Quiz Cases PhD Publications Case competition Dictionary About
Massive Weight Loss Surgery


Authors: Anne Herman Mosebo, MD, Julie Tastesen, MD, Magnus Balslev Avnstorp, MD

Patient history

Note the following information regarding the weight history of the patient: 

  • Cause of weight loss: bariatric surgery or lifestyle changes
  • Maximum weight and BMI (at any point in life), current weight and BMI, and the decrease in BMI points
  • Any mechanical issues during sports or other physical activities

Furthermore, a thorough preoperative assessment including prior medical history is fundamental. For further information, see “Preoperative assessment”.

Physical examination

Inspection of the skin:

  • Quality of the skin
  • Rash
  • Intertrigo
  • Fungus infection
  • Striae

Markings on the back

The initial markings are made with the patient in standing position. 

Draw three vertical lines:

  1. Draw a line following the columna ending a few fingerbreadths above crena ani (line A) 
  2. Draw a line midaxillary ending at the greater trochanter (bilaterally) (line B) 
  3. Draw a line following the lateral limit of the nates (bilaterally) (line C)

Palpate the iliac crest located in line B and mark the point three fingerbreadths below (point A). Perform inverse pinch test to determine the amount of excess skin to remove and mark this point (point B). Do this bilaterally. 

The following markings are made with the patient laying down: 

Mark the point a few fingerbreadths above crena ani (point C). Connect this point with point B in the midaxillary line. 

Perform inverse pinch test starting from point C to determine the amount of excess skin to remove and mark this point (point D). Connect line B and C with a horizontal line starting from point A. Continue this line to connect point D. 

Make sure the markings are symmetrical. To prevent over resection, let the patient bent forward. 

Figure 1 | Markings on the back when performing a belt lipectomy

Markings on the abdomen

Fleur-de-lis abdominoplasty is performed on the abdomen. 

Lower incision

With the patient standing:

  • Mark the point 7 cm above the commissure of the labia majora (point A) while performing tension to the skin by retracting excess skin superiorly 
  • Draw a horizontal line of approximately 4 cm on each side of point A (line A) 
  • Palpate and mark ASIS bilaterally (anterior superior iliac crest) (point B)
  • Connect line A to point B (line B). It is important to lift the excess skin while drawing line B. Otherwise there is a risk that the line will become flattened due to excess skin

With the patient laying down:

  • Mark the anterior midline through the xiphoid process and draw a vertical line ending in line A (line C)
  • Use inverse pinch test to estimate the correct amount of excess skin to remove on each side of line C
  • Place markings bilaterally along the abdomen starting from the xiphoid process continuing in the caudal direction ending approximately 6 cm below the umbilicus (point C)
  • Connect these markings vertically on each side of the abdomen creating line D. Line D will curve inwards below the umbilicus
  • Check for symmetry both with the patient standing and in supine position

Upper incision

  • This incision is evaluated during the procedure after Scarpa’s fascia has been sutured vertically (go to ‘’procedure’’ to read more about the procedure)


  • The marking of the umbilicus should be oval-shaped and approximately 1 cm of length on each side of the midline (line C). Due to traction of the skin during surgery it is important not to make this marking too large
Figure 2 | Markings on the abdomen when performing fleur-de-lis abdominoplasty

Preoperative information

Postoperative scarringLocations 
Risk of widening and hypertrophic transformation  
Postoperative risksInfection
Rupture of the incision site
Healing complications
Loss of sensation in the affected area
Reoperation in case of complications
Necrosis of the umbilicus 
Risk of seroma
DrainsDrains will be applied during surgery and removal will happen postoperatively
Pressure garments Pressure garments will be used postoperatively
Excessive skinInform about the risk of excessive skin returning in cases of fluctuating weight or due to natural aging of the skin 

Preoperative preparation

  • Broad blood samples
  • ECG: If patient age > 60 years or with known heart disease/symptoms of heart disease
  • Anesthesiologic consultation
  • Stabilize co-morbidities, e.g., diabetes
  • If the patient is taking blood thinners, this needs to be paused, bridged or INR monitored. Regulations from The Danish Society of Thrombosis and haemostasis are used in Denmark
  • Assess the venous thromboembolism risk by calculating the Caprini score of the specific patient: https://www.mdcalc.com/caprini-score-venous-thromboembolism-2005


Illustrator: Anne Herman Mosebo, MD

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