Characterizing the Saddlebag Deformity After Lower Body Lift

Characterizing the Saddlebag Deformity After Lower Body Lift Abstract Background One of the commonly cited sequelae of lower body lift is recurrence of the saddlebag deformity. However, there are currently no data that characterize the evolution of the saddlebag following lower body lift, nor is there a classification scheme to objectively quantify the severity of the deformity. Objectives The authors aimed to develop a grading scale to score the severity of the saddlebag deformity and, using this, determine the short- and long-term changes in the saddlebag following lower body lift. Methods Using the Pittsburgh Rating Scale, the Pittsburgh Saddlebag Rating Scale, a 4-point Likert scale, was developed to score the saddlebag deformity. Patients who underwent lower body lifts were parsed from a prospectively maintained database. Two educated observers independently reviewed both preoperative and postoperative photographs and graded the saddlebag deformity according to the Pittsburgh Saddlebag Rating Scale. Results Seventy-nine patients met inclusion criteria, including 5 males and 74 females. The average saddlebag score preoperatively was 1.34, while the average scores at short- and long-term follow up were 1.28 and 1.42, respectively. No significant differences in saddlebag severity scores were noted between preoperative and short- or long-term postoperative time points (P > 0.05). Conclusions This is the first study to objectively demonstrate the postoperative changes in the saddlebag following lower body lift. Results demonstrated that lower body lift does not effectively treat the saddlebag as the deformity only slightly improved in the short-term window but recurred within a year of surgery. Level of Evidence: 4 With the rise in popularity of various surgical and nonsurgical weight loss techniques to treat obesity, plastic surgeons have seen a concomitant increase in the number of patients presenting with redundant skin laxity after massive weight loss (MWL). Regardless of the method of weight loss, the skin redundancy following MWL becomes both a functional and aesthetic problem for the patient, correctable only by means of direct surgical excision. In this population, the lower trunk can be addressed with a lower body lift to simultaneously treat excess skin laxity of the abdomen, flank, lateral thigh, and gluteal regions in one operation.1 According to American Society for Aesthetic Plastic Surgery statistics, there were nearly 10,000 lower body lifts performed in 2016.2 The senior authors have a combined greater than 30-year experience in the treatment of the MWL population and employ the lower body lift to address the buttock and lateral thigh, while using the belt lipectomy, performed through a higher incision, to address the waist and flank. In their observations and from discussions with other experts in the field, a common sequela of the lower body lift is recurrence of the saddlebag deformity. A saddlebag—originally defined as the pair of bags hung from the saddle over the back of a horse—is often used informally as an anatomic reference to the protuberant region of the lateral thigh at the level of the inferior gluteal fold. Given that there is no true anatomic definition of this area, we will refer to it using this informal but widely understood term. Because the saddlebag deformity has not been well addressed in the literature, it is not surprising there is no current scoring system exists to specifically quantify it. Therefore, the purpose of this study is twofold. First, to introduce a novel saddlebag grading scale: the Pittsburgh Saddlebag Rating Scale. Second, to examine the evolution of the saddlebag deformity after lower body lift in the MWL population. The study hypothesis is that the saddlebag deformity improves in the short term after a lower body lift but recurs with longer follow-up periods. METHODS Patients were parsed using a prospectively maintained patient database in the Life After Weight Loss program at the University of Pittsburgh. The database consists of patients under the care of the two senior authors (J.A.G. and J.P.R.) who underwent body contouring operations following MWL, defined as weight loss greater than 50 pounds. The database was established in 2003. Patients who underwent surgery as late as 2016 were included in the study to ensure at least 1-year follow up. Variables collected included age; sex; body mass indices [maximum body mass index, current body mass index, and delta body mass index (maximum body mass index−current body mass index)]; comorbidities including tobacco use and diabetes; follow-up times; concurrent liposuction of saddlebag region with volume, if performed; and postoperative complications. Our study was approved by the Institutional Review Board of the University of Pittsburgh (PRO15080542), and the authors have no conflicts of interest to disclose. Patients were included if they had undergone a lower body lift by two senior surgeons at the University of Pittsburgh Medical Center between January 2003 and December 2016. Patients were excluded for the following reasons: having insufficient preoperative and postoperative photos, undergoing a belt lipectomy rather than lower body lift, or undergoing revision surgery of the saddlebag region prior to their postoperative photos. Surgical Technique Our approach to lower body lift has been described previously.3 In brief, patients are first marked standing in the preoperative area. The upper mark is designed by carrying the central point laterally to a point near the posterior superior iliac spine, while the lower mark is determined by means of a pinch test. Patients are initially placed in the prone position for excision of skin and subcutaneous tissue from the superior buttock, hip, and lateral thigh on each side. Lockwood dissection is performed to enhance lateral thigh release via discontinuous undermining. Closure is performed with the legs abducted to allow for minimal tension in the lateral thigh.3 Patients are then turned to the supine position and excision is extended to include the abdomen. Rating Scale A literature search was performed to select a grading scale with which to score the saddlebag severity, however, no rating scheme has been described. Therefore, the authors developed the Pittsburgh Saddlebag Rating Scale, an addition to the previously described Pittsburgh Rating Scale.4 The Pittsburgh Saddlebag Rating Scale is a 4-point Likert scale grading system used to score the saddlebag deformity (Table 1): grade 0, no protuberance (Figure 1); grade 1, slight protuberance (Figure 2); grade 2, prominent protuberance (Figure 3); grade 3, severe protuberance with a fold or pannus (Figure 4). Table 1. Pittsburgh Saddlebag Rating Scale, an Addition to the Previously Validated Pittsburgh Rating Scale Used to Grade Specific Anatomical Deformities in the Massive Weight Loss Population Pittsburgh saddlebag grade Description Grade 0 No protuberance Grade 1 Slight protuberance Grade 2 Prominent protuberance Grade 3 Severe protuberance with fold or double bubble Pittsburgh saddlebag grade Description Grade 0 No protuberance Grade 1 Slight protuberance Grade 2 Prominent protuberance Grade 3 Severe protuberance with fold or double bubble View Large Table 1. Pittsburgh Saddlebag Rating Scale, an Addition to the Previously Validated Pittsburgh Rating Scale Used to Grade Specific Anatomical Deformities in the Massive Weight Loss Population Pittsburgh saddlebag grade Description Grade 0 No protuberance Grade 1 Slight protuberance Grade 2 Prominent protuberance Grade 3 Severe protuberance with fold or double bubble Pittsburgh saddlebag grade Description Grade 0 No protuberance Grade 1 Slight protuberance Grade 2 Prominent protuberance Grade 3 Severe protuberance with fold or double bubble View Large Figure 1. View largeDownload slide