Decision making in abdominoplasty

Abdominoplasty as an acute postoperative pain model: insights from 8 years of clinical trials

ABSTRACT

To have a complete understanding of an experimental analgesic's efficacy in treating acute postoperative pain, it is necessary to understand its effect on both hard-tissue pain and soft-tissue pain. For this reason, regulatory bodies including the U.S. Food and Drug Administration and European EMA typically require drug developers to demonstrate efficacy in both hard-tissue and soft-tissue pain to grant a broad approval for an analgesic in acute postoperative pain. Hard-tissue models such as bunionectomy and molar extraction are well-validated and efficient with long histories in clinical trials, but until recently, a similarly well-standardized and fast-enrolling soft-tissue model was not available. Abdominoplasty was developed as an acute postoperative pain model and introduced to the clinical trial marketplace in 2014 to address the need for a viable soft-tissue model. Since then, at least 13 industry-sponsored studies, including multiple pivotal trials, have been conducted, providing a data set that can be used to interrogate the model's strengths and weaknesses. The authors outline the development history of abdominoplasty, discuss key clinical and design characteristics of the model, and review public data from abdominoplasty acute pain studies available to date. The data suggest that abdominoplasty is a well-validated soft-tissue surgical model that provides high-quality experimental outputs, enabling the efficacy of investigational analgesics in soft-tissue pain to be understood successfully.

The Global Prevalence of Seroma After Abdominoplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Abdominoplasty is one of the most common cosmetic surgeries performed worldwide. Seroma is also the most common local complication associated with abdominoplasty, which increases care costs, reduces patient satisfaction, and has serious complications for patients. Results of previous studies report different levels of seroma prevalence after abdominoplasty. The aim of this study is to standardize the statistics of the prevalence of seroma after abdominoplasty using meta-analysis.

METHODS

In this systematic review and meta-analysis study, data from studies conducted on the global prevalence of seroma after abdominoplasty was extracted using the keywords "Prevalence, Epidemiology, Complications, Abdominoplasty, Seroma, and Lipo abdominoplasty" in the databases of Science, Scientific Information Database, MagIran, Embase, Scopus, PubMed, Web of Science, and Google Scholar search engine without time limit until October 2020. The random-effects model was used to analyze the eligible studies, and the heterogeneity of the studies was investigated with the I² index. Data analysis was performed using Comprehensive Meta-Analysis software (Version 2).

RESULTS

In reviewing 143 studies (five studies related to Asia, 55 studies related to Europe, three studies related to Africa, and 80 studies related to the Americas) with a total sample size of 27834 individuals, the global prevalence of seroma after abdominoplasty was obtained as 10.9% (95% CI: 9.3-3.6.6%) and the highest prevalence of seroma was related to the Europe continent with 12.8% (95% CI: 10.15-3.9%). The results from meta-regression showed a declining trend in the global prevalence of seroma after abdominoplasty with an increase in the sample size, age of study participants, and the year of study (p < 0.05).

CONCLUSIONS

This study shows that the prevalence of seroma after abdominoplasty is high globally. Therefore, physicians and specialists must consider its importance and take the controlling and treatment measures seriously.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Secondary Abdominoplasty: Management of the Umbilicus after Prior Stalk Transection

Patients with prior umbilical stalk detachment, secondary to limited abdominoplasty or prior umbilical hernia repair, may in the future be candidates for full abdominoplasty. In these patients, a circumferential incision around the umbilicus detaches the remaining cutaneous blood supply, prompting concern for umbilical viability. Minimal literature exists to guide clinical decision-making for these patients. Inquiries were made to Louisiana Society of Plastic Surgery members and the Plastic Surgery Education Network online forum of the American Society of Plastic Surgeons. Metrics obtained included patient age, sex, nature of primary surgery, time between umbilical stalk detachment and secondary full abdominoplasty, complications, and whether rectus plication was performed at the time of secondary surgery. Eleven physicians provided complete documentation for 18 cases. All patients healed without evidence of umbilical ischemia or necrosis. Average patient age was 40.6 years. Average interval between procedures was 3.6 years. Sixty-seven percent of patients had the umbilicus delayed before the secondary procedure, with the median delay time being 18 days. Rectus fascia was plicated during secondary surgery in 72 percent of patients. This is the first reported series of patients undergoing full abdominoplasty after prior umbilical stalk detachment. It is also the first time the Plastic Surgery Education Network online forum has been used to collect research data, highlighting its potential as a valuable research tool. The data set was obtained from a wide range of practices, which allows for consideration of various technical solutions when this or other diverse clinical scenarios are encountered. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Abdominal Fat SIRT6 Expression and Its Relationship with Inflammatory and Metabolic Pathways in Pre-Diabetic Overweight Patients

