Trochanteric dermolipectomy in a patient after bariatric surgery: case report
Dermolipectomia trocantérica em paciente pós-cirurgia bariátrica: relato de caso

INTRODUCTION

Currently, with the increase in reducing gastroplasty or bariatric surgery, there has also been an increase in the number of patients with large weight losses who are looking for plastic surgery. One of the characteristics of these patients is the excess of dermal adipose tissue, which represents a real challenge for the plastic surgeon. Among the most common deformities, those that affect the lower limbs, especially the trochanteric region, represent an important psychological disorder for the patient and have a high degree of technical difficulty^1,2,3.

Therefore, the correct indication of the different procedures, based on an assessment, considering both the organic and the psychological aspects, is essential in the treatment of these deformities³.

In 1964, Pitanguy described a technique with scars camouflaged in natural grooves, which when understood and correctly indicated, offers very satisfactory results. With the advent of liposuction, there was a reformulation of the possibilities of treatment for trochanteric lipodystrophy, establishing new concepts, but not invalidating the procedures previously used^4,5.

Therefore, the objective was to report a case of trochanteric dermolipectomy in a patient after bariatric surgery, where liposuction alone would not solve the correction of the deformity.

CASE REPORT

Female patient, 55 years old, with a history of reducing gastroplasty (bariatric surgery) in December 2013, her pre-bariatric BMI was 52.3 kg/m² and had great weight loss (approximately 52 kg in 5 years). He reported significant discomfort with lipodystrophy and extensive flaccidity in the bilateral trochanteric region (Figure 1). After evaluation by the team, it was decided to perform bilateral trochanteric dermolipectomy. The patient underwent the procedure indicated in January 2019 at the Plastic Surgery Service Osvaldo Saldanha, in Santos/SP.

Figure 1 - Preoperative.

Figure 1 - Preoperative.

The criteria for surgery indication were: great weight loss after bariatric surgery (approximately 52 kg in 5 years, BMI pre-trochanteric dermolipectomic surgery equal to 31.8 kg/m²), excess skin and subcutaneous cell tissue (SSCT) in the bilateral trochanteric region and the patient’s desire to perform the correction of lipodystrophy in the aforementioned region.

Surgical technique

The excision areas are marked with the patient in an orthostatic position, prior to anesthesia (Figure 2). Patient under general anesthesia, is placed in prone position on the operating table. Asepsis, antisepsis and placement of sterile fields are performed. Incision in previous mark. The incision corresponds approximately to the grooves formed by the deformity due to lipodystrophy in the trochanteric region, starting at the junction of these two grooves, proceeding towards the anterosuperior iliac crest, but not reaching it. Once the skin incision is made, it is deepened until the muscular plane is reached, making a bevel in the caudal direction. The flaps are dried up to the limit of the defined area, with their total weight equal to 3kg and 200g. A continuous suction drain is used on each resected side and closed by planes (Figure 3).

Figure 2 - Marking

Figure 2 - Marking

Figure 3 - Immediate postoperative

Figure 3 - Immediate postoperative

The patient had a good postoperative evolution, without complications such as seroma, hematoma or suture dehiscence in the postoperative period (Figures 4 e 5).

Figure 4 - Preoperative, 20 days postoperatively, 1 month and 20 days postoperatively: anterior and posterior views.

Figure 4 - Preoperative, 20 days postoperatively, 1 month and 20 days postoperatively: anterior and posterior views.

Figure 5 - Preoperative, 20 days postoperatively, 1 month and 20 days postoperatively: bilateral side view.

Figure 5 - Preoperative, 20 days postoperatively, 1 month and 20 days postoperatively: bilateral side view.

DISCUSSION

Trochanteric lipodystrophy is attributed to several factors, hormonal and, mainly, hereditary. There is also the adipocyte theory, which states that there is a fixed number of adipocytes in the body containing two types of receptors sensitive to the same chemical mediators of the adrenergic system. It has been shown that adipocytes with alpha 2 receptors, in women, are located mainly in the trochanteric region, for this reason there is no improvement in the deformity of this region, despite great weight loss, being one of the most common complaints of patients, the fat deposit in this region. These patients have a characteristic gynecoid body: the pelvis is larger than the trunk, the breasts are small and the arms are thin. When these patients go on a diet, exercise and try in other ways to reduce body measures, they can only lose weight, but this disproportion remains and can even be accentuated^3,4,5.

Therefore, due to these deformities, these patients look for plastic surgery, so that they can minimize them. In trochanteric lipodystrophy, in cases of mild and moderate deformities, the scar resulting from a dermolipectomy is undoubtedly one of the most controversial points of the classic technique, in which the relationship between the benefit and the resulting deformity would be unfavorable. Regarding less severe deformities, there is currently the option of treatment by liposuction, which allows the correction without visible scars, consequently limiting the indications for classic dermolipectomy, with relatively apparent scars. On the other hand, liposuction used in a patient with major deformities, may aggravate them even further, resulting in sequelae whose correction needs to be performed using the trochanteric dermolipectomy technique^3,4,6.

The analysis of the different procedures performed in the 90’s showed that liposuction brought an indisputable benefit in cases of localized adiposity, limiting the indications for the dermolipectomy technique, especially in the trochanteric region, without, however, invalidating it for selected cases^5,7,8.

In conclusion, as described in this case report, due to the presence of great adiposity and flaccidity in the patient’s trochanteric region, the trochanteric dermolipectomy technique was indicated, since liposuction alone would not be enough to correct the patient’s complaints, which may further aggravate the deformity of the region in question.