**1. Introduction**

With the change of lifestyle, easy availability of fast food and takeaways of rich food, acquired obesity is seen in all sections of life regardless of an individual socioeconomic background. For these reasons, obesity has been steadily on the rise along with its associated comorbidities causing an increased burden on health care delivery systems. However a rise in awareness related to the risks associated with obesity and introduction of safe procedures for bariatric surgery has resulted in an increased number of people with massive weight loss. Unfortunately, one of the undesirable side effects following massive weight loss is the redundant skin excess. Skin laxity or excess can also be, hereditary, hormonal, drug induced, part of ageing process, weight loss following conservative measures, drastic weight fluctuations

or following childbirths etc. Common sites of skin laxity or excess following weight loss are seen around arms, thighs, buttocks, face, neck, breast and abdomen. These areas of skin laxity or excess can be extremely distressing, unmanageable hygienically and often affect social, personal aspects of life. Weight loss following bariatric surgery or by any other means is only half the job done and the objectives are not fully achieved until skin laxity issues related to weight loss are dealt with using appropriate surgical procedures. The real goals of body weight loss are not complete until self-esteem, self-confidence and body image is not restored using surgical methods. Various techniques have been described time to time and to address the excess skin or skin laxity issues following significant weight loss, which in some individual, affect nearly their entire body.

To device a procedure, mastery of the underlying anatomy and the role of these anatomical structures is paramount. The understanding, presence and introduction of the superficial fascial system by Lockwood in 1990 added anatomical sense to the procedures and longevity of the results [1]. However, reproducibility of a result is not with out adding simplicity and safety to the procedure. Great advancements to body contouring surgeries following massive weight loss came after the introduction of liposuction without undermining prior to skin excision. Liposuction assisted abdominoplasty has been described by Saldanha which has added safety, simplicity and reproducibility to the procedure [2]. The procedure is widely used and reported by many other surgeons [3, 4]. Hurwitz has described liposuction assisted brachioplasty with a similar concept that has added simplicity, safety and reproducibility to the procedure [5]. Similarly, liposuction assisted medial thigh lift using transverse incision with or without vertical excision of medial thigh skin has added safety to the procedure and has also been reported with acceptable results and fewer complications [6–8]. Addition of liposuction prior to skin excision allows honeycombing of the subcutaneous tissue following the use of blunt tipped cannulas for lipectomy. Process allows creation of a safe plane superior to the deep fascial layer with preservation of the important nerves and vessels. Skin excess is removed without the need of undermining or dissection of adjacent skin. Postoperative bleeding and bruising are minimal and in most of the instances, the procedure is performed as a day case without drains. Postoperative analgesia requirements are minimal and allows patient to ambulate early with a quick recovery. When transverse resection is done without excision of vertical segment of skin, improvement is only limited to upper 3rd of the inside. Transverse resection alone may give very well concealed scars but is not suitable for massive weight loss patients where skin resection in vertical axis is mandatory for adequate results.
