The Fleur-De-Lis Abdominoplasty

Accelerating Fleur-de-lis Panniculectomy with the Absorbable Dermal Stapler-A Study of Efficiency, Aesthetics, and Quality-of-life

BACKGROUND

Fleur-de-lis panniculectomy (FDL), a contouring technique involving vertical and horizontal tissue resections, often involves longer operative times and potential complications. This study assessed operative time, postoperative outcomes, and patient-reported quality of life (PRO) with Insorb® Absorbable Subcuticular Skin Stapler versus traditional sutures during FDL.

METHODS

A retrospective review from 2015 to 2022 of FDL patients excluded those with complex concomitant procedures. Demographics, operative details, and surgical outcomes were compared between patients using the dermal stapler and those with suture-only closures.

RESULTS

Forty subjects were identified, with 25 (62.5%) in the dermal stapler cohort. The dermal stapler significantly reduced total procedure time (66.76 vs. 125.33 min, p < 0.05). There were no significant differences in surgical site occurrences, aesthetic outcomes, readmissions, or reoperations. Multivariate regression analysis further highlighted the choice of closure technique as an independent predictor of operative time, with traditional sutures indicating a significantly increased operative time compared to using the dermal stapler (AOR 76.53, CI 38.11-114.95, p < 0.001). Regarding PROs, both groups saw improvements across multiple BODY-Q domains, but the dermal stapler group reported greater enhancements (six out of nine domains vs. three for sutures).

CONCLUSION

The absorbable dermal stapler significantly reduces FDL operative time without increasing wound healing or aesthetic dissatisfaction incidents and maintains comparable quality-of-life improvements to standard suture closure.

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 the Table of Contents or the online Instructions to Authors https://link.springer.com/journal/00266 .

Indications of Oblique Flankplasty

The oblique flankplasty is an important alternative in truncal body contouring surgery. Because of the proximity and direction of the incision, it is effective in narrowing the waist and addressing the challenging flank area. There are pros and cons to the technique, specifically when compared with a lower body lift, and these should be carefully considered for each patient.

Fleur-de-lis Miniabdominoplasty Access in Radical Resection of a Large Abdominal Wall Desmoid Tumor

Desmoid tumor (DT) is a rare benign soft tissue neoplasm that develops in the musculoaponeurotic structures, one-third of which involve the abdominal wall. Due to local aggressive infiltration of DT, the recurrence rate is approximately 45%-77%, according to the locations of the tumors, and 25%-50% for those with unclear surgical margins. Limited by adverse effects of radiotherapy and chemotherapy, surgical excision is still the standard management recommended. Differing from traditional midline or abdominoplasty access, we applied a fleur-de-lis miniabdominoplasty access in a 37-year-old woman who had primary abdominal wall DT with less than 1 cm depth from the umbilicus. The approach not only provides a better surgical field for radical tumor excision but also eliminates redundant skin and dog-ear formation at bilateral flanks. An appropriate surgical margin could be processed simultaneously when the tumor was close to the skin surface. After abdominal wall reconstruction, the postoperative course was uneventful, and no DT recurrence or incisional hernia was noted during the follow-up. The patient was satisfied with the tumor treatment and aesthetic outcome.

[Abdominoplasties and Suppurative Hydradenitis (Acne inversa) in Patients after Massive Weight Loss]

