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APPROACH TO THE ABDOMEN AFTER WEIGHT LOSS

APPROACH TO THE ABDOMEN AFTER WEIGHT LOSS
APPROACH TO THE ABDOMEN AFTER WEIGHT LOSS

Key Points

  • A lower abdominal incision may not adequately address the redundancy of the abdomen in a post–massive weight loss patient; vertical or lateral abdominal incisions may need to be utilized.
  • Contouring of the mons should be considered in most weight loss patients.
  • Postoperative seromas are an increased risk in this population, and intraoperative techniques may need to be altered to minimize this occurrence.
  • Hernias may be addressed safely at the time of panniculectomy.

DEFINITIONS

  • Abdominoplasty. Removal of skin and fat of the abdominal wall with tightening of the underlying musculature. In general, this is considered a cosmetic procedure.
  • Belt lipectomy. A method designed to circumferentially reduce truncal excess combining an abdominoplasty, lateral thigh lift, buttocks lift, and sometimes liposuction of select areas.
  • Lower body lift. Described initially by Lockwood and refers to a combined transverse thigh/buttock lift with a high-tension abdominoplasty.
  • Panniculectomy. Removal of skin and fat of the abdominal wall. In general, this is considered a reconstructive procedure.

As early as 1899, the term abdominal lipectomy was devised by Kelly to describe a transverse resection of a large pendulous abdomen.1 In 1910, Dr. Kelly described his experience with eight patients.2 Thorek in 1939 described his technique, which he called ‘plastic adipectomy’ for resecting ‘fat aprons’.3 These early operations were designed to relieve the functional problems associated with large fat aprons. However, early on the cosmetic benefits were noted. Kelly stated in 1910 that ‘quite apart, however, from the tremendous physical and, in some cases psychical benefit, I personally recommend and would do the operation in extreme cases for the cosmetic benefit’.2 From these early efforts have come the techniques known as abdominoplasty. Although abdominoplasty is a procedure well known to plastic surgeons, the management of the post– massive weight loss abdomen is much more complicated. Although variation can be seen in the traditional abdominoplasty patient, the post–massive weight loss patient presents with a wider range of anatomical variables as well as a higher rate of complications. As patients lose weight following bariatric surgery, they begin to develop loose and overhanging skin in many areas. Universally, the abdomen is a prime focal area of concern in post–massive weight loss patients. Various techniques have been described. The goals of all these techniques are to:

• allow excision of excess skin and fat, and • tighten the diastasis recti and/or repair hernias if present. In traditional abdominoplasty patients, the third goal is to have minimum scarring.4 This is not the case for the massive

weight loss patient. Contour is a more important goal than minimum scarring in this population, and several scars may be necessary to give the patient the desired contour.

Panniculectomy and abdominoplasty have been used interchangeably to describe surgical procedures to remove excess skin and fat of the abdominal wall. Panniculectomy describes procedures removing only skin and fat—i.e.

a functional operation that removes a symptomatic apron of skin—while abdominoplasty refers to not only the removal of skin and fat but also the tightening up of the muscles of the abdominal wall (it is a term that connotes aesthetic goals). Often, the abdominoplasty may be considered a cosmetic procedure while a panniculectomy refers to a more reconstructive type of operation.

A panniculcetomy may be done in patients who have not yet begun their weight loss to remove a large apron, or in patients who have an extremely large overhanging apron after massive weight loss and have interference with activities of daily life or a history of recurrent rashes. For the massive weight loss patient, an abdominoplasty is commonly done after weight loss is complete, and is performed to recontour the abdominal wall with removal of excess skin and fat as well as tightening up of the muscles underneath.