Example of a grade 0 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 56-year-old woman. Figure 1. View largeDownload slide Example of a grade 0 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 56-year-old woman. Figure 2. View largeDownload slide Example of a grade 1 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 52-year-old woman. Figure 2. View largeDownload slide Example of a grade 1 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 52-year-old woman. Figure 3. View largeDownload slide Example of a grade 2 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 38-year-old woman. Figure 3. View largeDownload slide Example of a grade 2 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 38-year-old woman. Figure 4. View largeDownload slide Example of a grade 3 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 47-year-old woman. Figure 4. View largeDownload slide Example of a grade 3 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 47-year-old woman. Data Collection and Statistical Analysis Two observers—a senior plastic surgery resident and body contouring fellow—independently reviewed preoperative and postoperative photographs of each patient in the posterior view. Patients were graded at 3 time-points: preoperative, short-term postoperative, and long-term postoperative. The short-term period was defined as a time period between 4 and 11 months, and the long-term period was defined as 12 months or more after surgery. Additionally, scar migration was assessed in the short term by comparing the superior marking, or theoretical anchor line, with the short-term scar position and in the long term by comparing scar location at short-term follow up vs long-term follow up. Location was assessed based on relationships with anatomic landmarks including the umbilicus, anterior superior iliac spine, natural waist, and gluteal cleft. Scores were compared using a two-sample t test and interobserver reliability was calculated using the kappa statistic. RESULTS Demographics The database yielded 170 patients within the study period. Of these, 79 patients, or 158 saddlebags, met inclusion criteria. This cohort consisted of 5 males and 74 females. The average age at surgery was 45.4 ± 13.8 years (range, 27-78 years), with an average BMI of 28.0 ± 4.3 kg/m2 (range, 20.8-43.0 kg/m2). The average delta BMI (ΔBMI) was 21.9 ± 7.7 kg/m2. Seventy-two patients had available photographs at short-term follow up, with an average visit time of 6 months (range, 4-10 months) postoperatively; 46 patients had available photographs at long-term follow up, with an average visit at 15 months (range, 12-48 months) postoperatively. Representative photos of two patients are shown preoperatively and at short- and long-term follow-up time points. The patient shown in Figure 5 followed up at 4 months and 1 year postoperatively with saddlebag scores of 1, 1, and 2 on the left and 1, 1, and 2 on the right. The patient pictured in Figure 6 followed up at 4 months and 4 years with saddlebag scores of 2, 2, and 2 on the left and 2, 1, and 2 on the right. Figure 5. View largeDownload slide Representative photograph of a 52-year-old woman with a BMI of 26.1 at preoperative (A), short-term (4 months) postoperative (B), and long-term (12 months) postoperative (C) visits. Figure 5. View largeDownload slide Representative photograph of a 52-year-old woman with a BMI of 26.1 at preoperative (A), short-term (4 months) postoperative (B), and long-term (12 months) postoperative (C) visits. Figure 6. View largeDownload slide Representative photograph of a 47-year-old woman with a BMI of 30.9 at preoperative (A), short-term (4 months) postoperative (B), and long-term (48 months) postoperative (C) visits. Figure 6. View largeDownload slide Representative photograph of a 47-year-old woman with a BMI of 30.9 at preoperative (A), short-term (4 months) postoperative (B), and long-term (48 months) postoperative (C) visits. All Patients A full breakdown of all patients by score is presented in Table 2. The most common saddlebag score preoperatively was 1 (45.6%), while the most common in the short- and long-term postoperative periods were 2 at 41.7% and 45.7%, respectively. The average saddlebag score preoperatively was 1.34, while the average scores at short- and long-term follow up were 1.28 and 1.42, respectively (Table 3). No significant differences in saddlebag severity scores were noted between preoperative and short- or long-term postoperative time points, or between short-term and long-term scores (P > 0.05). Interobserver reliability was 78% for all measurements. Table 2. Breakdown of Saddlebag Scores at Each Time Point Saddlebag score Preoperative (n = 79) Short-term postoperative (n = 72) Long-term postoperative (n = 46) 0 10.1% 9.7% 13.0% 1 45.6% 40.3% 32.6% 2 30.4% 41.7% 45.7% 3 12.7% 6.9% 6.5% Saddlebag score Preoperative (n = 79) Short-term postoperative (n = 72) Long-term postoperative (n = 46) 0 10.1% 9.7% 13.0% 1 45.6% 40.3% 32.6% 2 30.4% 41.7% 45.7% 3 12.7% 6.9% 6.5% View Large Table 2. Breakdown of Saddlebag Scores at Each Time Point Saddlebag score Preoperative (n = 79) Short-term postoperative (n = 72) Long-term postoperative (n = 46) 0 10.1% 9.7% 13.0% 1 45.6% 40.3% 32.6% 2 30.4% 41.7% 45.7% 3 12.7% 6.9% 6.5% Saddlebag score Preoperative (n = 79) Short-term postoperative (n = 72) Long-term postoperative (n = 46) 0 10.1% 9.7% 13.0% 1 45.6% 40.3% 32.6% 2 30.4% 41.7% 45.7% 3 12.7% 6.9% 6.5% View Large Table 3. Saddlebag Scores by Cohort Cohort Preoperative saddlebag score Short-term postoperative saddlebag score Long-term postoperative saddlebag score P-value All 1.34 1.28 1.42 >0.05 Females 1.37 1.29 1.42 >0.05 Males 1.2 0.81 1.42 >0.05 Concurrent liposuction 1.76 1.61 1.69 >0.05 No concurrent liposuction 1.14 1.19 1.31 >0.05 Cohort Preoperative saddlebag score Short-term postoperative saddlebag score Long-term postoperative saddlebag score P-value All 1.34 1.28 1.42 >0.05 Females 1.37 1.29 1.42 >0.05 Males 1.2 0.81 1.42 >0.05 Concurrent liposuction 1.76 1.61 1.69 >0.05 No concurrent liposuction 1.14 1.19 1.31 >0.05 View Large Table 3. Saddlebag Scores by Cohort Cohort Preoperative saddlebag score Short-term postoperative saddlebag score Long-term postoperative saddlebag score P-value All 1.34 1.28 1.42 >0.05 Females 1.37 1.29 1.42 >0.05 Males 1.2 0.81 1.42 >0.05 Concurrent liposuction 1.76 1.61 1.69 >0.05 No concurrent liposuction 1.14 1.19 1.31 >0.05 Cohort Preoperative saddlebag score Short-term postoperative saddlebag score Long-term postoperative saddlebag score P-value All 1.34 1.28 1.42 >0.05 Females 1.37 1.29 1.42 >0.05 Males 1.2 0.81 1.42 >0.05 Concurrent liposuction 1.76 1.61 1.69 >0.05 No concurrent liposuction 1.14 1.19 1.31 >0.05 View Large Preoperative saddlebag severity score did not demonstrate a strong correlation with current BMI (r2 = 0.17) or ΔBMI (r2 = 0.04). Seventy patients had photographs of preoperative markings that allowed for assessment of short-term scar migration. Ninety-seven per cent of patients were judged to have a lower scar position at short-term follow up. Of the 46 patients with long-term follow-up photographs, none were deemed to have experienced scar migration between the short- and long-term follow-up periods. Of the 79 patients, nine (11.4%) patients experienced postoperative complications. Eight (10.1%) of the complications were wound dehiscence, with 6 occurring in the buttock and 2 occurring in the lateral thigh. The other complication was a buttock seroma. One (1.3%) of the lateral thigh dehiscences occurred in a patient who had undergone a direct saddlebag excision. Subgroup Analyses Males vs Females A subgroup analysis was performed to compare saddlebag scores between genders. Female patients had significantly higher saddlebag scores at all time points vs their male counterparts (P < 0.05). In female patients, the average preoperative and postoperative scores were