Fleur-de-Lys abdominoplasty--a consecutive case series

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 .

A Procedure and Complication-Specific Assessment of Smoking in Aesthetic Surgery: A Systematic Review and Meta-Analysis

Background: The popularity of aesthetic surgery is on the rise, as is patients' expectations towards excellent surgical results. In order to meet these expectations, risk factors that hinder desired outcomes, such as smoking, need to be identified and addressed. To that end, the present study summarizes an updated systematic review focused on the effects of smoking on cosmetic surgical procedures and outcomes. Methods: A systematic review of studies comparing aesthetic surgical outcomes by procedure, between tobacco smokers and non-smokers was carried out, querying PubMed, Embase and the Cochrane databases. Data regarding surgical outcomes were extracted and meta-analyzed by a random effects model in conjunction with the Mantel-Haenszel statistical method. Results: Eighty-two studies were included in the final synthesis. Abdominoplasty/panniculectomy (n = 19 cohorts) and breast reduction (n = 27 cohorts) were the most common types of procedures included in this review. Other than mastopexy and rhinoplasty, smoking conferred a statistically significant increased risk of overall complications for all studied aesthetic procedures. Conclusions: The data demonstrates that smoking is a clear risk factor for the vast majority of aesthetic plastic surgeries studied. Although our meta-analysis suggests that smoking is not a risk factor for complications in mastopexies and rhinoplasties, these two specific analyses may have been biased, and should therefore be re-evaluated with future additional evidence. The results of this systematic review confirm the importance of smoking cessation and education relative to the outcomes of common cosmetic surgical procedures.

Venous Thromboembolism and Bleeding Events With Chemoprophylaxis in Abdominoplasty: A Systematic Review and Pooled Analysis of 1596 Patients

BACKGROUND

Many plastic surgeons avoid the administration of venous thromboembolism (VTE) chemoprophylaxis out of concern for surgical bleeding in abdominoplasty. Although previous studies have attempted to address the relationship between abdominoplasty and bleeding or VTE, poor reporting techniques remain a challenge. As a result, there has been a lack of reliable data to guide clinical practice.

OBJECTIVES

The authors sought to determine the prevalence of bleeding and VTE in abdominoplasty with and without chemoprophylaxis.

METHODS

A systematic review was performed following PRISMA guidelines utilizing PubMed, CINAHL, and Cochrane Central. Patient demographics, comorbidities, risk category (if available), bleeding events, VTE events, and chemoprophylaxis information were recorded.

RESULTS

Across 10 articles, 691 patients received chemoprophylaxis in the setting of abdominoplasty: 68 preoperatively, 588 postoperatively, and 35 received both; 905 patients did not receive chemoprophylaxis. A total of 96.8% of patients were female, 73% underwent concomitant liposuction, and none were clearly risk stratified. The overall incidence of VTE and bleeding was 0.56% (9/1596) and 1.6% (25/1596), respectively. Compared with no chemoprophylaxis, chemoprophylaxis was not associated with increased incidence of bleeding (1.3% [9/671] vs 0.91% [8/881], P = 0.417) or decreased incidence of VTE (0.87% [6/691] vs 0.33% [3/901], P = 0.187).

CONCLUSIONS

The prevalence of bleeding in abdominoplasty was low. Chemoprophylaxis was not associated with increased risk of bleeding or decreased risk of VTE, though the lack of risk stratification and heterogeneity of the cohort precludes firm conclusions. This study underscores the importance of utilizing validated risk-stratification tools to guide perioperative decision-making.

LEVEL OF EVIDENCE: 4

Post-bariatric Abdominoplasty: Identification of Risk Factors for Complications

PURPOSE

The aim was to evaluate the complication rate after abdominoplasty procedures performed in a high volume post-bariatric center and to identify predictors of complications.

MATERIAL AND METHODS

A retrospective analysis was performed and included all abdominoplasty procedures performed between January 2011 and December 2019. Complications classified according to the Clavien-Dindo classification were documented and potential risk factors were statistically evaluated.

RESULTS

A total of 898 patients were included. Overall complication rate was 29.8%. Type I complications (minor wound problems) occurred in 15.8% (n = 140). Type II complications requiring medical intervention occurred in 10% (n = 90). Five patients had deep venous thrombosis or pulmonary embolism; others received antibiotic treatment for wound infections. In total 42 type III complications occurred in 36 patients, with re-intervention for wound problems (n = 16), seroma (n = 16), umbilical necrosis (n = 4), and bleeding (n = 6). The weight of tissue resected (p < 0.001), the interval between bariatric and body contouring surgery (p < 0.05), preoperative BMI (p < 0.05), male gender (p < 0.05), diabetes mellitus type 2 (p = 0.05), and smoking (p < 0.05) were important predictors for developing complications.