As a general rule, more attention can be safely given to aesthetic goals as the BMI of the patient decreases. Wound complications tend to be higher when contouring operations are performed in patients who are still obese, and a more

aggressive approach can invite greater risk of local and even systemic sequelae. A belt lipectomy refers to a circumferential resection of skin and fat that often also includes the tightening of the abdominal musculature within the same procedure. Patients who have undergone an abdominal procedure, either an abdominoplasty or a panniculectomy, may then elect to undergo a belt lipectomy at a later time. For these patients, the resection is begun in the posterior aspect and the dog ears are excised anteriorly, thereby revising the abdominal portion of their previous procedure.
PREOPERATIVE PREPARATION
Following massive weight loss, patients may present with redundancy all over the face and torso. The decision-making process should involve consideration of the patient’s: • priorities, • aesthetic goals, • body contour, • finances, and • overall health. Plastic surgery after massive weight loss may be, and indeed is often, a multiple-staged procedure. Given the opportunity to prioritize which parts of their bodies they would like to have addressed first by a plastic surgeon, the abdomen is usually at the top of the list. Even with a discussion of the belt lipectomy, patients may opt to just do their abdomen initially. This decision may be due to financial constraints. For patients whom the plastic surgeon feels would benefit most from a belt lipectomy, the discussion needs to be had with the patient comparing doing an abdominoplasty versus doing a belt lipectomy. Although an abdominoplasty can be converted to a belt lipectomy, some surgeons feel that the best result in selected patients may be achieved only when a complete belt lipectomy is done as the first stage. Proponents of the belt lipectomy for
the initial stage feel that lateral excess can be accentuated by abdominoplasty alone.5,6 The assessment of the massive weight loss patient who presents for abdominoplasty should involve a close evaluation for possible hernias. If the patient has had an open procedure, there is a high incidence of incisional hernias. These can be safely repaired at the same time as the panniculectomy (Figs 5.1 and 5.2).7 In addition, patients who were previously very heavy often have umbilical hernias. These can sometimes be difficult to assess preoperatively. Certainly, if a hernia is present and in close proximity to the umbilicus the patient should be cautioned that the umbilicus may need to be sacrificed to get an optimal repair of the hernia. The stalk of the umbilicus in patients who were previously very heavy can be very long, and in some cases it might be necessary to create a neoumbilicus rather than utilize the patient’s original umbilicus. Many patients after massive weight loss have had previous procedures done with the resulting scars. Common and concerning scars are any scars above the umbilicus, including subcostal scars resulting from an open cholecystectomy. If a midline incision is to be used, this scar will not only be brought inferiorly but also medially, and will be resected in part. In general, this previous subcostal scar will end up at the level of the umbilicus (Figs 5.3 and 5.4). Despite this shortening of the scar, there is still concern about the viability of the skin and fat inferior to this scar. The potential risk of loss of tissue below this old scar should be raised with the patient. In general, perhaps due to the increased vascularity that developed when the patient was heavy, this tissue can survive without a problem. However, patients with other disease processes (such as cardiac disease) or patients who smoke will be at higher risk for tissue loss. Moreover, unconventional incisions can be designed to incorporate or accomodate upper abdominal scars. Many patients want to do several procedures under the same anesthetic. Abdominoplasty in the post–massive weight
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Figure 5.1 Incisional hernia following open bariatric surgery. Total weight loss: 120lbs (54kg).
loss population can often be combined with other procedures, while considering each patient individually and taking into consideration safety issues such as: • the total length of surgery planned, • the patient’s overall health, and • the length of time the surgery will take. In a review of 73 consecutive procedures, it was found that additional dermolipectomies do not increase abdominoplastyrelated morbidity and actually demonstrated better long-term results.8
Markings for resection of the abdominal panniculus are best done in the preoperative area with the patient in the standing position or prior to admission. Avoidance of dog ears is critical (Figs 5.5 and 5.6); marking the end of the overhanging panniculus is key to the avoidance of dog ears (Fig. 5.7). When the patient lies down, this lateral overhang is lost (Fig. 5.8). The inferior marking can be done on the operating table. The inferior marking should take into consideration the excess that may be present in the mons area and adjusted accordingly (Fig. 5.9). Many women will present with ptosis and/or exces
Preoperative preparation
