Abstract
Background
Lower body lift (LBL) is a powerful 360° contouring procedure, most commonly performed after massive weight loss.
Objectives
In this study, the author reviews outcomes of a large series of drainless LBL procedures performed by a single surgeon combined with high-volume liposuction and adjunctive body procedures. The surgeon’s technique is described.
Methods
A retrospective review was conducted on 137 consecutive patients who underwent drainless LBL between 2023 and 2025 by a single surgeon. Data collected included demographics, adjunctive procedures, liposuction volumes, fat grafting, hemoglobin levels, estimated blood loss (EBL), complications, and reoperations. All patients received preoperative optimization, including iron supplementation, and a multimodal perioperative protocol was employed. No drains were used for the procedures.
Results
The mean age was 44.5 years, and the mean BMI was 26.8 kg/m2. Average liposuction volume was 2518 cc, with 1976 cc of pure fat removed. Mean fat transfer volumes were 1075 cc (buttocks) and 628 cc (breasts). Average EBL was 572 cc. Adjunctive procedures included Brazilian butt lift (99.3%), 360 liposuction (96.4%), fleur-de-lis tummy tuck (41.6%), mastopexy (29.2%), and others. The complication rate was 6.6%, with 0.7% requiring reoperation. Complications included hematoma (n = 1), deep vein thrombosis (n = 1), transfusions (n = 2), and delayed healing (n = 5). No seromas or revisions were reported.
Conclusions
Drainless LBL with progressive tension sutures, scarpal flap preservation, and limited undermining is a safe and effective approach and can be combined with high-volume liposuction and multiple adjunctive procedures. This technique resulted in lower complication and revision rates compared with previously published series.
Level of Evidence: 4 (Therapeutic)
The lower body lift (LBL) procedure is a powerful 360° contouring procedure typically performed for patients following massive weight loss. This retrospective review assessed the outcomes of 137 consecutive patients who underwent drainless LBL procedures combined with high-volume liposuction and adjunctive body procedures, performed by a single surgeon.
METHODS
A retrospective review was conducted between September 2022 (when the author began using his current drainless technique) and March 2025 on 137 consecutive patients who underwent drainless LBL. All procedures were performed by a single surgeon with Registered Nurse First Assistants only, no other surgeons were involved. Many patients were weight loss patients, but many were also postpartum patients, high BMI patients (>30), and previous tummy tuck patients (Table 1). Data collected included demographics, comorbidities, adjunctive procedures performed, total liposuction volumes, pure fat volume harvested, fat transfer volumes, pre- and postoperative hemoglobin levels, hemoglobin changes, complications, and reoperations. No complications related to breast implant prosthetics or any sites other than the specific LBL sites (abdomen, back, and buttocks) were included in this study. Average follow-up time was 6 months.
Table 1.
Patient Demographics. The author used ChatGPT (OpenAI, San Francisco, CA) in the creation of this table. After using this tool, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication.
| Metric | Value |
|---|---|
| Number of patients | 137 |
| Mean age (years) | 44.5 |
| Mean BMI | 26.8 |
| BMI >30 | 16.1% |
| Hypertension | 11% |
| Diabetes mellitus | 7% |
| Recent nicotine use/smokers | 9% |
| Previous TT or LBL (revisions) | 32 (23.4%) |
| Metric | Value |
LBL, lower body lift; TT, tummy tuck.
Operative Technique
All procedures were performed under general anesthesia in a hospital setting. Patients were preoperatively evaluated and optimized by the surgeon, including being advised to initiate iron supplementation several weeks before surgery. Active smokers were not excluded from this study, and cessation was encouraged at consultation and before surgery. No nicotine testing was performed on any patients. Appropriate medications were held, including blood thinners and semaglutides. A multimodal perioperative pain management protocol was employed, including 1 g of tylenol, 300 mg of gabapentin, 400 mg of celebrex, and scopolamine patch, as well as tumescent anesthesia and local field blocks. This was continued perioperatively. All patients received lower extremity sequential compression devices and SQ heparin perioperatively and for 1 week postoperatively. Patient temperature was rigorously maintained by controlled room temperature, warmed tumescent fluid, Gaymar underbody warmers, and Bair huggers.
Patients were marked in the preoperative holding area, starting posterior then anterior. Areas of excision, liposuction, and fat injection were all marked. Markings were modified as needed in the operating room in the supine/prone positions.