CONCLUSION

In this large retrospective post-bariatric abdominoplasty series, the overall complication rate is low compared to other published series as a consequence of our completely standardized approach and technique. Our analysis shows a significant linear correlation between the amount of skin tissue resected and postoperative complications. Moreover, the longer the interval between bariatric surgery and abdominoplasty, the higher the complication rate. High preoperative BMI, diabetes mellitus type 2, smoking, and male gender were identified as independent significant risk factors for complications.

Vertical Abdominoplasty Technique and the Impact of Preoperative Comorbidities on Outcomes

Background

As the number of patients requiring bariatric surgery has increased, so has the demand for body contouring after massive weight loss. Surgery involving the abdomen in these patients is particularly challenging as both vertical and horizontal laxity if often present, making traditional abdominoplasty techniques less effective.

Objectives

The aim of this study was to review the operative technique and evaluate the preoperative comorbidities and operative decisions that may impact patient outcomes in those undergoing vertical abdominoplasty.

Methods

A review of the authors' technique is described. A retrospective chart review of patients who underwent vertical abdominoplasty for significant vertical and horizontal laxity after massive weight loss by a single surgeon between June 2007 and July 2019 was performed. Preoperative parameters, operative factors, and minor and major complications were evaluated.

Results

Our complication rate was 81% (13/16), which were all minor. No major complications were encountered. Patients with a history of nicotine use had a 100% complication rate. There was a trend toward higher seroma formation in patients with coronary artery disease and those with a history of smoking. There was also a trend toward higher wound dehiscence in patients with renal disease. The authors found no statistically significant correlation between complications and older age, higher weight of tissue resected, higher body mass index, and medical comorbidities.

Conclusions

This small series helps to elucidate the role of vertical abdominoplasty in the care of patients following massive weight loss and its associated morbidity. Proper patient selection, appropriate preoperative patient counseling, and sound surgical technique help to mitigate the negative outcomes.

Level of Evidence 4

Evidence-Based Abdominoplasty Review With Body Contouring Algorithm

Abdominal contour deformities are an aesthetic challenge to the plastic surgeon. Patients present with diverse clinical histories, multiple comorbidities, and unique aesthetic demands. Weight loss, previous pregnancy, and aging are 3 principal indications for abdominoplasty. Bariatric surgery has increased demand for body contouring procedures. This heterogeneous patient cohort means a "one-size-fits-all" abdominoplasty is not appropriate. Precise evaluation, evidence-based decision-making, and artistic acumen are required while balancing patient goals with safe, realistic, and long-lasting aesthetic outcomes. This article reviews surgical options for abdominal body contouring, providing an evidence-based treatment algorithm for selecting the appropriate procedure for each patient to maximize clinical and patient reported outcomes.

Medial thighplasty after massive weight loss: are there any risk factors for postoperative complications?

BACKGROUND

With the increasing incidence of obesity in Western societies, an increasing number of patients undergo bariatric surgery that leads to functional and aesthetic sequelae related to a rapid and massive weight loss, namely, skin and fat excess. The goal of surgical management after massive weight loss is to optimize the functional results obtained from bariatric surgery or diet by removal of the redundant skin folds. The authors report their experience with medial thighplasty after massive weight loss and identify factors predictive of postoperative complications.

METHODS

This retrospective study investigated 53 patients who underwent surgery for medial thighplasty after massive weight loss. Data were collected through chart review and submitted to statistical analysis.

RESULTS

The average weight loss before thighplasty was 43.5 ± 14.9 kg, and 39.6 % of the patients experienced at least one complication. The complications were seroma (9.4 %), wound dehiscence (20.8 %), scar migration (17 %), wound infection (5.7 %), and partial skin necrosis (1.9 %). The body mass index (BMI) before massive weight loss and the BMI before medial thighplasty were found to be risk factors for the development of a postoperative complication.

CONCLUSION

Few guidelines exist for the optimization of care and safety in this complex patient population. The information from this retrospective study complements the current data from the literature and can help surgeons select patients eligible for medial thighplasty. This report shows that the BMI before medial thighplasty should be taken into consideration for patients willing to undergo a body-contouring procedure.

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 .

"Inverted-Y": a modified vest-over-pants abdominoplasty pattern following bariatric surgery

BACKGROUND

The post-bariatric surgery patient presents several challenges to the surgeon. Correction of skin and subcutaneous redundancy can be difficult, particularly in massive-weight-loss patients with horizontal laxity, upper abdominal or flank laxity, and "double-roll" deformities. The aim of our study was to propose our modification of the "vest-over-pants" abdominoplasty technique to exploit all the advantages of the Planas technique in bariatric surgery patients and to solve the problem of extreme epigastric skin redundancy in difficult abdominal contour cases.