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Figure 5.2 Postoperative views after incisional hernia repair and resection of abdominal pannus, utilizing lower abdominal and midline incisions.
Figure 5.3 Subcostal midline incision after open bariatric procedure. Total weight loss: 111lbs (50kg).
sive fullness of the mons. While the patient may not specifically draw attention to these deformities, correction of mons shape and position should factor into any abdominalcontouring strategy. Patients will be very unhappy if a resection of their excess mons area is not done either at the time of a panniculectomy before weight loss (Fig. 5.10) or at the time of the panniculectomy after massive weight loss (Fig. 5.11). The resection of the abdominal panniculus will address the anterior abdomen, but will not address areas such as back rolls or excess fat in the posterior hip area. Preoperative evaluation of the patient needs to include discussion of the
patient’s anatomy and the extent of the panniculectomy, and areas that will not be addressed during this surgery. If the patient wishes to have these areas addressed, alternative procedures— such as a belt lipectomy, liposuction, or even wedge resections of these additional areas—should be discussed. Reviewing photos of patients with similar anatomical variations can make the discussion and the expectations easier (Figs 5.12–5.17). In patients who have undergone an open bariatric procedure, the previous midline scar is utilized to resect the excess skin and fat in both a horizontal and a vertical direction. In patients who have had a laparoscopic procedure or who have
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Figure 5.4 Subcostal incision scar postoperatively after resection of skin and fat in horizontal and vertical directions.
Figure 5.5 Dog ears after abdominal panniculectomy.
lost their excess weight through diet and exercise, an evaluation of the redundancy of the skin and fat in the upper abdomen should be done. If there is an excess of skin and fat in the upper abdomen, the possibility of a midline scar should be considered (Figs 5.18 and 5.19). Vertical incisions have been utilized to address the upper abdomen as early as 1916, when Babcock described vertical ellipses of fat and skin with wide undermining and midline approximation to contour the waist and lower abdomen.9 If a midline scar is not utilized, there may still be redundancy in the upper abdomen that the patients may not be happy about postoperatively.
The goal, as described by Savage,10 should be the removal of the greatest amount of skin and fat rather than concern about scars. A mixture of horizontal and/or vertical scars may be necessary to get the desired contour. The upper abdominal area may also be addressed at a later stage with the addition of a midline scar,11 or even, in some patients, a lateral scar may be used as a continuation of a brachioplasty scar, addressing the lateral folds of the breast as well as the residual laxity of the upper abdomen all in one incision. Some surgeons have even suggested an upper abdominal incision or ‘melon slice’ type of excision to remove upper abdominal excess.12
Preoperative preparation
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Figure 5.6 Correction of dog ears with conversion to belt lipectomy.
Figure 5.7 Abdominal markings with the patient standing.
ABDOMINOPLASTY IN THE MASSIVE WEIGHT LOSS PATIENT
Once the patient has been marked in the standing position, she or he can be taken to the operating room. Vertical marks should be made at the lateral aspect of the overhanging pannus while the patient is in the standing position. This then delineates the lateral extent of the resection and will help avoid dog ears (Fig. 5.7). The lower abdominal incision can be marked when the patient is supine on the operating table. The procedure is best done under general anesthesia with the patient in the supine position. Intermittent compression devices are placed on the patient as soon as he or she is on the operating table or earlier, and a Foley catheter is inserted. The abdomen is prepared from above the costal margin, laterally to the operating table and including the pubic area. Shaving of body hair may be done as indicated. Markings for the lower abdominal incision should be done at this time. The marking should take into consideration any excess of the mons area that exists. The lower incision should be placed 2–3cm above the labial cleft to place the final scar at this level and to adequately address the mons excess (Fig. 5.9). Once the patient is prepared, the surgery begins through the midline incision, if present. Incisional hernias, if present, are dissected out. The umbilicus is dissected out and left attached to its stalk. The incision is carried down to the pubic area and out to the lateral extent of the lower abdominal incision
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Figure 5.8 Abdominal markings with the patient supine on the operating room table.
Figure 5.9 Markings on the operating room table for resection of mons.
Figure 5.10 Panniculectomy done before bariatric surgery without resection of mons.
Abdominoplasty in the massive weight loss patient
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Figure 5.11 Panniculectomy done after bariatric surgery without resection of mons.
