Abdominoplasty is a well-established body contouring procedure commonly performed on patients following massive weight loss or pregnancy, or because of general aging.1–3 By surgically removing excess skin and fat from the abdomen, and performing rectus muscles plication as necessary, plastic surgeons can enhance the functionality and appearance of the abdomen.4 Although exact rates vary in the literature, acceptable complication rates have been achieved through selective identification of eligible candidates for surgery, some of whom undergo abdominoplasty in the outpatient setting.5–12 Body contouring has been historically discouraged in the overweight and obese patient population on the basis that increased body mass index hampers wound healing and promotes seroma formation.13–22
In addition to physical health safety concerns, the psychological impact of body contouring procedures has received a great deal of scholarly attention in recent years.23–25 Benefits such as improved emotional well-being and greater self-confidence have been attributed to surgical body contouring procedures in nonobese patients.26 Still, few studies have addressed the potential psychological benefits or drawbacks of abdominoplasty in the overweight or obese patient.
In contrast to the widely held belief that increased body mass index is a contraindication for abdominoplasty, a select subset of the literature supports the safety and functional efficacy of this procedure in the overweight and obese patient, prompting the need for more in-depth investigation.3,27–34 The purpose of this study was twofold: to determine the complication rate and associated risk factors that may predict patient outcomes, and to evaluate the psychological impact and patient satisfaction level following abdominoplasty in the overweight or obese patient.
PATIENTS AND METHODS
A retrospective review was conducted of 46 consecutive abdominoplasty and panniculectomy patients who underwent surgery over a 12-year period from January of 2004 to December of 2016. All operations were performed by one of three surgeons at a single plastic surgery practice. Abdominoplasty was defined as undermining of the abdominal flap to the level of the xiphoid with translocation of the umbilicus. Panniculectomy was defined as minimal undermining of the abdominal flap with excision of abdominal tissue without translocation of the umbilicus. All patients included in the study were overweight (body mass index ≥25 kg/m2), obese (body mass index ≥30 kg/m2), or morbidly obese (body mass index ≥35 kg/m2) before surgery. Regardless of the presence or absence of excessive visceral fat, all patients presented with a redundant pannus as their primary complaint, and it was the removal of this pannus and the recontouring of the abdomen that served as the ultimate operative goal.
At the time of surgery, the lowermost incision was made initially and the upper abdominal panniculus was separated away from the underlying abdominal wall up to the level of the costal margin. The umbilicus was freed from the flap and left attached to the abdominal wall. In cases where there was laxity to the abdominal wall, fascial plication using a nonabsorbable monofilament suture was performed as needed to provide the desired abdominal recontouring. Excision of redundant tissue and closure over two closed suction drains completed the procedure. The location for the umbilicus was sited in and it was brought out and secured into position. In selected cases, liposuction of the posterior hips and the epigastrium was performed based on the surgeon’s preoperative evaluation. In patients with risk factors such as diabetes mellitus or smoking, a more cautious operative approach, including limited undermining and avoidance of concomitant liposuction is warranted. All patients were treated postoperatively with avoidance of concomitant liposuction, two closed suction drains, and an abdominal binder.
Patient medical records were reviewed to identify comorbidities, smoking status, and any previous abdominal operations. The operative records were also reviewed to identify surgical details such as chemical deep venous thrombosis prophylaxis, concurrent procedures, need for muscle plication, and abdominal resection weight. In addition, the medical records were reviewed to identify postoperative details such as complications, and number and type of revision procedures required.
Finally, a patient survey was mailed to all patients (Fig. 1). The survey aimed to identify factors of patient satisfaction, focusing on specific aspects of a patient’s lifestyle that may have been affected. The survey also inquired about the subjective patient experience with complications and the recovery process. This study was reviewed and approved by the Spectrum Health Institutional Review Board on March 6, 2017 (Grand Rapids, Mich.).
Forty-six total patients underwent abdominoplasty or panniculectomy during the 12-year period and met the criterion of body mass index greater than or equal to 25 kg/m2. The majority of the patients [n = 41 (89.1 percent)] were women; five were men (10.9 percent). The average patient age was 49 years (range, 22 to 74 years). The average patient body mass index was 32.0 kg/m2 (range, 25 to 51 kg/m2), with the majority of the patients categorized as overweight (Table 1). Additional patient comorbidities are listed in Table 2.
Table 1. -
Body Mass Index Categories
||No. of Patients (%)
|Overweight (BMI ≥25 kg/m2)
|Obese (BMI ≥30 kg/m2)
|Morbidly Obese (BMI ≥35 kg/m2)
Table 2. -
||No. of Patients (%)
|Previous abdominal surgery
The majority of the patients [n = 37 (80.4 percent)] underwent abdominoplasty, with the remaining patients undergoing panniculectomy [n = 9 (19.6 percent)]. Four patients (8.7 percent) were administered deep vein thrombosis chemoprophylaxis. For two patients, Lovenox (Sanofi-Aventis, Bridgewater, N.J.) 40 mg daily was used starting preoperatively and continuing for 7 days. One patient, who was on Coumadin (Bristol-Myers Squibb, Princeton, N.J.) perioperatively, was started on Lovenox 100 mg every 12 hours for three doses preoperatively, and then one dose was given postoperatively. This patient developed a hematoma requiring return to the operative room and was bridged back to Coumadin before discharge to home. The fourth patient requiring chemoprophylaxis had just one dose of 5000 U of subcutaneous heparin used preoperatively.