not significantly different at both short- and long-term follow-up intervals (P > 0.05). The average preoperative saddlebag score was 1.37, and the average scores at short- and long-term follow up were 1.29 and 1.42, respectively (Table 3). In male patients, the average preoperative saddlebag score was 1.20, and the average scores at short- and long-term follow up were 0.81 and 1.42, respectively (Table 3). Given that only 4 male patients presented for long-term follow up, the sample size was insufficient for statistical analysis. Liposuction vs No Liposuction A subgroup analysis was performed comparing patients who underwent concurrent lateral thigh liposuction to those who did not. Patients who underwent concomitant liposuction had significantly higher saddlebag scores at all time points vs those who did not (P < 0.05). The average preoperative saddlebag score in the patients who had liposuction was 1.76, while the average scores at short- and long-term follow up were 1.61 and 1.69, respectively (Table 3). There was no significant difference between preoperative and short- or long-term postoperative saddlebag scores in patients who underwent concurrent liposuction (P > 0.05). The average volume of total lipoaspirate in this cohort was 1.3 liters. In the cohort of patients who did not undergo lateral thigh liposuction, the average preoperative saddlebag score was 1.14, and the averages at short- and long-term follow up were 1.19 and 1.31, respectively (Table 3). There was no statistically significant difference in saddlebag scores between preoperative and either postoperative time point (P > 0.05). Direct Excision of Saddlebag Two patients in our study underwent direct excision of the saddlebag. Both of these patients had preoperative saddlebag scores of 3. One patient experienced a wound dehiscence in the saddlebag region and had a short-term postoperative saddlebag score of 0. The other suffered no complications and had a short-term postoperative saddlebag score of 1. Neither of these patients presented for long-term follow up. DISCUSSION The Pittsburgh Saddlebag Rating Scale serves as an addition to the previously published and validated Pittsburgh Rating Scale,4 a measure of contour deformities following massive weight loss. It includes 4-point grading scales for 10 anatomic regions and generally ranges from a score of 0, indicating a normal appearance, to 3, indicating a severe deformity. Our rating scale supplements the existing 10 anatomic regions with a specific rating for the saddlebag region, specifically the region that falls between the hips/lateral thigh and lower thigh/knee regions in the old classification and is unique in that it does not include the entire hip and lateral thigh.3,4 We feel that this addition will allow for more objective quantification of the saddlebag and, potentially, facilitate future study regarding effective interventions for addressing this deformity. Additionally, we included representative photographs of patients with each saddlebag score to further illustrate the scoring system. Though these patients have varying body types, we observed that patients with higher BMIs often had more severe saddlebag deformities, although this trend was not statistically significant. Furthermore, our study confirmed the strong inter-user reliability of this scoring system at 78%. All subgroups in our study demonstrate a statistically non-significant trend toward a short-term improvement in saddlebag severity, followed by a long-term return to baseline or slight increase. This overall trend can be attributed to initial treatment of skin laxity with direct skin excision, followed by subsequent skin relaxation in the long term. This recurrent skin laxity is a difficult problem in the MWL patient in that it is unpredictable and can be severe. Additionally, the female subgroup has a higher saddlebag severity score at all time points than their male counterparts. This finding is consistent with the gynecoid fat distribution that preferentially deposits adiposity in the hips and thighs.5,6 However, we chose to also include men in the study as obesity can increase circulating estrogen levels and lead to a more gynecoid fat distribution, which may explain the findings of gynecomastia and saddlebags in male MWL patients.7-10 The liposuction subgroup also has a higher saddlebag severity score at all time points, which likely contributed to the decision to perform liposuction in this subgroup. Though the initial hypothesis was that the addition of liposuction would mitigate saddlebag recurrence, we ultimately did not find this to be true. Knowledge of final scar position is important for preoperative planning and markings. We were unable to find a study examining the changes in scar position over time in patients undergoing lower body lift. However, other studies have confirmed scar migration following medial thighplasty11 and cited this as a possible complication in lower body lift without objectively quantifying this phenomenon.12,13 In our study, nearly all patients had a descent of the short-term scar in comparison to the preoperative anchor line marking, while no patients were found to have a change in their scar position between short- and long-term follow up. This finding indicates that scar migration is an early phenomenon and that preoperative markings should not be expected to correspond to ultimate scar position. Despite its strength in reshaping the lateral thigh and buttocks as well as providing high patient satisfaction postoperatively, the lower body lift does not adequately address the saddlebag deformity in the long term. Our 13-year, single-center, two-surgeon study objectively demonstrates that patients do not exhibit an improved saddlebag score following lower body lift. Furthermore, even in patients who underwent concurrent liposuction, long-term saddlebag scores did not differ from preoperative scores. In searching common peer-review databases, only 3 articles could be located that specifically address surgical treatment of the saddlebag in the MWL patient.3,14,15 An article by Hurwitz et al discusses the difficulty in treating the saddlebag region and proposes a technique wherein the thighs are abducted in an attempt to eliminate the excess tissue in this area. Limitations of this study are the inclusion of only 9 patients and a maximum follow up of only 1 year. Furthermore, many of the patients received adjuvant treatments to address the saddlebag deformity following their initial surgery, thus confounding the results.3 Garcia et al present a case report of one patient who lost 50 pounds and was unhappy with the appearance of her saddlebag region.14 The patient was treated using a two-stage approach: liposuction followed by a second stage liposuction and direct excision with purse-string closure. The authors admit that the technique leaves undesired pleated skin and has a high risk of requiring secondary scar revision. No other examples were presented and no follow-up article with a larger cohort is available to critically assess the technique. Yet another modification was proposed in a technique article published in 2007.15 Davison et al describe a modified lower body lift that includes a V-shaped direct excision of the saddlebag region, which they claim eliminates the recurrence of the saddlebag deformity. Analysis of the photographs outlining postoperative outcomes in the article reveals that there is a clear improvement of the saddlebag deformity in all 3 cases presented, however, the deformity is not entirely corrected as there remains redundant tissue of the lateral hip. Furthermore, this procedure results in an additional scar, as well as a T-point incision, leading to an elevated risk of incisional complications. Other studies have focused on noninvasive approaches to the saddlebag. One study attempted to use an injection with a “fat burner”—a chemical