Figure 5.12 Patient with 72-lb (33kg) weight loss following laparoscopic bariatric surgery.
(Fig. 5.20). The skin and fat are then mobilized and rotated medially and inferiorly, and the excess skin and fat are resected. Tension should be applied to the skin and fat being resected in the upper abdomen to resect as much as possible in this area and to avoid upper abdominal fullness in the postoperative period (Figs 5.21 and 5.22).
Concern is always raised about elevating flaps under previous incisions. In patients in whom there is a lot of concern about tissue viability, such as nicotine users, undermining might be limited to the level of the previous surgery; in most patients, this area can safely be elevated and the tissue will survive.
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Figure 5.13 Resection of 11.4-lb (5185g) pannus, utilizing midline and lower abdominal incisions.
Figure 5.14 Patient with 200-lb (91kg) weight loss following placement of an adjustable gastric band.
Abdominoplasty in the massive weight loss patient
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Figure 5.15 Postoperative views after resection of abdominal pannus with midline and lower abdominal incisions in a patient with an adjustable gastric band.
Figure 5.16 This patient had undergone a 27-lb (12kg) panniculectomy before open bariatric surgery. Weight loss including panniculectomy totaled 157lbs (71kg).
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Figure 5.17 Postoperative views after abdominoplasty. The previous midline scar after open bariatric procedure was utilized to resect excess skin in both a horizontal and a vertical direction.
Figure 5.18 Excess skin and fat after weight loss from laparoscopic procedure with 120-lb (54kg) weight loss.
Abdominoplasty in the massive weight loss patient
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Figure 5.19 Postoperative resection of abdominal pannus, utilizing midline and lower abdominal incisions.
Figure 5.20 Elevation of skin flaps.
Once the skin and fat have been mobilized, the hernias (if present) or the diastasis recti can be addressed. A technique that has been very successful in these patients involves a hernia repair without opening the hernia sac and utilizing onlay mesh.7 The hernia sac is dissected free without opening the sac, and then the hernia repair is done by primary imbrication of the fascia. This avoids potential complications from opening the hernia sac and entering the peritoneal cavity, such as bowel
perforation or other intraabdominal problems. Ethibond suture (Ethicon, Inc., Somerville, New Jersey) is the preferred suture, as Prolene suture can leave long knots that in thinner patients can be palpable under the skin. The Ethibond suture is left long, and then the suture is passed through a soft mesh and tied over the mesh. A running Ethibond suture is then sewn around the periphery of the mesh. The umbilicus is then brought through a slit in the mesh (Figs 5.23–5.26). If the hernia involves the umbilicus, the umbilicus is amputated, and either the patient is closed without an umbilicus (Fig. 5.27) or a neoumbilicus can be constructed. Below the hernia, there will still be a diastasis recti; this should be repaired. In patients without a hernia, imbrication should still be undertaken. Various techniques have been proposed. Because of the extensive laxity, some surgeons have advocated a double-layer imbrication, first doing a standard imbrication, as in a non–massive weight loss patient, and then a second imbrication to tighten the hernia again and adequately tighten the fascial layer.5 If a continuous infusion pain pump is to be used, it should be placed at this time. The area of maximal pain would be expected to be along the hernia/diastasis recti repair, and so the catheters should be placed along this area. To avoid having the pain pump catheters being pulled out when the drains are emptied, it is advantageous to insert the pain pump catheters from the upper abdomen (Fig. 5.28). Seromas are a big concern in this abdomen following massive weight loss, and four drains are commonly used in this
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Figure 5.21 Resection of horizontal and vertical flaps.
Figure 5.22 Comparison of flaps before and after resection.
Figure 5.23 Incisional hernia sac after weight loss from open bariatric surgery.
population (Fig. 5.29), as opposed to two drains in the non–weight loss patient. These drains can be brought out in the standard manner in the pubic area. Our practice has been to leave the drains in place until the drainage is less than 40cc from each for a 24-h period, which usually is about 2 weeks. Closure of the abdomen can be carried out as the surgeon prefers. Our current closure is 2:0 Vicryl Plus for Scarpa’s fascia and 3:0 Vicryl Plus as a buried subdermal closure, and Dermabond as a skin sealant. Abdominal binders are used for patient comfort.
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Figure 5.24 Imbrication of hernia.
Figure 5.25 Anchoring of mesh through midline sutures.
Figure 5.26 Repaired hernia with primary imbrication and onlay mesh.
Figure 5.27 (a) Pre- and (b) postoperative hernia repair necessitating amputation of umbilicus.
