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


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

Procedure on the back of the patient


Step 1: Preoperative markings

The patient is laying faced down. The preoperative markings are shown. Reexamine the preoperative markings by performing pinch test both digital and using instruments. 


Step 2: Incisions

Use a knife to cut through the dermis of all markings. A monopolar electro dissector is used for dissection of excess skin starting medially going lateral in the scarpas fascia plane. A bipolar diathermy is used meanwhile to ensure hemostasis. 


Step 3: Dissection

Continue dissecting in the lateral direction in the scarpas plane. 


Step 4: Dissection continued

Continue the dissection to the vertical marking in the midaxillary line (line B) and remove the excessive skin corresponding to the vertical line.  


Step 5: Dissection continued

Use the same technique to remove excessive skin on the other site of the back. 


Step 6: Place first suture

The first suture is placed centrally in order to suture the skin. Ensure hemostasis before closure of the skin.  


Step 7: Place sutures

Place sutures in three layers using absorbable sutures; 0 size-sutures in Scarpa’s fascia, 2/3-0 inverted dermal sutures and 3-0 intracutaneous running sutures. 


Step 8: Superficial sutures

Place the superficial sutures in the intracutaneous layer of the skin. 


Step 9: Sutures in three layers

The skin is sutured in three layers.  


Step 10: Cover with micropore tape

Micropore tape is used to cover the incision lines and on top dressing is placed. 
When the procedure of the back is finished, the patient is turned to lay faced up.  

Procedure on the abdomen of the patient


Step 11: Incisions

Make an incision through the skin according to the markings, starting from the xiphoid process. 


Step 12: Incision of the umbilicus

The umbilicus is incised and dissected from the abdominal tissue. Carefully cut through the skin while stretching the umbilicus. Pay special attention to the blood supply of the umbilicus. 


Step 13: Dissection

Starting from the xiphoid process gradually excise the abdominal skin flap using a monopolar electro dissector. Starting from the xiphoid process the desired level to reach is superficial to the rectus fascia. Stay just above Scarpa’s fascia the last 5-7 cm above the lower incision. Use a bipolar diathermy to ensure hemostasis. 


Step 14: The umbilicus is freed

When the umbilicus is freed from the abdominal flap, two forceps can be used to hold the umbilicus in place. Continue to ensure hemostasis. 


Step 15: Horizontal incision

Make an incision in the horizontal line approximately 7 cm above labia majora. 


Step 16: Excess skin

Pull the abdominal skin flap in the caudal direction to estimate the amount of excess skin. This will create a triangle flap of excessive tissue on both sides of the abdomen. 


Step 17: Line A

Mark the predicted line of incision (line A). Do this bilaterally. 


Step 18: Sutures in three layers

Place sutures in three layers. Place the deepest sutures trough Scarpa’s Fascia starting from the xiphoid process following the vertical scar. 


Step 19: Examination

After placing the sutures in the deepest layer, examine the need of removing further skin before resecting the two skin flaps. Make an incision following the horizontal line A (See Figure 17). Excise the abdominal flaps bilaterally in the sub Scarpa’s fascia level.  


Step 20: Place drains

After removing the two skin flaps, place two drains bilaterally.


Step 21: Sutures

Place dermal and intracutaneous sutures.  


Step 22: Sutures continued

The umbilicus is sutured as well with dermal and intracutaneous sutures in the desired position.  


Step 23: Cover with micropore tape

Cover the sutured incisions with micropore tape.  

Pearls and pitfalls


  • There is a difference between the preoperative markings on the back in men and women. A male patient normally prefers a scar that is linear and lower, while a female patient normally prefers a wing-shaped scar, which enhances the contour of the nates


  • The amount of excessive skin to remove is always at the discretion of the surgeon: Removing too much will prolong the wound healing while removing too little may leave remaining excess skin 

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