: The role of sirtuin 6 (SIRT6) in adipose abdominal tissue of pre-diabetic (pre-DM) patients is poorly known. Here, we evaluated SIRT6 expression in visceral abdominal fat of obese pre-diabetic patients and the potential effects of metformin therapy. Results indicated that obese pre-DM subjects showed low SIRT6 protein expression and high expression of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), peroxisome proliferator-activated receptor gamma (PPAR-γ), and sterol regulatory element-binding transcription factor 1 (SREBP-1). Obese pre-DM patients showed high values of glucose, insulin resistance (HOMA-IR), C reactive protein (CRP), nitrotyrosine, tumor necrosis factor-α (TNF-α) and interleukin 6 (IL-6), and low values of insulin (p < 0.05). Of note, abdominal fat tissue of obese pre-DM patients treated with metformin therapy presented higher SIRT6 expression and lower NF-κB, PPAR-γ, and SREBP-1 expression levels compared to pre-DM control group. Collectively, results show that SIRT6 is involved in the inflammatory pathway of subcutaneous abdominal fat of obese pre-DM patients and its expression responds to metformin therapy.

Abdominoplasty with Circumferential Liposuction: A Review of 1000 Consecutive Cases

BACKGROUND

The authors present the technique called "abdominoplasty with concurrent circumferential liposuction," where the whole trunk is addressed as a single aesthetic unit.

METHODS

Between January of 2008 and June of 2016, abdominoplasty with circumferential liposuction was performed in 1000 patients (984 women and 16 men) by the senior author. Patients had a mean body mass index of 27.5 kg/m (range, 18.1 to 34.5 5 kg/m). Liposuction was performed circumferentially and the abdominal flap was detached up to the costal margins. Simultaneous fat grafting was also performed if required. Outcomes and complications were documented.

RESULTS

Traditional abdominoplasty incisions were used in 359 patients, whereas extended incisions were used in 641 patients. The mean duration of follow-up was 27 months (range, 12 days to 61 months), and the mean duration of surgery was 154 minutes (range, 109 to 260 minutes). The mean amount of simultaneously aspired supernatant lipoaspirate was 1940 cc (range, 1700 to 4580 cc). Simultaneous gluteal fat grafting was performed in 34 percent. None of the patients had any skin necrosis. The most common complication was seroma (19 percent).

CONCLUSIONS

In abdominoplasty, the entire central body should be considered as a single unit. Circumferential widespread liposuction with standard undermining of the abdominal flap up to the costal margins is safe and yields superior aesthetic outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Inflammatory Cytokines and SIRT1 Levels in Subcutaneous Abdominal Fat: Relationship With Cardiac Performance in Overweight Pre-diabetics Patients