SUMMARY OF SURGICAL TECHNIQUE (Figs 5.20–5.26) 1. Mark the lateral extent of the overhanging pannus in the standing position. 2. Mark for lower abdominal incision and mons resection when patient is on the table. 3. Elevate the skin and fat to the costal margins and to the anterior axillary line. 4. Repair hernia (if present) or diastasis recti. 5. Resect excess skin and fat in both vertical and horizontal directions (if utilizing midline incision). 6. Close over four drains.
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Figure 5.28 Insertion of pain pump catheters through the upper abdomen.
Figure 5.29 Insertion of four drains.
MANAGEMENT OF THE MASSIVE ABDOMINAL PANNUS BEFORE BARIATRIC SURGERY
For several reasons, a patient may present to a plastic surgeon for removal of an extremely large pannus without having undergone any weight loss. In some patients with a large overhanging panniculus that impedes ambulation and makes hygiene difficult, some surgeons will combine bariatric surgery with panniculectomy.13,14 Our experience has been that there is a very high complication rate with combining the panniculectomy with the bariatric surgery. Our current practice is to do the panniculectomy first and allow the patient to recover fully before proceeding with the bariatric surgery (Figs 5.30 and 5.31). Other morbidly obese patients will require removal of their massive pannus in order to give gynecologists access to the abdomen for gynecologic procedures, such as hysterectomy for uterine cancer, or to give colorectal
surgeons access to the abdomen for the surgical treatment of colorectal cancer. The weight of the pannus can make surgical dissection difficult as well as lead to significant blood loss. In addition, the difficulty in preparing below the pannus can increase the risk of wound infection in patients who already have increased risk of infection due to other comorbidities. For these reasons, the use of a suspension-type system can be useful, especially when combined with an open wound management technique. Several suspension-type devices have been used, and some surgeons have even had specialized cranes built.13,15,16 In our experience, orthopedic devices are readily available in the operating room (Hoyer crane or shoulder suspension device) and can be used to lift the weight of the pannus off the patient’s abdomen. The lateral extent of the pannus is marked preoperatively with the patient standing (Fig. 5.32). After attainment of general anesthesia, the patient is prepared and draped. The suspension device is then draped with a sterile drape (microscope drape, laparoscopic camera drape, and impervious stockinet) and large clamps (Adair clamps) are placed along the extent of the panniculus. A sterile rope is then passed through the clamps and attached to the suspension device. The suspension device can then be raised to suspend the pannus (Fig. 5.33). The dissection is then started at the most lateral sides of the pannus, and it is carried down to the fascia. The dissection is carried out at this level toward the midline. The task can be carried out by two teams, both working simultaneously toward the midline. As the dissection progresses, the crane is elevated, lifting the pannus off the abdominal wall and helping delineate the desired plane of dissection at the fascial level (Fig. 5.34). This elevation has the effect of draining some of the blood from the pannus into the patient, as well as increasing visibility of the desired surgical plane. Care should be taken as the umbilicus is approached, as some patients may have an umbilical hernia that may not have been palpable due to the patient’s
Management of the massive abdominal pannus before bariatric surgery
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Figure 5.30 Preoperative view before panniculectomy, prior to bariatric surgery.
Figure 5.31 Postoperative view after resection of 22-lb (10kg) pannus.
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Figure 5.32 Massive pannus, the patient supine on the operating room table.
Figure 5.33 Elevation of a massive pannus with a shoulder suspension device.
size before surgery. The patient’s umbilicus is usually amputated during this procedure. The risk of infection is increased in morbidly obese patients, and the preparation of a large pannus is difficult. Despite this, some surgeons report success with closing the wound and report an acceptable infection rate.17 Our experience has been different, and therefore we have developed an open wound management technique to minimize the risk of infection. Large mattress sutures using #2 nylon are placed at approximately 6-inch intervals. For patient comfort, it is preferable to put the knot of the suture above the incision rather than on the lower flap. This is to facilitate later removal of the sutures. As these patients are usually morbidly obese, it can be difficult to get the patient on an examination table, and so the removal of the sutures is sometimes done with the patient in a wheelchair or a sitting position. Placing
the knots on the upper flap therefore makes access easier for removal of the sutures. Packing is then done with a Kerlix gauze soaked in saline and wrung out (Fig. 5.35). The packing is changed twice daily, and the sutures are removed starting at 2 weeks. This technique has been used successfully both for patients before bariatric surgery and in patients requiring hysterectomy or bowel surgery.