METHODS

Sixteen post-bariatric surgery patients (10 females and 6 males, nonsmokers) with moderate to severe epigastric skin laxity were enrolled in the study. They all had undergone a biliopancreatic diversion (BPD) by laparotomy and had undergone this body-contouring procedure from 2006 to 2010.

RESULTS

After the inverted-Y abdominoplasty, 12 patients (75 %) had an uneventful recovery. On the other hand, one subject (6.25 %) had a seroma and four (25 %) had wound dehiscence and delayed wound healing. No skin necrosis was reported. In one patient (6.25 %) scar revision in areas that had delayed healing was performed. The addition of a vertical incision has not led to an increased rate of postoperative complications, but the rates are in line with the satisfactory results described with the Planas technique in bariatric surgery patients. In addition, various advantages have been observed compared to traditional vertical resection patterns.

CONCLUSION

This case series has quantitative limitations and further investigations are needed. However, this study suggests that inverted-Y abdominoplasty could be a good compromise between the need to minimize complication rates and ensure an optimum aesthetic result and patient satisfaction rate in some abdominal defects in massive-weight-loss patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article.

Fleur-de-lis panniculectomy after bariatric surgery: our experience

BACKGROUND

Plastic surgeons are faced with increasing numbers of patients presenting for insurance-covered skin excision procedures following bariatric surgery. Panniculectomy for symptomatic relief of rashes is commonly performed, but an isolated infraumbilical amputation-type panniculectomy is a highly unaesthetic procedure, leaving many patients deeply dissatisfied. It may be also fraught with complications due to large incisions and potential for dead-space. In these patients, many surgeons avoid the fleur-de-lis panniculectomy, despite the body contour aesthetic advantage, because of increased time, more scarring, and a perceived increase in complications.

METHODS

This is a retrospective chart review of 130 consecutive postbariatric surgery patients who had panniculectomy over a 2-year period at our institution.

RESULTS

A total of 30 patients underwent a traditional panniculectomy and 100 patients had a fleur-de-lis panniculectomy. Mean weight loss from bariatric surgery to panniculectomy was 58.2 kg, with an average body mass index (BMI) of 30. Fifty-seven patients had additional procedures performed at the time of panniculectomy. Twenty-two patients (17%) had complications, with 5 in the traditional group (17%) and 17 in the fleur-de-lis group (17%) (P = 1.0). Six males (40%) had more complications compared with 18 females (15.7%) (P = 0.034). Patients with BMI <30 had 10 complications compared with patients with BMI ≥30 had 15 complications.

CONCLUSIONS

There are many benefits of fleur-de-lis over traditional panniculectomy, even for medical necessity cases. There is limited undermining of tissue which minimizes/eliminates skin necrosis. Our experience with primarily fleur-de-lis panniculectomies shows a complication rate lower than most published data. Fleur-de-lis potentially creates a better symptom correction and cosmetic outcome by resecting maximal skin in both vertical and horizontal directions. These findings must be balanced against a potentially longer operation.

Pulmonary embolism after combined abdominoplasty and flank liposuction: a correlation with the amount of fat removed

BACKGROUND

We prospectively followed patients who underwent esthetic abdominoplasty and flank liposuction to determine the influence of the amount of fat removed on the occurrence of pulmonary embolism.

MATERIALS AND METHODS

We recruited patients undergoing abdominoplasties and flank liposuction and composed 2 groups according to the amount of fat removed, one of small resections (<1500 g) and the other of great resections (>1500 g). All patients received deep vein thrombosis prophylaxis.

RESULTS

Since January 2005, we enrolled 103 patients and registered 3 embolisms (2.9%). All occurred in nonsmokers, had no risk factor for deep vein thrombosis, and a resection weight greater than 1500 g (21.4%; 3/14). The calculated relative risk conferred by the amount of fat greater than 1500 g was 7.4. An association was also found with duration of surgery: all embolisms occurred in patients that underwent long operation (>140 minutes; 8.8%; 3/34) with a relative risk of 3.0.

CONCLUSIONS

The amount of fat removed during plastic surgery is a factor influencing the occurrence of pulmonary embolism in patients undergoing abdominoplasty/flank liposuction, and the duration of surgery is a concomitant factor. Should this data be confirmed, specific measures for prevention of this serious complication could be developed.

Post-bariatric panniculectomy: pre-panniculectomy body mass index impacts the complication profile

BACKGROUND

Morbid obesity continues to increase in the United States, which accounts for the increase in bariatric procedures performed. After these patients experience massive weight loss, many are left with a redundant pannus that poses physical limitations and psychosocial disturbances. An increasing proportion of bariatric patients are returning for body-contouring procedures.