mixture of phosphatidylcholine, deoxycholate, and ethanol—for treatment of one trochanteric region with the contralateral side acting as a control.16 Results were disappointing and showed no significant reduction in fat content at 3 months using an objective measuring tool. Other authors suggest various nonsurgical methods of treating adiposity of the lateral thigh, such as cryolipolysis.17,18 This may be of benefit in other cohorts, but has not been studied in the MWL population, which not only has excess adiposity, but also excess skin that cannot be treated by nonsurgical means alone. Therefore, techniques to treat the saddlebag region in the MWL patient must include some form of excision, whether via suction-assisted lipectomy or direct dermatolipectomy. In our series, we employed the leg abduction closure and Lockwood dissection selective undermining techniques.3,19 The leg abduction closure technique increases the amount of soft tissue that can be removed prior to closure, while Lockwood undermining is intended to allow for increased upward pull on the lateral thigh by discontinuously undermining distal to the incision. However, the Lockwood technique can predispose to bleeding in the dissection tunnels and to prolonged postoperative edema. In spite of implementing these modifications, we still found that the saddlebag deformity still recurred at long-term follow up. Another proposed technique for mitigating the saddlebag deformity is the use of anchoring or quilting sutures. The impact of these interventions remains unknown. The cause of saddlebag recurrence has not been clearly elucidated. This phenomenon may be a result of underlying musculoskeletal anatomy, such as trochanteric angulation. Because the lower body lift only addresses the soft tissue, it cannot effectively correct bony or muscular deformities. Other theories to explain saddlebag recurrence include descent of soft tissues, as evidenced by our observation of downward scar migration, inefficient pull on tissues more distal in the lateral thigh, or the presence of the lateral thigh zone of adherence just inferior to the saddlebag. Further study of the saddlebag deformity will examine future interventions to target the underlying cause of recurrence. While surgeon assessment of saddlebag severity is important, it has not been studied whether the saddlebag deformity impacts patient satisfaction. Multiple studies have demonstrated that patient satisfaction is high after body contouring procedures.20-24 Using a validated patient-reported outcomes questionnaire, Vierhapper et al demonstrated that post-MWL patients who undergo lower body lift have an overall improved quality of life.24 Specifically, patients report higher levels of satisfaction, attractiveness, and self-esteem. These findings persisted at an average of 5 years postoperatively. They conclude that lower body lift is an essential component in the treatment of the MWL patient. However, this study did not specifically address the saddlebag deformity. One possible explanation may be that patients do not see the protuberance clearly on anterior or oblique views, as the saddlebag is best visualized from a posterior angle. Limitations of our study include small population size—however, our center sees one of the largest populations of massive weight loss patients, making this the largest study examining the saddlebag deformity in massive weight loss patients thus far presented in the literature. Additionally, due to our clinic’s conversion from paper charts to an electronic medical record, we did encounter patients who were missing data regarding body mass indices or the use of liposuction. Further, only 46 of the 89 patients in the study presented for long-term follow up. However, we repeated our statistical analysis excluding the patients without long-term follow up, and our results were unchanged. Finally, while patients undergoing belt lipectomies were excluded, they routinely had saddlebag scores of 0 to 1, and, given that the emphasis of belt lipectomy is on the flanks, it has no impact on the saddlebag scores. Future studies will investigate the number of patients undergoing subsequent revision procedures to address the saddlebag via direction excision, liposuction, or other modalities, as well as the effectiveness of these interventions. We also plan to evaluate the impact of gluteal autoaugmentation on the saddlebag deformity. Additionally, it will be interesting to evaluate whether postoperative changes in body mass index correlated with saddlebag recurrence. CONCLUSIONS The post-MWL saddlebag deformity remains a persistent and difficult-to-treat problem following body contouring surgery. To better characterize and study this deformity, we propose the Pittsburgh Saddlebag Rating Scale, which serves as a useful adjunct to the previously validated Pittsburgh Rating Scale. Use of this scale demonstrates that, despite current optimal therapy, the post-MWL saddlebag deformity persists at long-term follow up. Thus, future efforts must be directed to determine the optimal therapy for the treatment of the saddlebag deformity in the MWL population. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Carloni R , De Runz A , Chaput B , et al. Circumferential contouring of the lower trunk: indications, operative techniques, and outcomes-a systematic review . Aesthetic Plast Surg . 2016 ; 40 ( 5 ): 652 - 668 . Google Scholar CrossRef Search ADS PubMed 2. Cosmetic surgery national data bank statistics . Aesthet Surg J . 2017 ; 37 ( suppl_2 ): 1 - 29 . 3. Hurwitz DJ , Rubin JP , Risin M , Sajjadian A , Sereika S . Correcting the saddlebag deformity in the massive weight loss patient . Plast Reconstr Surg . 2004 ; 114 ( 5 ): 1313 - 1325 . Google Scholar CrossRef Search ADS PubMed 4. 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Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Characterizing the Saddlebag Deformity After Lower Body Lift

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© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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Abstract

Abstract Background One of the commonly cited sequelae of lower body lift is recurrence of the saddlebag deformity. However, there are currently no data that characterize the evolution of the saddlebag following lower body lift, nor is there a classification scheme to objectively quantify the severity of the deformity. Objectives The authors aimed to develop a grading scale to score the severity of the saddlebag deformity and, using this, determine the short- and long-term changes in the saddlebag following lower body lift. Methods Using the Pittsburgh Rating Scale, the Pittsburgh Saddlebag Rating Scale, a 4-point Likert scale, was developed to score the saddlebag deformity. Patients who underwent lower body lifts were parsed from a prospectively maintained database. Two educated observers independently reviewed both preoperative and postoperative photographs and graded the saddlebag deformity according to the Pittsburgh Saddlebag Rating Scale. Results Seventy-nine patients met inclusion criteria, including 5 males and 74 females. The average saddlebag score preoperatively was 1.34, while the average scores at short- and long-term follow up were 1.28 and 1.42, respectively. No significant differences in saddlebag severity scores were noted between preoperative and short- or long-term postoperative time points (P > 0.05). Conclusions This is the first study to objectively demonstrate the postoperative changes in the saddlebag following lower body lift. Results demonstrated that lower body lift does not effectively treat the saddlebag as the deformity only slightly improved in the short-term window but recurred within a year of surgery. Level of Evidence: 4 With the rise in popularity of various surgical and nonsurgical weight loss techniques to treat obesity, plastic surgeons