OPTIMIZING OUTCOMES
• Mark the lateral extent of the hanging pannus so there will be no dog ears. • Consider either a midline excision or a lateral excision for patients with a lot of mid–upper abdominal laxity. • The risk of seroma formation is increased in this population—use four drains. • Resect the mons if redundant.
SUMMARY OF SURGICAL TECHNIQUE (Figs 5.30–5.35) 1. Mark lateral extent of incision with patient in standing position. 2. Pannus prepared and draped. 3. Sterile draping of Hoyer crane or shoulder suspension device over table. 4. Large Adair clamps applied along extent of pannus. 5. Sterile rope passed through clamps and tied to crane. 6. Resection started at lateral aspects, and once the fascia is reached the dissection is carried to the midline simultaneously from each side. 7. As the pannus is resected,the crane is elevated and the pannus is raised off the patient. 8. Mattress sutures of a large nylon are placed every 4–6 inches. 9. Loosely pack in between the mattress sutures with Kerlix wet-todry.
Although this population of patients can be some of our happiest patients, there are some factors that need to be taken into consideration to maximize the outcome. One of the most important is the avoidance of dog ears. Marking the patient in the standing position to delineate the lateral extent of the overhanging pannus (Fig. 5.7) will minimize this problem. The lower abdominal incision is much longer in post–massive weight loss patients than in other patients presenting for an abdominoplasty. It is also important to resect a portion of the mons if lax. A patient who has undergone a panniculectomy and has been left with a redundant mons is often disappointed. We generally resect the mons horizontally down at three fingerbreadths above the labial cleft.18 Undermining the mons will lead to increased
risk of lymphatic drainage and should be avoided. My decision on how much mons to resect is made on the operating table, as it can be difficult to elevate the area under the pannus while the patient is standing (Fig. 5.9). Recurrent laxity is a problem in any patients after massive weight loss. No matter how tight the skin is pulled, it can be expected to relax over time, leading to some recurrence of the defect. The upper abdomen is an area where recurrent laxity can be particularly bothersome to the patient. Patients are more willing to trade contour for scars, and the possibility of a midline incision should be considered. In some patients, a lateral excision could also be used, especially as a continuation of a brachioplasty incision and especially in patients with laxity lateral to their breast area. The risk of seromas is higher in this population. The fat appears different in these patients—it is clear that there are still too many fat cells present (although they appear depleted), from the appearance of the fat. Use of four drains is advised to adequately drain the area. Even then, some patients will develop a seroma (see Complications and their management section).
POSTOPERATIVE CARE
Avoidance of pulmonary embolus is of utmost importance. During the procedure, pneumatic stockings are used, and early mobilization in the postoperative period is key. Some surgeons advocated the use of low-molecular-weight heparin starting before or after the procedure, but there is not a clear consensus at this time. What is agreed on is the importance of early mobilization as quickly as possible. We have found that it is useful to insist that in order to eat, the patients must be out of bed in a chair. A one-night stay in either an aftercare facility or a hospital may be recommended because the amount of fluid shifts due to the amount of tissue that is removed, as well as to monitor for a hematoma. Some surgeons base their decision on the BMI of the patient at the time of abdominoplasty. In one study, patients with a BMI up to 34kg/m2 were considered for outpatient abdominoplasty. Patients with a BMI of 35kg/m2 were kept overnight in the hospital. For borderline cases involving an obese patient, the decision was made after a qualified anesthesia provider was consulted.19 As the skin is very stretched and there is a large dead space in these patients, it can be difficult to assess the abdomen for a hematoma, particularly in the early phase of a fluid collection. The abdominal skin may never become taut, despite even a liter of blood being present. If clinical suspicions are high (low blood pressure, increased drainage, or sanguinous drainage), then an ultrasound can be helpful in confirming the diagnosis.
COMPLICATIONS AND THEIR MANAGEMENT
An interesting observation has been made regarding the risk of complications between non-obese, borderline, and obese
Complications and their management
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Figure 5.34 Resected pannus.
Figure 5.35 Pannus closed with #2 nylon mattress stitch and packed with Kerlix.