METHODS

This is a retrospective cohort study set in a tertiary care center. We evaluated 126 post-bariatric panniculectomies performed over a 3-year period. Perioperative and postoperative data were collected through chart review. Descriptive and inferential analyses were performed using SPSS 11.0.

RESULTS

Ninety-six percent of patients were female. Mean age of the population was 42 (+/-12). The average post-bariatric weight loss and pre-panniculectomy weight were 53 (+/-16) kg and 78 (+/-14) kg, respectively. Complication rates were as follows: seroma 17%, hematoma 13%, surgical site infection (SSI) 17%, transfusion 6%, skin breakdown/necrosis 11%, and re-exploration 11%. Forty percent of patients experienced a complication. Using multivariate logistic regression, we evaluated age, pre-panniculectomy body mass index (BMI), American Society of Anesthesiologists (ASA) class, specimen weight, and operative duration; only pre-panniculectomy BMI was an independent predictor for developing a postoperative complication (odds ratio 3.3, confidence interval 1.2 to 8.4, P < .01).

CONCLUSIONS

Post-bariatric patients who have sustained significant weight loss report subjective improvement after panniculectomy. Even though this population has experienced significant weight loss, they are still at an increased risk for postoperative complications. Maximal reduction in BMI should be stressed to these patients in order to reduce their risk of complications following panniculectomy.

Surgical solutions to the problem of massive weight loss

In response to the global rise in obesity, bariatric surgery has become increasingly more popular and successful. As a result, the demand for body contouring following massive weight loss is rapidly growing. Although bariatric procedures may produce impressive weight loss, people who achieve massive weight loss are often unhappy with the hanging folds of skin and subcutaneous tissue that remain. This review examines the nature of the post-bariatric deformity in each body region and briefly reviews common approaches to their treatment.

Anthropometric Measurements and Their Value in Predicting Complications Following Reduction Mammaplasty and Abdominoplasty

Body mass index (BMI) is the traditional way of assessing patients for body contouring surgery and has been shown to have a predictive value for surgical complications. In recent years, there have been discussions about accuracy of BMI as an indicator of obesity, and other obesity indices have been developed. This study aimed to measure and compare different anthropometric variables and examine their association with surgical morbidity. Prospective measurements of height, weight, waist, and percentage body fat were obtained preoperatively in 60 patients undergoing body contouring surgery. Demographics, patient characteristics, operative details, and postoperative complications were recorded. Statistical analysis was performed using chi, ANOVA, or Spearman rank correlations as appropriate. We found that BMI, percentage of body fat, weight, height-to-weight ratio, and waist circumference all correlate well as indicators of obesity and showed similar trends in their association with surgical complications.

Evolution of ischemic tissue injury in a random pattern flap: A new mouse model using intravital microscopy

BACKGROUND

Dissection of random pattern flaps may cause microcirculatory dysfunction and ischemia, which jeopardize wound healing due to impaired tissue viability. The aim of this study was to develop an in vivo model that enables continuous monitoring of the interplay between microcirculatory dysfunction, ischemia, and tissue injury by intravital microscopy.

MATERIALS AND METHODS

A laterally based random pattern skin flap (15 x 11 mm) including the panniculus carnosus was raised in the back of mice and fixed into a dorsal skinfold chamber (n = 10). Arteriolar blood flow, functional capillary density, number of apoptotic cells, and area of tissue necrosis were analyzed by intravital fluorescence microscopy in the proximal, middle, and distal part of the flap at day 1, 3, 5, and 7 after surgery. Chamber preparations without flap harvesting served as controls (n = 6).

RESULTS

At day 1, the distal part of the flap showed a decreased arteriolar blood flow (266 +/- 124 pl/s versus controls: 1418 +/- 351 pl/s; P < 0.05), which resulted in severe alteration of functional capillary density (43 +/- 11 cm/cm2 versus 270 +/- 7 cm/cm2; P < 0.001). The impaired microcirculation was associated with apoptotic cell death (277 +/- 50 cells/mm2 versus 50 +/- 5 cells/mm2; P < 0.05). Microcirculatory dysfunction persisted over 7 days, and, finally, resulted in 49 +/- 3% flap necrosis.

CONCLUSIONS

This new model enables repetitive and simultaneous in vivo microscopic evaluation of microvascular hypoperfusion, apoptosis, and tissue necrosis in a random pattern flap. By the use of gene-targeted mice, it bears great potential to analyze distinct mechanisms of flap failure. It further represents an ideal tool to study novel protective strategies, including induction of angiogenesis, heat shock proteins, and HIF-1alpha.