have seen a concomitant increase in the number of patients presenting with redundant skin laxity after massive weight loss (MWL). Regardless of the method of weight loss, the skin redundancy following MWL becomes both a functional and aesthetic problem for the patient, correctable only by means of direct surgical excision. In this population, the lower trunk can be addressed with a lower body lift to simultaneously treat excess skin laxity of the abdomen, flank, lateral thigh, and gluteal regions in one operation.1 According to American Society for Aesthetic Plastic Surgery statistics, there were nearly 10,000 lower body lifts performed in 2016.2 The senior authors have a combined greater than 30-year experience in the treatment of the MWL population and employ the lower body lift to address the buttock and lateral thigh, while using the belt lipectomy, performed through a higher incision, to address the waist and flank. In their observations and from discussions with other experts in the field, a common sequela of the lower body lift is recurrence of the saddlebag deformity. A saddlebag—originally defined as the pair of bags hung from the saddle over the back of a horse—is often used informally as an anatomic reference to the protuberant region of the lateral thigh at the level of the inferior gluteal fold. Given that there is no true anatomic definition of this area, we will refer to it using this informal but widely understood term. Because the saddlebag deformity has not been well addressed in the literature, it is not surprising there is no current scoring system exists to specifically quantify it. Therefore, the purpose of this study is twofold. First, to introduce a novel saddlebag grading scale: the Pittsburgh Saddlebag Rating Scale. Second, to examine the evolution of the saddlebag deformity after lower body lift in the MWL population. The study hypothesis is that the saddlebag deformity improves in the short term after a lower body lift but recurs with longer follow-up periods. METHODS Patients were parsed using a prospectively maintained patient database in the Life After Weight Loss program at the University of Pittsburgh. The database consists of patients under the care of the two senior authors (J.A.G. and J.P.R.) who underwent body contouring operations following MWL, defined as weight loss greater than 50 pounds. The database was established in 2003. Patients who underwent surgery as late as 2016 were included in the study to ensure at least 1-year follow up. Variables collected included age; sex; body mass indices [maximum body mass index, current body mass index, and delta body mass index (maximum body mass index−current body mass index)]; comorbidities including tobacco use and diabetes; follow-up times; concurrent liposuction of saddlebag region with volume, if performed; and postoperative complications. Our study was approved by the Institutional Review Board of the University of Pittsburgh (PRO15080542), and the authors have no conflicts of interest to disclose. Patients were included if they had undergone a lower body lift by two senior surgeons at the University of Pittsburgh Medical Center between January 2003 and December 2016. Patients were excluded for the following reasons: having insufficient preoperative and postoperative photos, undergoing a belt lipectomy rather than lower body lift, or undergoing revision surgery of the saddlebag region prior to their postoperative photos. Surgical Technique Our approach to lower body lift has been described previously.3 In brief, patients are first marked standing in the preoperative area. The upper mark is designed by carrying the central point laterally to a point near the posterior superior iliac spine, while the lower mark is determined by means of a pinch test. Patients are initially placed in the prone position for excision of skin and subcutaneous tissue from the superior buttock, hip, and lateral thigh on each side. Lockwood dissection is performed to enhance lateral thigh release via discontinuous undermining. Closure is performed with the legs abducted to allow for minimal tension in the lateral thigh.3 Patients are then turned to the supine position and excision is extended to include the abdomen. Rating Scale A literature search was performed to select a grading scale with which to score the saddlebag severity, however, no rating scheme has been described. Therefore, the authors developed the Pittsburgh Saddlebag Rating Scale, an addition to the previously described Pittsburgh Rating Scale.4 The Pittsburgh Saddlebag Rating Scale is a 4-point Likert scale grading system used to score the saddlebag deformity (Table 1): grade 0, no protuberance (Figure 1); grade 1, slight protuberance (Figure 2); grade 2, prominent protuberance (Figure 3); grade 3, severe protuberance with a fold or pannus (Figure 4). Table 1. Pittsburgh Saddlebag Rating Scale, an Addition to the Previously Validated Pittsburgh Rating Scale Used to Grade Specific Anatomical Deformities in the Massive Weight Loss Population Pittsburgh saddlebag grade Description Grade 0 No protuberance Grade 1 Slight protuberance Grade 2 Prominent protuberance Grade 3 Severe protuberance with fold or double bubble Pittsburgh saddlebag grade Description Grade 0 No protuberance Grade 1 Slight protuberance Grade 2 Prominent protuberance Grade 3 Severe protuberance with fold or double bubble View Large Table 1. Pittsburgh Saddlebag Rating Scale, an Addition to the Previously Validated Pittsburgh Rating Scale Used to Grade Specific Anatomical Deformities in the Massive Weight Loss Population Pittsburgh saddlebag grade Description Grade 0 No protuberance Grade 1 Slight protuberance Grade 2 Prominent protuberance Grade 3 Severe protuberance with fold or double bubble Pittsburgh saddlebag grade Description Grade 0 No protuberance Grade 1 Slight protuberance Grade 2 Prominent protuberance Grade 3 Severe protuberance with fold or double bubble View Large Figure 1. View largeDownload slide Example of a grade 0 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 56-year-old woman. Figure 1. View largeDownload slide Example of a grade 0 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 56-year-old woman. Figure 2. View largeDownload slide Example of a grade 1 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 52-year-old woman. Figure 2. View largeDownload slide Example of a grade 1 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 52-year-old woman. Figure 3. View largeDownload slide Example of a grade 2 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 38-year-old woman. Figure 3. View largeDownload slide Example of a grade 2 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 38-year-old woman. Figure 4. View largeDownload slide Example of a grade 3 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 47-year-old woman. Figure 4. View largeDownload slide Example of a grade 3 saddlebag on the Pittsburgh Saddlebag Rating Scale in a 47-year-old woman. Data Collection and Statistical Analysis Two observers—a senior plastic surgery resident and body contouring fellow—independently reviewed preoperative and postoperative photographs of each patient in the posterior view. Patients were graded at 3 time-points: preoperative, short-term postoperative, and long-term postoperative. The short-term period was defined as a time period between 4 and 11 months, and the long-term period was defined as 12 months or more after surgery. Additionally, scar migration was assessed in the short term by comparing the superior marking, or theoretical anchor line, with the short-term scar position and in the long term by comparing scar location at short-term follow up vs long-term follow up. Location was assessed based on relationships with anatomic landmarks including the umbilicus, anterior superior iliac spine, natural waist, and gluteal cleft. Scores were compared using a two-sample