patients undergoing abdominoplasty. A multifactorial analysis of variance showed that the preoperative weight at the time of abdominoplasty had a highly statistically significant effect on the incidence of complications, whereas previous bariatric surgery did not.20 One group of patients seems to have the highest complication rate for any body-sculpting procedure: those who have had the greatest change in their BMI from prebariatric surgery to postbariatric surgery. Also, patients with a high BMI (over 35kg/m2) at the time of plastic surgery have an increased complication rate, with seromas being the most common problem.6 For the abdominal procedures, those at greatest risk of problems would include the group with a subset of those patients who carried their weight in the abdominal area. These patients, who can be described as having the apple pattern or male pattern of fat distribution, have the greatest amount of residual abdominal fat and skin, and therefore would be at risk for the highest rate of complications. This stems from the large number of fat cells present in their abdominal areas. When the patients were heavy, they had too many fat cells (hyperplasia) and they were too large (hypertrophy). When the patients lose weight, they still have too many fat cells, although the cells are now shrunken. The skin and fat that are resected contain many shrunken fat cells, but the skin and fat left behind still contain more fat cells per area than in patients who have never been morbidly obese. Fat cells are known to secrete many substances, such as leptin and inflammatory cytokines, that effect endothelial permeability. The secretion of these substances by this large population of fat cells may lead to the increased risk of seroma
formation over the risk seen in patients undergoing abdominoplasty without massive weight loss. Ideally then, to minimize the risk of problems, one would choose to operate on the patient who has not lost a significant amount of weight and whose lost weight was not from their abdomen. Clearly, this is not the typical postbariatric patient, and therefore the risk of seroma formation must be dealt with. The use of four drains has already been discussed; this is important in adequately draining the space. Different surgeons manage the drains differently. Some surgeons routinely remove the drains at 2 weeks whether or not the drainage has decreased, and will then deal with the complication of seroma formation as it occurs. Others will remove the drains only when a certain drainage level (our criterion is 40cc per day) has been reached. In either case, seroma formation can occur. Serial aspiration is the most common method used to deal with seromas. Using a 14-gauge angiocatheter through the incision, many seromas can be dealt with by aspiration. The patient is then seen either weekly or biweekly for continued aspiration until the seroma has resolved. If the seroma cannot be aspirated in the office, then an ultrasound with drain placement may be required. Various techniques have been suggested as methods to control seroma formation. Some surgeons use mattress-type sutures21 to minimize the dead space and therefore reduce the available space for seroma formation. Others have used tissue sealants during the procedure. Surgeons have been using tissue sealants to minimize the occurrence of seromas during latissimus flap surgery22 and have recently adapted its use to this area. The use of tissue sealants (most notably Tisseel, Baxter
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Figure 5.36 Result of T-juncture breakdown and secondary healing.
Corp., Deerfield, Illinois) for reducing the risk of seromas is an off-label use of the product. The use of Tisseel seems to reduce the number of seromas that occur and, when seromas do occur, their size is diminished.23 When drainage is persistent, some surgeons have been using doxycycline in the drains. Similarly to the use of doxycycline in thoracic surgery to decrease pleural effusions, the doxycycline is diluted (100mg in 5cc of saline) and injected into the drain. The drain is then left unclamped for 4h and then suction is again applied. Some patients may complain of a temporary burning sensation, but most do not report any symptoms. The burning sensation, if felt, seems to be more common in patients who are less than 2 weeks out from their procedure. Anecdotal evidence shows that, for some patients, this method is effective in expediting the resolution of the seroma. The most common site of wound breakdown is at the T juncture where the vertical and horizontal incisions come together. Debridement and packing will usually allow this area to heal, but patients may require a scar revision (Fig. 5.36). Infections are not that common but, when they do occur, can be troublesome to manage. If a patient presents with an infection, it is important to recall which bariatric procedure the patient had undergone. Patients who have undergone a malabsorptive procedure, especially a duodenal switch, may not absorb adequate antibiotics and so may require intravenous therapy. We have handled this situation by admitting the patients, having a peripherally inserted central catheter line placed, and then continuing the intravenous antibiotics at home.
CONCLUSION
The post–massive weight loss patient is both challenging and rewarding. Although the surgery may be more difficult, in requiring different incisions or even a staged approach, the outcome may be life-changing for the patient. Careful planning and discussions with the patient, as well as some different intraoperative routines, can minimize the complications as well as undesirable outcomes.
REFERENCES