Of the patients who underwent abdominoplasty, 29 (78.4 percent) had plication of the rectus abdominis muscles performed. Of the patients who underwent panniculectomy, three (33.3 percent) had plication performed. Forty-one percent of patients underwent a concurrent procedure at the time of abdominoplasty or panniculectomy [n = 19 (41.3 percent)], and 24 patients (52.2 percent) underwent concurrent liposuction (n = 24) (Table 3). The abdominal resection weight was reported in nearly half of the patients (n = 20). The average abdominal resection weight was 4834.9 g (range, 2022 to 14,770 g). Surgical times were not available in this study, which is a limitation because longer surgical times have been linked to an increased rate of complications.3
Table 3. -
Concurrent Procedures and Concurrent Liposuction
||No. of Patients
|Revision reconstructed breast
|Concurrent liposuction (abdomen, hips/flanks)
Five patients underwent more than one concurrent procedure.
Six patients underwent concurrent liposuction in more than one local area.
The follow-up time for this study was 6 months to 10 years (mean, 15 months). In this patient cohort, a major complication requiring a return to the operating room occurred in four patients (8.7 percent). These procedures included débridement of necrotic tissue (n = 3), evacuation of a hematoma (n = 2), and excision of a chronic seroma cavity (n = 2) (three patients had more than one reason for return to the operating room, but all reasons were addressed during one operative intervention). A minor complication—defined as that amenable to treatment with office aspirations, antibiotics, or local wound care—was noted in 18 patients (39.1 percent). The breakdown of these minor complications is detailed in Table 4. Finally, four patients (8.7 percent) were returned to the operating room to address persistent aesthetic concerns related to scar revision, dog-ear excision, or additional liposuction.
Table 4. -
||No. of Patients (%)
|Delayed wound healing
|Deep vein thrombosis
Seven patients experienced two complications, and two patients experienced three complications.
Thirty-six patients (78.3 percent) responded to the survey. Patients were surveyed anywhere from 6 months to 13 years after surgery (mean, 5 years). The overwhelming majority of patients who responded to the survey [n = 34 (94.4 percent)] stated that they were satisfied with the final outcome and 35 (97.2 percent) stated they would choose to have the procedure again. Again, a vast majority of patients who responded to the survey identified improvement in quality of life after the operation [n = 35 (97.2 percent)] (Table 5). Of the patients who responded to the survey, 16 (45.7 percent) stated they lost additional weight after surgery, 10 (28.6 percent) did not lose weight after surgery, and nine (25.7 percent) gained weight after surgery. Of note, one of the patients who responded to the survey did not respond to this specific question. The majority of the patients who responded to the survey stated that, postoperatively, their body appeared about the size they expected [n = 26 (72.2 percent)]. Some patients stated that their body appeared smaller postoperatively than they had expected [n = 8 (22.2 percent)], and only two patients (5.6 percent) reported that their body appeared larger postoperatively than they had expected. Table 6 describes how patients reported the appearance of their scars. Most patients stated that their postoperative recovery was as they had expected [n = 23 (63.9 percent)] (Table 7). Figure 2 is an example of an obese patient who was satisfied with her postoperative result and reported improvement in quality of life as a result of her surgery.
Table 5. -
||No. of Patients (%)
|Clothes fit better
|Confidence is better
|Walk around more comfortably
|Intertrigo has improved
Table 6. -
Patient-Reported Scar Quality*
||No. of Patients (%)
|Light and thin
|Red and ropey
One patient described the scar in multiple categories
Table 7. -
Patient-Reported Postoperative Recovery
||No. of Patients (%)
|Overall longer than expected
|Swollen longer than expected
|Other, faster than expected
|Other, easier than expected
Abdominoplasty and panniculectomy in the overweight and obese patient present a surgical decision-making challenge for the treating surgeon. The complication rate in this subset of patients is generally recognized as elevated compared with other patients, and a common recommendation is for the patient to lose weight before proceeding with body contouring surgery. However, the discomfort and physical effects of a large pannus are real. Even with weight loss, the excess skin and fat of the pannus will not completely recede and can still present as an impediment to normal function and exercise. For this reason, with the full understanding that this cohort of patients had a potentially higher risk of complications, body contouring in the form of either an abdominoplasty or panniculectomy was offered in an attempt to relieve the discomfort and physical effects of the excess skin and fat and offer the potential to jumpstart a weight loss process. It was our hope that the risks associated with the surgical procedure and the associated complications would be manageable enough to make the procedure worthwhile for the patients. This is in fact what was observed.
The overall complication rate was significant at 47.8 percent. However, many of these complications were of minor import and were able to be managed conservatively. More important was the small, 8.7 percent subset of complications that mandated a return to the operating room to manage tissue necrosis, hematoma, and internal scarring secondary to a seroma cavity. In each of these cases, the complication was fully resolved with the operative procedure. In addition, despite this significant complication rate, the postoperative survey data documented a very satisfied patient population, with 94.4 percent of the respondents stating that they were happy with their outcome and 97.2 percent who would have the procedure again. Based on these data, realistic preoperative counseling for this patient population can be provided. A real quality-of-life improvement can be obtained by offering body contouring even in the face of obesity, with the caveat being that the risk of minor postoperative complications is high. In appropriately selected patients, this risk may be acceptable and is offset by the overall success of the procedure. It must be noted, however, that this study is limited by its retrospective nature, its small sample size, the purely descriptive nature of the data, and the use of a survey tool that looks primarily at patient satisfaction. Future prospective comparative studies would further validate the quality-of-life improvement that is achieved in this study.35
Abdominoplasty and panniculectomy in overweight and obese patients is associated with an elevated minor complication rate compared with nonoverweight individuals. However, even in the face of this elevated complication rate, patient satisfaction is overwhelmingly high, making body contouring procedures in this patient population an acceptable option in appropriately selected patients.
The authors thank Joanie Dowling, L.P.N., Alan T. Davis, Ph.D., and Tracy J. Koehler, M.A.
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