t test and interobserver reliability was calculated using the kappa statistic. RESULTS Demographics The database yielded 170 patients within the study period. Of these, 79 patients, or 158 saddlebags, met inclusion criteria. This cohort consisted of 5 males and 74 females. The average age at surgery was 45.4 ± 13.8 years (range, 27-78 years), with an average BMI of 28.0 ± 4.3 kg/m2 (range, 20.8-43.0 kg/m2). The average delta BMI (ΔBMI) was 21.9 ± 7.7 kg/m2. Seventy-two patients had available photographs at short-term follow up, with an average visit time of 6 months (range, 4-10 months) postoperatively; 46 patients had available photographs at long-term follow up, with an average visit at 15 months (range, 12-48 months) postoperatively. Representative photos of two patients are shown preoperatively and at short- and long-term follow-up time points. The patient shown in Figure 5 followed up at 4 months and 1 year postoperatively with saddlebag scores of 1, 1, and 2 on the left and 1, 1, and 2 on the right. The patient pictured in Figure 6 followed up at 4 months and 4 years with saddlebag scores of 2, 2, and 2 on the left and 2, 1, and 2 on the right. Figure 5. View largeDownload slide Representative photograph of a 52-year-old woman with a BMI of 26.1 at preoperative (A), short-term (4 months) postoperative (B), and long-term (12 months) postoperative (C) visits. Figure 5. View largeDownload slide Representative photograph of a 52-year-old woman with a BMI of 26.1 at preoperative (A), short-term (4 months) postoperative (B), and long-term (12 months) postoperative (C) visits. Figure 6. View largeDownload slide Representative photograph of a 47-year-old woman with a BMI of 30.9 at preoperative (A), short-term (4 months) postoperative (B), and long-term (48 months) postoperative (C) visits. Figure 6. View largeDownload slide Representative photograph of a 47-year-old woman with a BMI of 30.9 at preoperative (A), short-term (4 months) postoperative (B), and long-term (48 months) postoperative (C) visits. All Patients A full breakdown of all patients by score is presented in Table 2. The most common saddlebag score preoperatively was 1 (45.6%), while the most common in the short- and long-term postoperative periods were 2 at 41.7% and 45.7%, respectively. The average saddlebag score preoperatively was 1.34, while the average scores at short- and long-term follow up were 1.28 and 1.42, respectively (Table 3). No significant differences in saddlebag severity scores were noted between preoperative and short- or long-term postoperative time points, or between short-term and long-term scores (P > 0.05). Interobserver reliability was 78% for all measurements. Table 2. Breakdown of Saddlebag Scores at Each Time Point Saddlebag score Preoperative (n = 79) Short-term postoperative (n = 72) Long-term postoperative (n = 46) 0 10.1% 9.7% 13.0% 1 45.6% 40.3% 32.6% 2 30.4% 41.7% 45.7% 3 12.7% 6.9% 6.5% Saddlebag score Preoperative (n = 79) Short-term postoperative (n = 72) Long-term postoperative (n = 46) 0 10.1% 9.7% 13.0% 1 45.6% 40.3% 32.6% 2 30.4% 41.7% 45.7% 3 12.7% 6.9% 6.5% View Large Table 2. Breakdown of Saddlebag Scores at Each Time Point Saddlebag score Preoperative (n = 79) Short-term postoperative (n = 72) Long-term postoperative (n = 46) 0 10.1% 9.7% 13.0% 1 45.6% 40.3% 32.6% 2 30.4% 41.7% 45.7% 3 12.7% 6.9% 6.5% Saddlebag score Preoperative (n = 79) Short-term postoperative (n = 72) Long-term postoperative (n = 46) 0 10.1% 9.7% 13.0% 1 45.6% 40.3% 32.6% 2 30.4% 41.7% 45.7% 3 12.7% 6.9% 6.5% View Large Table 3. Saddlebag Scores by Cohort Cohort Preoperative saddlebag score Short-term postoperative saddlebag score Long-term postoperative saddlebag score P-value All 1.34 1.28 1.42 >0.05 Females 1.37 1.29 1.42 >0.05 Males 1.2 0.81 1.42 >0.05 Concurrent liposuction 1.76 1.61 1.69 >0.05 No concurrent liposuction 1.14 1.19 1.31 >0.05 Cohort Preoperative saddlebag score Short-term postoperative saddlebag score Long-term postoperative saddlebag score P-value All 1.34 1.28 1.42 >0.05 Females 1.37 1.29 1.42 >0.05 Males 1.2 0.81 1.42 >0.05 Concurrent liposuction 1.76 1.61 1.69 >0.05 No concurrent liposuction 1.14 1.19 1.31 >0.05 View Large Table 3. Saddlebag Scores by Cohort Cohort Preoperative saddlebag score Short-term postoperative saddlebag score Long-term postoperative saddlebag score P-value All 1.34 1.28 1.42 >0.05 Females 1.37 1.29 1.42 >0.05 Males 1.2 0.81 1.42 >0.05 Concurrent liposuction 1.76 1.61 1.69 >0.05 No concurrent liposuction 1.14 1.19 1.31 >0.05 Cohort Preoperative saddlebag score Short-term postoperative saddlebag score Long-term postoperative saddlebag score P-value All 1.34 1.28 1.42 >0.05 Females 1.37 1.29 1.42 >0.05 Males 1.2 0.81 1.42 >0.05 Concurrent liposuction 1.76 1.61 1.69 >0.05 No concurrent liposuction 1.14 1.19 1.31 >0.05 View Large Preoperative saddlebag severity score did not demonstrate a strong correlation with current BMI (r2 = 0.17) or ΔBMI (r2 = 0.04). Seventy patients had photographs of preoperative markings that allowed for assessment of short-term scar migration. Ninety-seven per cent of patients were judged to have a lower scar position at short-term follow up. Of the 46 patients with long-term follow-up photographs, none were deemed to have experienced scar migration between the short- and long-term follow-up periods. Of the 79 patients, nine (11.4%) patients experienced postoperative complications. Eight (10.1%) of the complications were wound dehiscence, with 6 occurring in the buttock and 2 occurring in the lateral thigh. The other complication was a buttock seroma. One (1.3%) of the lateral thigh dehiscences occurred in a patient who had undergone a direct saddlebag excision. Subgroup Analyses Males vs Females A subgroup analysis was performed to compare saddlebag scores between genders. Female patients had significantly higher saddlebag scores at all time points vs their male counterparts (P < 0.05). In female patients, the average preoperative and postoperative scores were not significantly different at both short- and long-term follow-up intervals (P > 0.05). The average preoperative saddlebag score was 1.37, and the average scores at short- and long-term follow up were 1.29 and 1.42, respectively (Table 3). In male patients, the average preoperative saddlebag score was 1.20, and the average scores at short- and long-term follow up were 0.81 and 1.42, respectively (Table 3). Given that only 4 male patients presented for long-term follow up, the sample size was insufficient for statistical analysis. Liposuction vs No Liposuction A subgroup analysis was performed comparing patients who underwent concurrent lateral thigh liposuction to those who did not. Patients who underwent concomitant liposuction had significantly higher saddlebag scores at all time points vs those who did not (P < 0.05). The average preoperative saddlebag score in the patients who had liposuction was 1.76, while the average scores at short- and long-term follow up were 1.61 and 1.69, respectively (Table 3). There was no significant difference between preoperative and short- or long-term postoperative saddlebag scores in patients who underwent concurrent liposuction (P > 0.05). The average volume of total lipoaspirate in this cohort was 1.3 liters. In the cohort of patients who did not undergo lateral thigh liposuction, the average preoperative saddlebag score was 1.14, and the averages at short- and long-term follow up were 1.19 and 1.31, respectively (Table 3). There was no statistically significant difference in saddlebag scores between preoperative and either postoperative time point (P > 0.05). Direct Excision of Saddlebag Two patients in our study underwent direct excision of the saddlebag. Both of these patients had preoperative saddlebag scores of 3. One patient experienced a wound dehiscence in the saddlebag region and had a short-term postoperative saddlebag score of 0. The other