Post-bariatric surgical procedures in patients after massive weight loss (MWL) are often associated with elevated minor and major complications (17-55%). If there is additionally a long history of hydradenitis suppurativa (HS) in the lower abdomen and groin area, complications of infection can appear in all patients. Differentiated pre-, peri- and postoperative therapy regime is then indicated.From 2010 to 2021, a total of 12 (66.6% women, 33.3% men) consecutive patients underwent conventional (Pittsburg rating scale [PRS]: Grade 2) or fleur-de-lis abdominoplasty (PRS: Grade 3) after massive weight loss. All patients simultaneously suffered long term HS in the lower abdomen and groin area (Hurley classification Grade 2: n = 10, Grade 3: n = 2). The prevalence in our study was 1.09%.Postoperative minor and major complications (follow-up 12 months) are determined and correlated with risk factors (e.g. age, method of weight loss, nicotine abuse…).Mean age was 45.2 years (± 10.3), mean BMI pre-operative 33.24 kg/m² (± 8.7), the mean decrease in BMI was 19.01 kg/m² (± 5.9) and the maximum BMI before weight loss 52.25 kg/m². The mean duration of the suppurative hydradenitis was 31.5 years and n = 2 (17.0%) had current medical therapy against this. All patients showed further locations of the HS in other parts of the body and 66.6% had had surgical procedures because of the HS. 42.0% had nicotine abuse. The mean operation time was 98 minutes and the mean resection weight was 2210 grams. The overall complication rate was n = 10 (83.0%), and the rate of major complications n = 8 (66.4%) with surgical intervention in full anaesthesia. No patient had an infected haematoma, abscess or acute bleeding in the first 24 hours postoperatively.The antibiotic regime prevented the expected soft tissue infection in all patients. Inspection of the abdomen and groin area 4 weeks before surgery is recommended, in order to start preoperative therapy for the HS.

[Lipoabdominoplasty in post-bariatric Surgery: a relevant Alternative to Fleur-de-Lis abdominoplasty?]

BACKGROUND

The number of bariatric procedures, and thus also the number of post-bariatric operations, has increased dramatically in recent years. Although long scars are common in post-bariatric surgery and accepted in favour of body shape reconstruction, we increasingly notice the wish for aesthetically pleasing results in addition to the desire for body contouring. In particular, Fleur-de-Lis abdominoplasty (FdL) is viewed critically by younger patients after massive weight loss due to the visible vertical scar. Surgeons are also often bothered by the unsatisfying aesthetic outcome as well as the higher rate of complications.

METHODS

Retrospective analysis of 20 female patients with massive weight loss following bariatric surgery, who received lipoabdominoplasty instead of Fleur-de-Lis abdominoplasty in the period from January 2019 to June 2020. Data analysis was based on measurements of preoperative vertical and horizontal excess skin and fat (Pittsburgh Rating Scale), Body Mass Index, surgical technique and final result.

RESULTS

Twenty female patients with an indication for FdL abdominoplasty underwent radical liposuction of the abdomen combined with abdominoplasty. The original weight before massive weight reduction ranged between 100 and 168 kg. Average weight reduction was 56.5 kg. The mean BMI was 27.3 kg/m². The average age of our cohort was 40 years. One patient (5 %) had a major complication. This was an infected seroma which could be treated conservatively. Two other patients (10 %) developed an uninfected seroma as a minor complication.

CONCLUSION

Our work shows that lipoabdominoplasty can be performed safely and well even in patients after massive weight loss. It is possible to achieve good body contours without vertical incisions and with a high degree of patient satisfaction. The number of patients who have to undergo FdL abdominoplasty can be successfully reduced by this technique.

A Comparative Analysis of Fleur-de-Lis and Traditional Panniculectomy after Bariatric Surgery

INTRODUCTION

The Fleur-de-Lis panniculectomy (FdL) adds a vertical component to correct complex contour deformities after massive weight loss by addressing supra-umbilical horizontal skin excess which is not addressed with infra-umbilical transverse panniculectomy (TP). We aim to perform a head-to-head comparison of clinical outcomes and patient reported outcomes (PROs) between FdL and TP.

METHODS

A retrospective review of patients ≥18 with a history of bariatric surgery undergoing FdL or TP by a single plastic surgeon between 07/01/2015 and 05/31/2020 was conducted. Surgical site occurrences (SSOs) including surgical site infection (SSI), delayed healing, cellulitis, seroma, hematoma, surgical site occurrences requiring procedural intervention (SSOpi), and a composite of other postoperative outcomes were assessed. In addition, patient satisfaction was analyzed using the Body-Q questionnaire across 12 domains.