All procedures began in the prone position on a Wilson frame. Stab incisions were made, and a superwet technique was utilized with double-concentrated tumescent solution (1000 mg lidocaine, 2 mg of epinephrine, and 25 mEq of sodium bicarbonate diluted in 1000 mL of lactated ringers), followed by liposuction, tissue resection, and additional lipocontouring. Liposuction was performed as needed in the upper/lower back, thighs, and hips. Liposuction was also performed in areas of anticipated resection, both superficial and deep to the superficial fascial system (SFS) for purposes of fat harvesting and tissue thinning below the SFS. No undermining of the back was performed. Tissue was resected at approximately the level of the SFS. No subfascial dissection was performed. Tissues were reapproximated with 0 PDS in the fascia, 0 Stratafix, and 2-0/3-0/4-0 Monocryl in the dermis. Fat transfer was done utilizing expansion vibration lipofilling between the deep and superficial fascia of the buttocks. Ultrasound was not utilized routinely in the fat grafting portion of the procedure.
The patient was flipped to the supine position and reprepped and draped. Tumescent was infiltrated. Breast procedures were generally performed before the abdominal portion. Liposuction was performed subscarpally, focusing not only on flanks and lower abdomen but also on the central and upper abdomen. The patient was flexed and the amount of tissue to be resected was approximated and marked. Upper and lower incisions were made, and tissue removal was performed infraumbilical at the level of Scarpa's. Scarpa's was incised/released along the superior edge, and limited undermining was performed supraumbilical, preserving rectus perforators. The area of diastasis was marked from xiphoid to pubis, and Scarpa's was resected full thickness over the area of diastasis infraumbilical. The remaining preserved lower abdominal scarpal flaps were elevated starting in the midline, extending laterally to the semilunar line and then thinned by removing subscarpal fat to the level of the Anterior Superior Iliac Spine (ASIS)/semilunar line. Diastasis repair was done in 2 layers with 0-PDS and 0-Stratafix sutures after injecting ∼20 cc of Marcaine with epi below the anterior rectus fascia. Additional transverse fascial plication was added as needed infraumbilical. Scarpas was reapproximated over the infraumbilical midline with PDS sutures. The bed was flexed, and progressive tension sutures were used in the midline supraumbilical. The umbilicus was inset, and a neo-umbilical site was defatted after temporarily stapling the lower abdomen. Progressive tension sutures were used in the lower midline sparingly and along the semilunar line. Aggressive pubic liposuction, defatting, and skin removal were always performed on every patient. Fat was resected subscarpally in the abdominal flap up to the umbilicus to keep the lower abdomen as flat as possible. Scarpa's was closed at the incision with 0 PDS, followed by skin closure with Monocryl, similar to the back. Hi-Def lipocontouring was completed, including further liposuction in the central and upper abdomen above Scarpa's. Additional fat transfer to the breasts or hip dips was performed as indicated. In the case of a fleur-de-lis (FDL), a similar procedure was performed with limited undermining. Progressive tension sutures were used to reapproximate the upper abdominal flaps to the midline. Mastisol and brown tape were applied over the incision. A lower body compression garment and binder (and bra as indicated) were placed before extubation. No surgical drains were used anteriorly or posteriorly. Patients were transferred to a hospital bed with an air mattress in a flexed, semi-Fowler position.
Most patients were kept overnight for observation. Hemoglobin levels were checked before discharge on all patients kept overnight. No routine fluid administration was done postoperatively. Most patients received somewhere between 2.5 and 3 L of crystalloid for LBL alone. Small fluid boluses were given as needed for low blood pressure postoperatively but were rarely needed. Patients were given oral medication as described above, with IV pain medicine administered as needed. Patients ambulated to and from the bathroom on postoperative Day (POD) 0. The surgeon saw every patient on POD 1 before discharge. Any patients done as outpatients were seen the next day. Patients were transfused if hemoglobin was below 8 and symptoms were significant enough to warrant it. Patients were discharged home with foam and compression garments, and lymphatic massages were recommended to be started within 7 days of surgery. Buttock offloading was recommended for 6 weeks postoperatively. Standard follow-up visits occurred at 1 week, 4 weeks, 3 months, and as needed thereafter. Scar protocols were initiated with silicone gel and tape. Kenalog injections were done as needed for areas of hypertrophic scarring. Complications and reoperations were recorded prospectively.