suffered no complications and had a short-term postoperative saddlebag score of 1. Neither of these patients presented for long-term follow up. DISCUSSION The Pittsburgh Saddlebag Rating Scale serves as an addition to the previously published and validated Pittsburgh Rating Scale,4 a measure of contour deformities following massive weight loss. It includes 4-point grading scales for 10 anatomic regions and generally ranges from a score of 0, indicating a normal appearance, to 3, indicating a severe deformity. Our rating scale supplements the existing 10 anatomic regions with a specific rating for the saddlebag region, specifically the region that falls between the hips/lateral thigh and lower thigh/knee regions in the old classification and is unique in that it does not include the entire hip and lateral thigh.3,4 We feel that this addition will allow for more objective quantification of the saddlebag and, potentially, facilitate future study regarding effective interventions for addressing this deformity. Additionally, we included representative photographs of patients with each saddlebag score to further illustrate the scoring system. Though these patients have varying body types, we observed that patients with higher BMIs often had more severe saddlebag deformities, although this trend was not statistically significant. Furthermore, our study confirmed the strong inter-user reliability of this scoring system at 78%. All subgroups in our study demonstrate a statistically non-significant trend toward a short-term improvement in saddlebag severity, followed by a long-term return to baseline or slight increase. This overall trend can be attributed to initial treatment of skin laxity with direct skin excision, followed by subsequent skin relaxation in the long term. This recurrent skin laxity is a difficult problem in the MWL patient in that it is unpredictable and can be severe. Additionally, the female subgroup has a higher saddlebag severity score at all time points than their male counterparts. This finding is consistent with the gynecoid fat distribution that preferentially deposits adiposity in the hips and thighs.5,6 However, we chose to also include men in the study as obesity can increase circulating estrogen levels and lead to a more gynecoid fat distribution, which may explain the findings of gynecomastia and saddlebags in male MWL patients.7-10 The liposuction subgroup also has a higher saddlebag severity score at all time points, which likely contributed to the decision to perform liposuction in this subgroup. Though the initial hypothesis was that the addition of liposuction would mitigate saddlebag recurrence, we ultimately did not find this to be true. Knowledge of final scar position is important for preoperative planning and markings. We were unable to find a study examining the changes in scar position over time in patients undergoing lower body lift. However, other studies have confirmed scar migration following medial thighplasty11 and cited this as a possible complication in lower body lift without objectively quantifying this phenomenon.12,13 In our study, nearly all patients had a descent of the short-term scar in comparison to the preoperative anchor line marking, while no patients were found to have a change in their scar position between short- and long-term follow up. This finding indicates that scar migration is an early phenomenon and that preoperative markings should not be expected to correspond to ultimate scar position. Despite its strength in reshaping the lateral thigh and buttocks as well as providing high patient satisfaction postoperatively, the lower body lift does not adequately address the saddlebag deformity in the long term. Our 13-year, single-center, two-surgeon study objectively demonstrates that patients do not exhibit an improved saddlebag score following lower body lift. Furthermore, even in patients who underwent concurrent liposuction, long-term saddlebag scores did not differ from preoperative scores. In searching common peer-review databases, only 3 articles could be located that specifically address surgical treatment of the saddlebag in the MWL patient.3,14,15 An article by Hurwitz et al discusses the difficulty in treating the saddlebag region and proposes a technique wherein the thighs are abducted in an attempt to eliminate the excess tissue in this area. Limitations of this study are the inclusion of only 9 patients and a maximum follow up of only 1 year. Furthermore, many of the patients received adjuvant treatments to address the saddlebag deformity following their initial surgery, thus confounding the results.3 Garcia et al present a case report of one patient who lost 50 pounds and was unhappy with the appearance of her saddlebag region.14 The patient was treated using a two-stage approach: liposuction followed by a second stage liposuction and direct excision with purse-string closure. The authors admit that the technique leaves undesired pleated skin and has a high risk of requiring secondary scar revision. No other examples were presented and no follow-up article with a larger cohort is available to critically assess the technique. Yet another modification was proposed in a technique article published in 2007.15 Davison et al describe a modified lower body lift that includes a V-shaped direct excision of the saddlebag region, which they claim eliminates the recurrence of the saddlebag deformity. Analysis of the photographs outlining postoperative outcomes in the article reveals that there is a clear improvement of the saddlebag deformity in all 3 cases presented, however, the deformity is not entirely corrected as there remains redundant tissue of the lateral hip. Furthermore, this procedure results in an additional scar, as well as a T-point incision, leading to an elevated risk of incisional complications. Other studies have focused on noninvasive approaches to the saddlebag. One study attempted to use an injection with a “fat burner”—a chemical mixture of phosphatidylcholine, deoxycholate, and ethanol—for treatment of one trochanteric region with the contralateral side acting as a control.16 Results were disappointing and showed no significant reduction in fat content at 3 months using an objective measuring tool. Other authors suggest various nonsurgical methods of treating adiposity of the lateral thigh, such as cryolipolysis.17,18 This may be of benefit in other cohorts, but has not been studied in the MWL population, which not only has excess adiposity, but also excess skin that cannot be treated by nonsurgical means alone. Therefore, techniques to treat the saddlebag region in the MWL patient must include some form of excision, whether via suction-assisted lipectomy or direct dermatolipectomy. In our series, we employed the leg abduction closure and Lockwood dissection selective undermining techniques.3,19 The leg abduction closure technique increases the amount of soft tissue that can be removed prior to closure, while Lockwood undermining is intended to allow for increased upward pull on the lateral thigh by discontinuously undermining distal to the incision. However, the Lockwood technique can predispose to bleeding in the dissection tunnels and to prolonged postoperative edema. In spite of implementing these modifications, we still found that the saddlebag deformity still recurred at long-term follow up. Another proposed technique for mitigating the saddlebag deformity is the use of anchoring or quilting sutures. The impact of these interventions remains unknown. The cause of saddlebag recurrence has not been clearly elucidated. This phenomenon may be a result of underlying musculoskeletal anatomy, such as trochanteric angulation. Because the lower body lift only addresses the soft tissue, it cannot effectively correct bony or muscular deformities. Other theories to explain saddlebag recurrence include descent of soft tissues, as