Objectives: In obese patients the superficial adipose tissue expresses cytokines, and sirtuins, that may affect myocardial function. In this study, we investigated the effect of metformin therapy added to a hypocaloric diet on the inflammatory pattern and cardiac performance (MPI) in obese patients with pre-diabetic condition. Materials and Methods: Fifty-eight obese patients that were enrolled for abdominoplastic surgery were divided into patients with pre-diabetic condition (n 40) and normo-glycemic patients (n18). Patients with pre-diabetic condition were randomly assigned to metformin therapy added to a hypocaloric diet (group 1, n 20) or to a hypocaloric diet therapy alone (group 2, n20). Patients with normo-glycemic condition were assigned to a hypocaloric diet therapy. Results: During enrollment, obese patients with a pre-diabetic condition (group 1 and 2) presented higher glucose values, lower values of insulin, and higher values of the homeostasis model for the assessment of insulin resistance (HOMA-IR) than obese patients with normo-glycemic condition(group 3). In addition, they had higher values of C Reactive protein (CRP), interleukin 6 (IL6), and lower values of sirtuin 1(SIRT1). In the 12th month of the follow-up, metformin therapy induced in patients with pre-diabetic condition (group 1) a significant reduction of glucose values, HOMA-IR, and inflammatory markers such as CRP (1.04 ± 0.48 vs. 0.49 ± 0.02 mmol/L, p < 0.05), IL6 (4.22 ± 0.45 vs. 3.33 ± 0.34 pg/ml, p < 0.05), TNFα (6.95 ± 0.59 vs. 5.15 ± 0.44 pg/ml, p < 0.05), and Nitrotyrosine (5,214 ± 0,702 vs. 2,151 ± 0,351 nmol/l, p < 0.05). This was associated with a significant reduction of Intima-media thickness (1.01 ± 0.15 vs. 0.86 ± 0.15 mm, p < 0.05), Septum (14 ± 2.5 vs. 10.5 ± 2 mm, p < 0.05), Posterior wall (11 ± 1.5 vs. 8 ± 1 mm, p < 0.05), LV mass (192.5 ± 49.5 vs. 133.2 ± 37.6 g, p < 0.05) and of MPI (0.58 ± 0.03 vs. 0.38 ± 0.02, p < 0.05). At 12 months of follow-up, group 2 experienced only a reduction of cholesterol (4.15 ± 0.94 vs. 4.51 ± 0.88 mmol/L, p < 0.05) and triglycerides (1.71 ± 1.18 vs. 1.83 ± 0.54 mmol/L, p < 0.05). At 12 months of follow-up, group 3 experienced a significant reduction of inflammatory markers, and also of echographic parameters, associated with amelioration of myocardial performance. To date, IL6 expression was related to higher values of left ventricle mass (R-value 0.272, p-value 0.039), and to higher IMT (R-value 0.272, p-value 0.039), such as those observed for CRP (R-value 0.308, p-value 0.021), for glucose blood values (R-value 0.449, p-value 0.001), and for HOMA-IR (R-value 0.366, p-value 0.005). An inverse correlation was found between subcutaneous fat expression of SIRT1 and myocardial performance index (R-value-0.236, p-value 0.002). Conclusion: In obese patients with pre-diabetic condition a metformin therapy may reduce inflammation and oxidative stress, and this may be associated with the amelioration of the cardiac performance. Clinical research trial number: NCT03439592.

Use of an algorithm in choosing abdominoplasty techniques

OBJECTIVE

to validate an algorithm for the choice of the abdominoplasty surgical technique among the five approaches established in the literature, according to the characteristics of the abdominal wall.

METHODS

we conducted a retrospective study of 245 patients undergoing abdominoplasty, for whom the method of choice of the surgical technique was the proposed algorithm, based on the degree of abdominal flaccidity determined by bimanual maneuver. We studied its applications and conveniences, as well as the complications inherent in each group studied.

RESULTS

according to the algorithm used, the most frequently chosen technique was "Technique IV" (transverse dermolipectomy of Pitanguy - or with a Baroudi-Kepke incision), in 25.71% of the cases. "Technique I" (mini abdominoplasty) had the lowest incidence and the lowest rate of complications. On the opposite, "Technique III", dermolipectomy with remaining vertical scarring, presented a higher incidence of complications, requiring extreme caution in its indication, particularly in relation to patients' expectations regarding the resulting scar and its legal aspects. Among all conducts, the most frequent complication was seroma, with a 10.2% occurrence, solved by simple syringe aspiration and use of elastic compression mesh.

CONCLUSION

the proposed algorithm facilitated the choice of abdominoplasty techniques, offering satisfactory results, which are in line with the complication rates published in the world literature.

Abdominoplasty with "Scarpa Fascia" preservation: Case Report

INTRODUCTION

Abdominoplasty is one of the most performed operations in Plastic Surgery in the world. Postoperative seroma is one of the most frequently cited complications in literature. The aim of this study is to propose our experience with abdominoplasty with Scarpa Fascia preservationand compare it with recent scientific literature.

PRESENTATION OF CASE

We present the case of a 55-year-old woman underwent bariatric surgery in 2014, after which she lost 55kg of weight. We decided to perform an abdominoplasty with transposition of the umbilicus and preservation of the Scarpa Fascia. In fact, this technique seems to have a positive impact on reducing seroma formation, reducing the amount of drained fluids and the drainage time.

DISCUSSION

The saving of the adipose-fascial layer according to different Authors would allow the reduction of the volume of drained fluid, of the time spent by the drains and the average hospital stay.