RESULTS

The analysis included 56 patients; 26 and 30 patients who were treated with FdL and TP, respectively. Cohorts were statistically similar in terms of age, gender, BMI, and co-morbid conditions. The overall complication rate was 50% (FdL n = 14 (53.9%), TP n = 14 (46.7%); p = 0.592). On multivariate analysis, pannus weight was associated with the development of SSO (p = 0.04). FdL incision, however, was not an independent risk factor for adverse outcomes. Absolute improvement in PROs was similar in both cohorts across multiple domains.

CONCLUSION

FdL showed a comparable safety and efficacy profile to TP when performed in post-bariatric surgery patients, with equivalent improvement in PROs across multiple domains. Preoperative weight loss should be encouraged in this population as pannus weight is an independent risk factor for complications.

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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Kempe incision for decompressive craniectomy, craniotomy, and cranioplasty in traumatic brain injury and stroke

OBJECTIVE

Decompressive craniectomy (DC) is an effective, lifesaving option for reducing intracranial pressure (ICP) in traumatic brain injury (TBI), stroke, and other pathologies with elevated ICP. Most DCs are performed via a standard trauma flap shaped like a reverse question mark (RQM), which requires sacrificing the occipital and posterior auricular arteries and can be complicated by wound dehiscence and infections. The Ludwig Kempe hemispherectomy incision (Kempe) entails a T-shaped incision, one limb from the midline behind the hairline to the inion and the other limb from the root of the zygoma to the coronal suture. The authors' objective in this study was to define their implementation of the Kempe incision for DC and craniotomy, report clinical outcomes, and quantify the volume of bone removed compared with the RQM incision.

METHODS

A retrospective review of a single-surgeon experience with DC in TBI and stroke was performed. Patient demographics, imaging, and outcomes were collected for all DCs from 2015 to 2020, and the incisions were categorized as either Kempe or RQM. Preoperative and postoperative CT scans were obtained and processed using a combination of automatic segmentation (in Python and SimpleITK) with manual cleanup and further subselection in ITK-SNAP. The volume of bone removed was quantified, and the primary outcome was percentage of hemicranium removed. Postoperative surgical wound infections, estimated blood loss (EBL), and length of surgery were compared between the two groups as secondary outcomes. Cranioplasty data were collected.

RESULTS

One hundred thirty-six patients were included in the analysis; there were 57 patients in the craniotomy group (44 patients with RQM incisions and 13 with Kempe incisions) and 79 in the craniectomy group (41 patients with RQM incisions and 38 Kempe incisions). The mean follow-up for the entire cohort was 251 ± 368 days. There was a difference in the amount of decompression between approaches in multivariate modeling (39% ± 11% of the hemicranium was removed via the Kempe incision vs 34% ± 10% via the RQM incision, p = 0.047), although this did not achieve significance in multivariate modeling. Wound infection rates, EBL, and length of surgery were comparable between the two incision types. No wound infections in either cohort were due to wound dehiscence. Cranioplasty outcomes were comparable between the two incision types.

CONCLUSIONS

The Kempe incision for craniectomy or craniotomy is a safe, feasible, and effective alternative to the RQM. The authors advocate the Kempe incision in cases in which contralateral operative pathology or subsequent craniofacial/skull base repair is anticipated.

Trunkoplasty after massive weight loss - a case series with a one-stage body contouring procedure for the NHS patient

Body contouring post massive weight loss (MWL) is a considerable task and is often a functional rather than esthetic operation. Clinicians are often encouraged to solve multiple issues in a single setting that can be difficult in the MWL patient. A simple abdominoplasty often does not provide a satisfactory outcome in such patients and may result in disharmony of the esthetic unit of the trunk. Trunkoplasty is a technique that combines a fleur-de-lis abdominoplasty and reverse abdominoplasty. This is a one-stage operation to address the extra skin of the whole trunk esthetic unit. The average operation time was 4 h with a 3-surgeon team. No blood transfusions were required. There were 3 out of 15 patients with wound-related problems and no incidence of postoperative hematomas. There were no returns to theaters. Seromas formed were not symptomatic and no interventions were required. The average inpatient stay was 6.9 days and a return to work after 4 weeks. It can improve abdominal contour, define the waist, and improve mons ptosis in one stage without any change in position. This procedure has some specific advantages (accommodates preexisting abdominal scars), but also has shortcomings as compared to "standard" circumferential body contouring.