RESULTS
One hundred and thirty-seven patients were included in the retrospective review. Average follow-up was 6 months. The mean patient age was 44.5 years (Figure 1), and mean BMI was 26.8 kg/m2 (Figure 2). One hundred and thirty-five patients were female (98.5%) and 2 were male (1.5%). Comorbidities included: hypertension (HTN) (11%), Diabetes Mellitus (DM) (7%), and recent nicotine use/active smokers (9%). Average liposuction volume was 2518 cc, with 1976 cc of pure fat removed. Mean fat transfer volumes were 1075 cc to the buttocks (bilateral) and 628 cc to the bilateral breasts (when performed). Average estimated blood loss (EBL) was 572 cc. The mean preoperative hemoglobin was 13.25 g/dL, postoperative was 9.72 g/dL, with a mean drop of 3.66 g/dL (Table 2, Figure 3). Common adjunctive procedures included Brazilian butt lift (BBL) (136), 360 liposuction (132), FDL tummy tuck (57), mastopexy (40), breast augmentation (33), mini reverse tummy tuck (11), thigh lift (6), brachioplasty (2), and mesh abdominal repair (1). Thirty-two patients (23.4%) had previous tummy tuck and LBL conversions with revision of the entire tummy tuck scar or conversion to FDL and liposuction anteriorly occasionally umbilical revisions were also performed (Table 3).
Figure 1.
Age distribution of patients. The author used ChatGPT (OpenAI, San Francisco, CA) in the creation of this figure. After using this tool, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication.
Figure 2.
BMI distribution of patients. The author used ChatGPT (OpenAI, San Francisco, CA) in the creation of this figure. After using this tool, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication.
Table 2.
Operative and Perioperative Metrics. The author used ChatGPT (OpenAI, San Francisco, CA) in the creation of this table. After using this tool, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication.
| Metric | Value |
|---|---|
| Avg. total liposuction volume (cc) | 2518 |
| Avg. pure fat removed (cc) | 1976 |
| Avg. fat transfer to buttocks volume (cc) | 1075 |
| Avg. fat transfer to breast volume (cc) | 628 |
| Estimated blood loss (cc) | 572 |
| Preoperative hemoglobin (g/dL) | 13.25 |
| Postoperative hemoglobin (g/dL) | 9.72 |
| Hemoglobin drop (g/dL) | 3.66 |
Figure 3.
Distribution of hemoglobin drop per patient. The author used ChatGPT (OpenAI, San Francisco, CA) in the creation of this figure. After using this tool, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication.
Table 3.
Adjunctive Procedures Performed. The author used ChatGPT (OpenAI, San Francisco, CA) in the creation of this table. After using this tool, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication.
| Procedure | Patients | Percentage |
|---|---|---|
| BBL | 136 | 99.3 |
| 360 Liposuction | 132 | 96.4 |
| FDL tummy tuck | 57 | 41.6 |
| Mastopexy | 40 | 29.2 |
| Breast augmentation | 33 | 24.1 |
| Mini reverse tummy tuck | 11 | 8.0 |
| Thigh lift | 6 | 4.4 |
| Brachioplasty | 2 | 1.5 |
| Mesh abdominal repair | 1 | 0.7 |
BBL, Brazilian butt lift; FDL, fleur-de-lis.
The complication rate was 6.6%, and the reoperation rate was 0.7%. Specific complications included 1 hematoma, necessitating a return to the operative room, 1 small area of flank dehiscence in a male patient who did not wear postoperative compression garments as recommended (sutured in office), 5 cases of prolonged healing (>8 weeks postoperatively, primarily along the flanks, midline back incisions, and periumbilical), 1 deep vein thrombosis (DVT), no pulmonary embolus (PE)), and 2 patients who received blood transfusions (1 and 2 units). Zero seromas were clinically detected. Zero revisions were requested or performed (Table 4).
Table 4.
Postoperative Complications. The author used ChatGPT (OpenAI, San Francisco, CA) in the creation of this table. After using this tool, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication.
| Complication | Count | Percentage |
|---|---|---|
| Hematoma (return to OR) | 1 | 0.7 |
| Flank dehiscence | 1 | 0.7 |
| Prolonged healing (>6 weeks) | 5 | 3.6 |
| DVT | 1 | 0.7 |
| Transfusion | 2 | 1.5 |
DVT, deep vein thrombosis; OR, operative room.