CONCLUSION

The abdominoplasty with the Scarpa Fascia preservation is a safe, repeatable technique with good aesthetic results. The saving of deep adipose tissue allows to reduce the time and the quantity of drained liquids. In our experience patient undergoing this technique has shorter hospital stays with no complications.

Local heat preconditioning in skin sparing mastectomy: a pilot study

BACKGROUND

Experimental data has shown an association with a reduction of flap necrosis after local heat-application to a supraphysiological level resulting from the up-regulation of heat shock proteins, such as HSP-32. The proteins maintained capillary perfusion and increased tissue tolerance to ischaemia. The purpose of this translational study was to evaluate the effect of local heat preconditioning before skin sparing mastectomy and immediate breast reconstruction.

METHODS

A prospective non-randomised trial was performed from July 2009-April 2010. 50 consecutive patients at risk of skin flap necrosis (BMI >30, sternal-to-nipple distance>26 cm or breast size>C-cup) were included. Twenty-five patients were asked to heat-precondition their breast 24-h prior to surgery using a hot water bottle with a water temperature of 43 °C (thermometers provided), in three 30-min cycles interrupted by spontaneous cooling to room temperature. Skin flap necrosis was defined by the need for surgical debridement. LDI images were taken pre- and post-mastectomy to demonstrate an increase in tissue vascularity.

RESULTS

36% of women (n=25) without local heat-treatment developed skin flap necrosis, 12% developed skin flap necrosis in the treatment group, resulting in a 24% difference (n=25; p=0.047 (95%CI 1%-47%)). LDI scanning of the heated breast demonstrated an increase in vascularity compared to the contralateral non-heated breast. Median length of inpatient stay for treatment group was 4 days (95%CI(4, 7)), controls 8 days (95%CI(8, 9) (p=<0.001)).

CONCLUSIONS

The data suggests that in selected cases, local heat preconditioning is a simple and non-invasive method of reducing skin necrosis and length of hospital stay following skin sparing mastectomy.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12612001197820.

LEVEL OF EVIDENCE

II.

Retrospective Analysis of Type II Psillakis-like Mini-Abdominoplasties in a Single Cosmetic Surgery Practice: A Pilot Study

Introduction:

Mini-abdominoplasty is a surgical procedure available to patients with mild skin laxity and no underlying structural deficits including hernias or diastasis recti. This procedure can be performed safely with local anesthesia and minimal recovery time.

Materials and Methods:

All patients at a single private practice undergoing mini-abdominoplasties between 2005 and 2009 were identified. All procedures were performed using intravenous sedation, tumescent anesthesia, limited undermining, and without rectus plication or umbilical stalk resection. Identified patients were asked to complete a postprocedure questionnaire regarding postoperative complications and patient satisfaction.

Results:

Eight patients underwent mini-abdominoplasties, 7 of whom had concomitant liposuction. All patients were contacted and completed the questionnaire. No major postoperative complications were reported. Patient-reported pain, bruising, and edema following the procedure were mild in nature. Patient-evaluated overall improvement in the appearance of their abdomen was 78.13%.

Conclusions:

Type II Psillakis-like mini-abdominoplasty performed with tumescent anesthesia and intravenous sedation offers a safe and effective management of redundant abdominal skin tissue with high patient-reported improvement.

Extended abdominoplasty: applications and a new classification system for abdominoplasty

BACKGROUND

Aesthetic deformities of the abdomen requiring skin resection are usually treated with procedures limited to the abdomen and in some cases with circumferential abdominoplasty. There are some patients who require an intermediate procedure between abdominoplasty and circumferential abdominoplasty; these patients have been neglected in the plastic surgery literature.

METHODS

The medical records of 268 patients who underwent aesthetic procedures of the abdomen between January 2008 and July 2010 were retrospectively reviewed. Patients who had abdominal laxity extending into the flanks and who underwent extended abdominoplasty with liposuction of the back were evaluated. The surgical technique is described and its applications are reviewed.

RESULTS

Twenty-five patients underwent extended abdominoplasty. All patients were extremely satisfied with the results. Only minor complications occurred. Two patients had marginal skin necrosis and one patient had a wound site infection but all of them had satisfactory resolution of their complications.

CONCLUSION

Extended abdominoplasty is a safe procedure with highly satisfactory results that should become common practice in plastic surgery. There is a group of patients who are best served by this procedure and a new classification system of the abdominal contour deformities that includes these patients is needed and is proposed by the authors.