Enhancing Masculine Features After Massive Weight Loss

BACKGROUND

Whereas body contouring surgery after massive weight loss in women emphasizes sculptured adipose and broader lower torso, little attention has been devoted to accentuating the male physique.

OBJECTIVE

To determine if boomerang excision pattern correction of gynecomastia with J torsoplasty combined with an abdominoplasty with oblique excisions directly over bulging flanks provide effective and safe optimizing of muscle visibility and upper torso dominance.

METHODS

A description of comprehensive body contouring through an abdominoplasty and a series of obliquely oriented ellipses of the male torso is followed by review of 19 consecutive patients.

RESULTS

Seventeen patients were performed in a single stage. Nine of the last ten cases included J torsoplasty and oblique excision extensions over the flanks. Of the 17 patients responding to a ten-question survey, 15 were satisfied with chest improvement. One of the first eight patients with a transverse lower body lift was satisfied with the flank bulges. All of the last eight cases with direct oblique flank excisions were satisfied with their lower body. Five patients (26 %), having a total of 74 operative procedures, had significant complications of chest hematoma, persistent hip and buttock seromas, superior NAC edge necrosis, and distal necrosis of the fleur de lis abdominoplasty. One boomerang correction underwent minor revisions. One transverse lower body lift underwent major revision. No complications occurred in the last ten patients, having oblique flank excisions instead of transverse lower body lifts.

CONCLUSION

Comprehensive excisional body contouring surgery of a central high tension abdominoplasty with a series of obliquely oriented ellipses throughout the torso appears to provide low risk improved body contour for the muscular male.

LEVEL OF EVIDENCE IV

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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Abdominoplasty After Massive Weight Loss

After massive weight loss (MWL), patients present with deformities that are more severe and often different than those observed in standard cosmetic abdominoplasty. The first step is careful consideration of the special factors involved in preoperative screening of patients with MWL presenting for body contouring surgery. Once these patient factors are optimized and surgery is considered, careful analysis of anatomic deformities should ensue. Technical variations of standard abdominoplasty are often required. With proper attention to safe screening, analysis of the anatomic deformities, and application of relevant techniques, plastic surgeons can have a positive impact on the lives of these patients.

Comparison of Aesthetic Quality of the Final Scar in Abdominoplasty with Conventional and Mini Inverted t-Scar

Background and objectives: Abdominoplasty is one of the most commonly performed cosmetic procedures. The excess skin in the conventional abdominoplasty is transversely excised and a single horizontal scar is formed. The mini inverted t-scar abdominoplasty is a modification of the “Fleur-de-lis” technique and involves the use of a small vertical incision in comparison to the long vertical incision. The aim of this technique is to lower the position of the final abdominal scar instead of addressing the horizontal laxity. In this study, we have compared the aesthetic satisfaction, width and the position of the scar with conventional abdominoplasty and mini inverted t-scar abdominoplasty. Materials and Methods: Thirty patients undergoing abdominoplasty and breast reconstruction with transverse rectus abdominis flap (TRAM) and deep inferior epigastric flap (DIEP) were included in the study. In 15 patients, abdominal closure with the conventional transverse scar was performed. In the remaining 15 patients, closure with a mini inverted t-scar was performed. Scar width, scar height and satisfaction scores were evaluated in both groups. Results: Scar widths, scar heights and patients’ and as well as surgeons’ satisfaction scores were better in the mini inverted t-scar group than the conventional group. Conclusions: The visibility of the vertical scar alone should not be a reason to avoid mini inverse t-scar abdominoplasty. Mini inverted t-scar can be an option to achieve a better hidden high-quality scar.

Modified Fleur-de-lis Abdominoplasty for Massive Weight Loss Patients

INTRODUCTION

Fleur-de-lis abdominoplasty is an effective procedure for correcting abdominal contour abnormalities in both the vertical and horizontal orientation. Tension on the approximated tissue edges and reduced microvascular perfusion is mainly responsible for wound dehiscence and delayed wound healing in the T-point area and seroma formation. To reduce these complications, we developed a modification of the fleur-de-lis abdominoplasty technique forming upper abdominal skin flaps with deepithelialized mediocaudal edges.