DISCUSSION
This is the first large study to report on drainless LBL surgery and in combination with large-volume liposuction and adjunctive procedures. These findings support the safety of a drainless LBL, utilizing a technique that includes scarpal flap preservation, limited abdominal flap undermining, and progressive tension sutures.
This study aligns with previous research (Figure 4), demonstrating the efficacy of progressive tension sutures in reducing complications such as seromas.1,2 In addition, studies evaluating high-volume liposuction, SAFE liposuction techniques, and circumferential superficial fascia lifting further support the safety and efficacy of comprehensive body contouring procedures when modern techniques and appropriate patient selection are utilized.3-6 Wall emphasized the importance of preserving tissue planes and minimizing trauma in circumferential liposuction with abdominoplasty—principles reflected in our approach, particularly through scarpal preservation and superficial plane dissection.4
Figure 4.
Complication and revision rates in prior lower body lift studies. The author used ChatGPT (OpenAI, San Francisco, CA) in the creation of this figure. After using this tool, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication.
The author believes that scarpal preservation, minimal undermining, and the use of progressive tension sutures significantly contributed to the low seroma rate observed in this series and allowed larger volume liposuction to be performed as well as adjunctive procedures without the use of drains. These techniques limit dead space, maximize tissue perfusion, and encourage adherence of tissue planes, reducing fluid accumulation and minimizing seromas.
The author's technique of scarpal preservation is a variation of that described originally by Saldanha et al7 who described a similar technique, but with no scarpal undermining and no subscarpal fat resection. The author believes that subscarpal fat removal is critical to reduce infraumbilical fullness that can occur in a subset of patients. This applies to fat removal on both the abdominal wall and abdominal flap. The use of transverse infraumbilical plication can also ameliorate this condition. The author believes that Scarpa's is a “sticky” layer and that contact between the abdominal wall Scarpa’s and the abdominal flap Scarpa's helps reduce the incidence of seroma, in combination with quilting sutures. The use of scarpal flaps is also helpful in allowing the surgeon to aggressively resect subscarpal fat in the pubic area, an area where seromas and infection can occur. Scarpal flaps can also be used to cover mesh when used to reinforce the lower abdominal wall.
Aggressive high-definition liposuction, as evidenced by the average lipoaspirate of 2518 cc, likely contributed to some of the observed delayed healing in the flanks and midline back. This is because of mechanical friction, additional swelling created from liposuction and some devascularization from thinning the flanks. Similarly, aggressive defatting of the neo-umbilicus may have played a role in delayed healing in that area as well. The 1 patient who had a dehiscence was a male who was noncompliant with garment usage and woke up with a small area of dehiscence in his left flank ∼10 days postoperatively that we resutured in the office under local. There was no associated seroma, hematoma, or skin necrosis. It may have been related to a technical issue related to visibility in suturing this area where the posterior excision overlaps with the anterior excision.
The elevated blood loss observed reflects the complexity of this post-massive weight loss population, characterized by poor tissue quality, extensive resections (42% underwent concurrent FDL), and frequent adjunctive procedures—most notably mastopexy (29%). Additionally, 16.1% of patients had a BMI over 30. Nearly all patients (99.3%) also had a BBL, and 96.4% underwent 360 liposuction, with an average of ∼2 L of pure fat removed per case. Among the 5 patients who had an LBL without 360 liposuction, the average EBL was 450 mL, compared with 678 mL in the 132 patients who had LBL with 360 liposuction. Notably, some patients without 360 liposuction still underwent adjunctive procedures.
The accuracy of hemoglobin levels on POD 1 can be debated. Hemoglobin levels are checked routinely by the author to identify unrecognized bleeding postoperatively, as well as to differentiate postoperative hypotension resulting from fluid shift, hypovolemia, and anemia. The author has found differences up to 1 point when rechecking levels at any given time. It is worth noting that the only patient that required reoperation did not have a hemoglobin level checked before discharge, and her vitals were stable at discharge. Her reoperation was done on POD 2.
