly improved results and decreased complications of trunk/thigh lifts. The enhanced safety of current trunk/thigh lifts has allowed new combinations to treat multiple body contour deformities in a single stage. Laxity of the entire lower trunk and thigh regions can be treated in one stage in selected patients. The lower body lift combines the transverse flank/thigh/buttock lift and the fascial anchoring medial thigh lift in one operation. In addition to the expected tightening of the flank, buttocks, and total thighs, this procedure results in a surprising degree of epigastric and hypogastric tightening of mild to moderate abdominal laxity without direct surgical undermining or umbilical transposition. Ten patients having the lower body lift alone or in combination with liposuction and other body contouring procedures were followed for 6 to 24 months. The primary indication for surgery is moderate to severe soft-tissue laxity of the lower trunk and thighs with minimal or mild residual fat deposits. Skin contour irregularities due to skin laxity (cellulite of laxity) or to postliposuction adhesions are frequently present and may be severe. Patients with significant fat deposits may be treated initially with liposuction 3 to 4 months earlier to become candidates for this procedure. Key technical elements of this procedure include (1) both supine and lateral decubitus positioning with the hip flexed and abducted to allow overcorrection, (2) appropriate direct surgical undermining through superficial fascial system zones of adherence in the superior thigh while avoiding the lymphatics of the femoral triangle, (3) more distal undermining of the thighs with an atraumatic undermining cannula, (4) resection of redundant lower trunk and thigh tissues with incisional closure within high-cut bikini lines, and (5) complete superficial fascial system and dermal suspension throughout the repair. The lower body lift requires 5 to 6 hours of operating time, 2 units of autologous blood, 2 nights of nursing care, and 3 weeks off work. Although no major complications occurred, minor complications were significantly higher than with the component procedures alone and occurred in 50 percent of patients. Technical changes and improved patient selection have significantly improved the rate of complications in subsequent patients. Results have been consistent, and patient satisfaction has remained high.