MATERIALS AND METHODS

A total of 76 consecutive patients underwent fleur-de-lis abdominoplasty over a 2-year period. Of these, 38 (50%) underwent standard fleur-de-lis abdominoplasty and 38 (50%) had modified fleur-de-lis abdominoplasty.

RESULTS

Full-thickness skin defects as major complications and nonoperative treated seroma formations were significantly reduced in modified fleur-de-lis abdominoplasty patients.

CONCLUSIONS

Modified fleur-de-lis abdominoplasty reduces the rate of full-thickness skin defects at T-junction and the development of seroma formation.

Corset Trunkplasty: Recommended with Abdominal Skin Laxity and Open Cholecystectomy Scar

BACKGROUND

Patients undergoing abdominoplasty with previous upper abdominal wall scars are at an increased risk for postoperative complications. The corset trunkplasty is a newer technique to treat abdominal wall laxity of the entire anterolateral abdomen while incorporating any previous open cholecystectomy scar. The authors performed a comparative outcomes study to determine whether the corset procedure would decrease the incidence of postoperative complications in patients with abdominal wall laxity and an open cholecystectomy scar when compared with traditional abdominoplasty.

METHODS

A retrospective study was performed on patients who underwent traditional and corset abdominoplasty. Patients were divided into four groups: traditional with scar, corset with scar, traditional no scar, and corset no scar. Evaluated metrics included procedure time, postoperative length of stay, complications, reoperations, and readmission rates.

RESULTS

Fifty-eight subjects were included in the study (traditional with scar, n = 15; corset with scar, n = 13; traditional no scar, n = 15; and corset no scar, n = 15). Demographics were similar among groups: body mass index, 33.7 kg/m; age, 44.3 years; and American Society of Anesthesiologists status, 2.5. The corset procedure took longer than the traditional method, regardless of whether a scar was present (146.1 minutes versus 125.7 minutes). However, the traditional with scar group had the greatest length of stay and higher complication, readmission, and reoperation rates. The corset with scar group had comparable outcomes to the corset no scar and traditional no scar groups.

CONCLUSIONS

The corset trunkplasty procedure resulted in fewer adverse outcomes compared with traditional abdominoplasty in patients with previous open cholecystectomy scar. Its use should be considered in patients with significant abdominal wall laxity and existing upper abdominal surgical scars.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Enhancing Masculine Features After Massive Weight Loss

Background

Whereas body contouring surgery after massive weight loss in women emphasizes sculptured adipose and broader lower torso, little attention has been devoted to accentuating the male physique.

Objective

To determine if boomerang excision pattern correction of gynecomastia with J torsoplasty combined with an abdominoplasty with oblique excisions directly over bulging flanks provide effective and safe optimizing of muscle visibility and upper torso dominance.

Methods

A description of comprehensive body contouring through an abdominoplasty and a series of obliquely oriented ellipses of the male torso is followed by review of 19 consecutive patients.

Results

Seventeen patients were performed in a single stage. Nine of the last ten cases included J torsoplasty and oblique excision extensions over the flanks. Of the 17 patients responding to a ten-question survey, 15 were satisfied with chest improvement. One of the first eight patients with a transverse lower body lift was satisfied with the flank bulges. All of the last eight cases with direct oblique flank excisions were satisfied with their lower body. Five patients (26 %), having a total of 74 operative procedures, had significant complications of chest hematoma, persistent hip and buttock seromas, superior NAC edge necrosis, and distal necrosis of the fleur de lis abdominoplasty. One boomerang correction underwent minor revisions. One transverse lower body lift underwent major revision. No complications occurred in the last ten patients, having oblique flank excisions instead of transverse lower body lifts.

Conclusion

Comprehensive excisional body contouring surgery of a central high tension abdominoplasty with a series of obliquely oriented ellipses throughout the torso appears to provide low risk improved body contour for the muscular male.

Level of Evidence IV

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 the Table of Contents or the online Instructions to Authors www.springer.com/00266.