It is also worth noting that many of the patients in this cohort were surgical weight loss patients and presented with lower baseline hemoglobin levels secondary to previous weight loss surgery, some as low as 10 preoperatively. Also, many weight loss patients take iron routinely and may not absorb iron well. Furthermore, the anticipated hemoglobin drop would not be until POD 2 to 3 so the authors’ rationale to check routinely on POD 1 is to have a general idea of hemoglobin status, to identify any potential unrecognized bleeding because no drains are used, and to differentiate from other sources of hypotension such as fluid shifting or narcotic related.
Aly et al reported outcomes for 40 patients who underwent belt lipectomy with a 56% complication rate using traditional techniques with drains.8 Hurwitz's single-stage body lift series of 134 patients reported a 40% complication rate and 33% revision rate, also using traditional techniques.9 Nemerofsky et al reported a 40% complication and 33% revision rate in their series of 134 patients undergoing belt lipectomy with liposuction.10 Their use of traditional techniques and drains may explain the higher complication rates compared with the present series. Makipour et al published 42 outpatient circumferential body lift patients and reported a 36% complication rate and a 26% revision rate, despite lower average lipoaspirate volumes (932 cc) and the use of drains.11
Rohrich et al, reported a 28.5% overall complication rate and 5.3% revision rate in their central body lift series of 151 patients, including 22 seromas (14.6%), 2 dehiscences (1.3%), and 3 major complications (2.0%), including DVT and PE.12 Their average liposuction volume was 4150 cc. In contrast, in the current study, the author demonstrates a significantly lower complication (6.6%) and revision rate (0.7%), possibly because of the use of drainless techniques and meticulous surgical planning. Rohrich's use of both liposuction and excision supports the safety of combining high-volume liposuction with body lift procedures, as echoed in our findings. The author of this study did not report the actual fat content of the lipoaspirate or hemoglobin levels, so it is unclear what percentage of the lipoaspirate was fat. Our data demonstrated >78% of the lipoaspirate was pure fat.
In contrast to all the above studies which utilized drains, our drainless technique with scarpal preservation, limited undermining, and progressive tension sutures showed markedly lower complication (6.6%), reoperation (0.7%), and revision (0%) rates. This supports our belief that eliminating drains, limiting undermining, and incorporating our technique with progressive tension sutures enhances patient outcomes. Additionally, surgeon experience with high-volume body contouring procedures likely contributed to the reduced complication rates observed.
This study has the following limitations. First, it is a retrospective review of a single-surgeon experience without a control group or comparison arm, which limits the generalizability of the findings and introduces potential selection and observer bias. The average follow-up period of 6 months is relatively short and may not fully capture long-term outcomes such as scar maturation. The heterogeneous patient population—including massive weight loss patients, postpartum patients, high BMI individuals, and revision cases—makes it challenging to draw definitive conclusions for any specific subgroup. Additionally, patient-reported outcomes, limiting insights into quality of life and satisfaction, were not included in the study. Finally, although perioperative hemoglobin levels were routinely assessed, the variability in timing and interpretation of these values, as noted in the discussion, may reduce the reliability of blood loss estimates and transfusion needs.
CONCLUSIONS
Drainless LBL with scarpal preservation, limited undermining, and progressive tension sutures is a safe and effective procedure in postweight loss and nonweight loss patients and revision patients. It can be safely combined with high-volume liposuction and adjunctive body/breast contouring procedures, including BBL, 360 liposuction, FDL tummy tuck, mastopexy, breast augmentation, mini reverse tummy tuck, thigh lift, brachioplasty, and mesh repair, with low complication and reoperation rates for experienced surgeons. Aesthetic outcomes can be achieved with low complication rates (Figures 5, 6, Video).
Figure 5.
Preoperative Anterior (A) oblique (C, E) posterior (G) and 6 month postoperative anterior (B), oblique (D,F) posterior (H) views of a 32 year old female after drainless lower body lift with 360 liposuction and fat transfer to the buttocks.
Figure 6.
Preoperative anterior (A), posterior (C) and 3 - month postoperative anterior (B), posterior (D) views from technique video of 44 year old female after drainless lower body lift, 360 liposuction and fat transfer buttocks.
Disclosures
The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. During the preparation of this work, the author used ChatGPT (OpenAI, San Francisco, CA) to create Tables 1-4 and Figures 1-4, do calculations on averages, as well as citations/references and revise/edit the manuscript. After using this tool/service, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication.
Funding
The author received no financial support for the research, authorship, and publication of this article.
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