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ADDITIONAL READING
Al-Basti HB, El-Khatib HA, Taha A, et al. Intraabdominal pressure after full abdominoplasty in obese multiparous patients. Plast Reconstr Surg 2004; 113(7):2145–2150. Baroudi R, Ferreira C. Seroma: how to avoid it and how to treat it. Aesthetic Surg J 1999; 18:439. Belin RP, Stone NH, Fischer RP, et al. Improved technique of panniculectomy. Surgery 1966; 59(2):222–225. Blomfield PI, Le T, Allen DG, et al. Panniculectomy: a useful technique for the obese patient undergoing gynecological surgery. Gynecol Oncol 1998; 70:80–86. Bolton MA, Pruzinsky T, Cash TF, et al. Measuring outcomes in plastic surgery: body image and quality of life in abdominoplasty patients. Plast Reconstr Surg 2003; 112(2):619–625.
Additional reading
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Lockwood TE. Lower-body lift. Aesthetic Surg J 2001; 21:335. Matarasso A. Abdominoplasty. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic surgery: indications, operations and outcomes, vol 5. Aesthetic surgery. St. Louis: Mosby; 2000:2783–2821. Matarasso A. Liposuction as an adjunct to a full abdominoplasty revisted. Plast Reconstr Surg 2000; 106(5):1197–1202. Matarasso A. The male abdominoplasty. Clin Plast Surg 2004; 31(4):555–569. McCabe WP, Kelly AP Jr, Frame B. Panniculectomy following intestinal bypass. Br J Plast Surg 1974; 27:346–351. McGraw LH. Surgical rehabilitation after massive weight reduction: case report. Annual Meeting of the American Society for Aesthetic Plastic Surgery, March 12, 1973, California. Meyerowitz BR, Gruber RP, Laub DR. Massive abdominal panniculectomy. JAMA 1973; 225(4):408–409. Micha JP, Rettenmaier MA, Francis L, et al. ‘Medically necessary’ panniculectomy to facilitate gynecologic cancer surgery in morbidly obese patients. Gynecol Oncol 1998; 69:237–242. Oguz AT, Wachtman G, Heil B, et al. Panniculectomy as an adjuvant to bariatric surgery. Ann Plast Surg 2004; 53(4):360–366. Petty P, Manson PN, Black R, et al. Panniculus morbidus. Ann Plast Surg 1992; 28(5):442–452. Powell JL, Kasparek DK, Connor GP. Panniculectomy to facilitate gynecologic surgery in morbidly obese women. Obstet Gynecol 1999; 94(4):528–531. Rubin JP, Nguyen V, Schwentker A. Perioperative management of the post-gastric-bypass patient presenting for body contour surgery. Clin Plast Surg 2004; 31:601–610. Soundararajan V, Hart NB, Royston CMS. Abdominoplasty following vertical banded gastroplasty for morbid obesity. Br J Plast Surg 1995; 48:423–427. Stanhope CR, Winburn KA, Silberman MB. Indicated noncosmetic panniculectomy in gynecologic surgery. J Pelvic Surg 2002; 8:197–201. Van Geertruyden JP, Vandeweyer E, de Fontaine S, et al. Circumferential torsoplasty. Br J Plast Surg 1999; 52(8):623–628. Van Uchelen JH, Werker PM, Kon M. Complications of abdominoplasty in 86 patients. Plast Reconstr Surg 2001; 107(7):1869–1873. Young SC, Freiberg A. A critical look at abdominal lipectomy following morbid obesity surgery. Aesthetic Plast Surg 1991; 15:81–84. Zook EG. Abdominoplasty following gastrointestinal bypass surgery. Plast Reconstr Surg 1983; 4:508–509. Zook EG. Massive weight loss patient. Clin Plast Surg 1975; 2(3):457.

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