evidenced by our observation of downward scar migration, inefficient pull on tissues more distal in the lateral thigh, or the presence of the lateral thigh zone of adherence just inferior to the saddlebag. Further study of the saddlebag deformity will examine future interventions to target the underlying cause of recurrence. While surgeon assessment of saddlebag severity is important, it has not been studied whether the saddlebag deformity impacts patient satisfaction. Multiple studies have demonstrated that patient satisfaction is high after body contouring procedures.20-24 Using a validated patient-reported outcomes questionnaire, Vierhapper et al demonstrated that post-MWL patients who undergo lower body lift have an overall improved quality of life.24 Specifically, patients report higher levels of satisfaction, attractiveness, and self-esteem. These findings persisted at an average of 5 years postoperatively. They conclude that lower body lift is an essential component in the treatment of the MWL patient. However, this study did not specifically address the saddlebag deformity. One possible explanation may be that patients do not see the protuberance clearly on anterior or oblique views, as the saddlebag is best visualized from a posterior angle. Limitations of our study include small population size—however, our center sees one of the largest populations of massive weight loss patients, making this the largest study examining the saddlebag deformity in massive weight loss patients thus far presented in the literature. Additionally, due to our clinic’s conversion from paper charts to an electronic medical record, we did encounter patients who were missing data regarding body mass indices or the use of liposuction. Further, only 46 of the 89 patients in the study presented for long-term follow up. However, we repeated our statistical analysis excluding the patients without long-term follow up, and our results were unchanged. Finally, while patients undergoing belt lipectomies were excluded, they routinely had saddlebag scores of 0 to 1, and, given that the emphasis of belt lipectomy is on the flanks, it has no impact on the saddlebag scores. Future studies will investigate the number of patients undergoing subsequent revision procedures to address the saddlebag via direction excision, liposuction, or other modalities, as well as the effectiveness of these interventions. We also plan to evaluate the impact of gluteal autoaugmentation on the saddlebag deformity. Additionally, it will be interesting to evaluate whether postoperative changes in body mass index correlated with saddlebag recurrence. CONCLUSIONS The post-MWL saddlebag deformity remains a persistent and difficult-to-treat problem following body contouring surgery. To better characterize and study this deformity, we propose the Pittsburgh Saddlebag Rating Scale, which serves as a useful adjunct to the previously validated Pittsburgh Rating Scale. Use of this scale demonstrates that, despite current optimal therapy, the post-MWL saddlebag deformity persists at long-term follow up. Thus, future efforts must be directed to determine the optimal therapy for the treatment of the saddlebag deformity in the MWL population. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Carloni R , De Runz A , Chaput B , et al. Circumferential contouring of the lower trunk: indications, operative techniques, and outcomes-a systematic review . Aesthetic Plast Surg . 2016 ; 40 ( 5 ): 652 - 668 . Google Scholar CrossRef Search ADS PubMed 2. Cosmetic surgery national data bank statistics . Aesthet Surg J . 2017 ; 37 ( suppl_2 ): 1 - 29 . 3. Hurwitz DJ , Rubin JP , Risin M , Sajjadian A , Sereika S . Correcting the saddlebag deformity in the massive weight loss patient . Plast Reconstr Surg . 2004 ; 114 ( 5 ): 1313 - 1325 . Google Scholar CrossRef Search ADS PubMed 4. Song AY , Jean RD , Hurwitz DJ , Fernstrom MH , Scott JA , Rubin JP . A classification of contour deformities after bariatric weight loss: the pittsburgh rating scale . Plast Reconstr Surg . 2005 ; 116 ( 5 ): 1535 - 1544 ; discussion 1545. Google Scholar CrossRef Search ADS PubMed 5. Janjic D . Android-type obesity and gynecoid-type obesity . Praxis (Bern 1994) . 1996 ; 85 ( 49 ): 1578 - 1583 . Google Scholar PubMed 6. Yáñez M , Albala C . Body fat distribution: anthropometric indicators . Rev Med Chil . 1995 ; 123 ( 12 ): 1520 - 1524 . Google Scholar PubMed 7. Kley HK , Deselaers T , Peerenboom H , Krüskemper HL . Enhanced conversion of androstenedione to estrogens in obese males . J Clin Endocrinol Metab . 1980 ; 51 ( 5 ): 1128 - 1132 . Google Scholar CrossRef Search ADS PubMed 8. Derby CA , Zilber S , Brambilla D , Morales KH , McKinlay JB . Body mass index, waist circumference and waist to hip ratio and change in sex steroid hormones: the Massachusetts Male Ageing Study . Clin Endocrinol (Oxf) . 2006 ; 65 ( 1 ): 125 - 131 . Google Scholar CrossRef Search ADS PubMed 9. Braunstein GD . Aromatase and gynecomastia . Endocr Relat Cancer . 1999 ; 6 ( 2 ): 315 - 324 . Google Scholar CrossRef Search ADS PubMed 10. Krotkiewski M , Björntorp P , Sjöström L , Smith U . Impact of obesity on metabolism in men and women. Importance of regional adipose tissue distribution . J Clin Invest . 1983 ; 72 ( 3 ): 1150 - 1162 . Google Scholar CrossRef Search ADS PubMed 11. Bertheuil N , Thienot S , Huguier V , Ménard C , Watier E . Medial thighplasty after massive weight loss: are there any risk factors for postoperative complications ? Aesthetic Plast Surg . 2014 ; 38 ( 1 ): 63 - 68 . Google Scholar CrossRef Search ADS PubMed 12. Cormenzana P , Samprón NM . Circumferential approach to contouring of the trunk . Aesthet Surg J . 2004 ; 24 ( 1 ): 13 - 23 . Google Scholar CrossRef Search ADS PubMed 13. Heitmann C , Germann G . [Body contouring surgery after massive weight loss. Part I: abdomen and extremities] . Chirurg . 2007 ; 78 ( 3 ): 273 - 284 ; quiz 285. Google Scholar CrossRef Search ADS PubMed 14. Garcia JA , Driscoll DN , Donelan MB . Pursestring thigh lift: direct approach for a problematic deformity . Ann Plast Surg . 2006 ; 57 ( 3 ): 330 - 332 . Google Scholar CrossRef Search ADS PubMed 15. Davison SP , Clemens MW , Chang S . Modified circumferential torsoplasty for the massive-weight-loss patient . Ann Plast Surg . 2007 ; 59 ( 4 ): 453 - 458 . Google Scholar CrossRef Search ADS PubMed 16. Kopera D , Horejsi R , Werner S , Moeller R . Injection lipolysis for reduction of saddlebag trochanteric bulges–half-side controlled pilot study . J Dtsch Dermatol Ges . 2008 ; 6 ( 4 ): 287 - 290 . Google Scholar CrossRef Search ADS PubMed 17. Stevens WG , Bachelor EP . Cryolipolysis conformable-surface applicator for nonsurgical fat reduction in lateral thighs . Aesthet Surg J . 2015 ; 35 ( 1 ): 66 - 71 . Google Scholar CrossRef Search ADS PubMed 18. 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Google Scholar CrossRef Search ADS PubMed 22. van der Beek ES , Geenen R , de Heer FA , van der Molen AB , van Ramshorst B . Quality of life long-term after body contouring surgery following bariatric surgery: sustained improvement after 7 years . Plast Reconstr Surg . 2012 ; 130 ( 5 ): 1133 - 1139 . Google Scholar CrossRef Search ADS PubMed 23. Coriddi MR , Koltz PF , Chen R , Gusenoff JA . Changes in quality of life and functional status following abdominal contouring in the massive weight loss population . Plast Reconstr Surg . 2011 ; 128 ( 2 ): 520 - 526 . Google Scholar CrossRef Search ADS PubMed 24. Vierhapper MF , Pittermann A , Hacker S , Kitzinger HB . Patient satisfaction, body image, and quality of life after lower body lift: a prospective pre- and postoperative long-term survey . Surg Obes Relat Dis . 2017 ; 13 ( 5 ): 882 - 887 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Aesthetic Surgery JournalOxford University Press

Published: May 8, 2018

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