A Meta-Analysis of the Effects of Abdominoplasty Modifications on the Incidence of Postoperative Seroma

Hemostatic Agents Do Not Significantly Affect Seroma Formation in Abdominal Body Contouring

BACKGROUND

Objective: Seroma formation is plaguing complication in abdominal body contouring surgery (ABCS) that has been loosely associated with the use of intraoperative hemostatic agents. The aim of this study was to investigate the association between hemostatic agent usage and seroma development following ABCS.

METHODS

A retrospective review of patients undergoing ABCS between 2010 and 2020 was completed. Cases who received hemostatic agents were matched to controls (1:2) based on potential confounders including age, BMI, and ASA score. Demographic data, operative details, and postoperative complications including development of seroma, hematoma, venous thromboembolism, wound dehiscence, and delayed wound healing were collected.

RESULTS

Seven hundred and seven patients were included in the study. Sixty-five patients (9.2%) received at least one hemostatic agent. The most used agents were topical thrombin (n = 33, 50.1%), dry matrices including oxidized cellulose, microporous polysaccharides, and absorbable gelatin matrices (n = 15, 23.1%) followed by combination fibrin sealant/thrombin preparations (n = 9, 14.0%). No significant differences with respect to demographic data or medical comorbidities between the cases and controls were identified. Bivariate analysis demonstrated no significant differences in the rate of development of seroma (OR: 0.83, 95% confidence interval [CI] = 0.23-1.99, p = 0.781), hematoma (OR: 3.72, 95% confidence interval [CI] = 0.95-14.65, p = 0.060), venous thromboembolism (OR: 0.40, 95% confidence interval [CI] = 0.44-3.81, p = 0.433).

CONCLUSION

Hemostatic agent use, regardless of type, does not significantly affect the risk of seroma, hematoma, and venous thromboembolism development, nor does it influence the rates of delayed wound healing or wound dehiscence.

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 .

Lipoabdominoplasty with Anatomical Definition: Update

There is a continuous search for better technical alternatives for the treatment of abdominal contour deformities in the practice of plastic surgeons. LADE-lipoabdominoplasty (LAP) with anatomical definition-is a step ahead of the traditional LAP technique. This technique incorporated the principles of highlighting the definition of the abdominal musculature, achieving more natural results with fewer reminders of a surgical intervention. The esthetic results are much harmonious, with a true abdominal rejuvenated appearance. We can reduce morbidity by the preservation of perforating blood vessels and suspension of Scarpa's fascia. The correct selection of the patient makes the procedure safe and reproducible.

Safety and Efficacy of Outpatient Drainless Abdominoplasty: A Single-Surgeon Experience of 454 Consecutive Patients

BACKGROUND

The incidence of seroma after abdominoplasty is accepted as approximately 10% (with a range) in the literature. Progressive tension sutures (PTS) have arisen as a means of reducing seroma, however there are conflicting data regarding their efficacy.

OBJECTIVES

The primary aim of this study was to describe the incidence of postabdominoplasty seroma in the setting of drainless abdominoplasty with PTS.

METHODS

A retrospective chart review was performed of all abdominoplasties (n = 454) during a 20-year period. At approximately the halfway point of this time frame, the abdominoplasty technique was changed from the use of 2 drains to the use of PTS without drains. Additionally, pulsed electromagnetic field therapy (PEMF) and liposomal bupivacaine (Exparel, Pacira Pharmaceuticals, Inc., Parsippany, NJ) were added as pain control adjuncts.

RESULTS

There were 194 patients in the drain group and 260 patients in the PTS/no drains group. The group without drains contained a significantly higher proportion of massive weight loss patients (4.1% vs 9.2%, P = .041). The majority of the group without drains underwent outpatient surgery (89.7% vs 98.8%, P < .001). The overall complication rate was significantly lower in the no drains group (31.4% vs 13.8%, P < .001). The incidence of seroma was dramatically reduced in the group without drains (24.7% vs 0.0%, P < .001).

CONCLUSIONS

PTS are highly effective in preventing seroma and can be safely employed as an alternative to drains in abdominoplasty. PEMF may play a role in seroma prevention and is also helpful for pain control. With these techniques to mitigate complications and minimize postoperative pain, abdominoplasty can be performed safely and effectively in a purely outpatient setting.

LEVEL OF EVIDENCE: 3

The Effect of Drains and Compressive Garments Versus Progressive Tensioning Sutures on Seroma Formation in Abdominoplasty

Seroma is a common problem following abdominoplasty surgery. Both compressive garments with drains and progressive tension sutures have their advocates to minimise seroma formation. This is a retrospective study in which patients underwent an identical surgical procedure, except for use of drains and garments in comparison to progressive tension sutures between 2005 and 2020. Two hundred thirty-two patients were included in the study 61 in the drains and garment group (DG group), and 171 with progressive tension sutures (PTS group) alone. There was a lower incidence of seroma formation in the PTS group (X2 (1, N = 232) = 6.35, P = .012). The weight of tissue excised in the PTS group was greater than the DG group (P < .001). There was there a significantly higher tissue excision weights for patients who developed a seroma, compared with those who did not (P=.02). Patients, who developed a seroma in the PTS group, had significantly greater excision weights than the DG group. Liposuction did not change the incidence of seroma in each group (X2 (4, N = 232) = 6.701, P = .08 n/s). This study demonstrates the effectiveness of progressive tension sutures in reducing the incidence of seroma formation following abdominoplasty, particularly when large excision weights are involved. The addition of small volume liposuction distant to the abdominal flap does not increase the incidence of seroma formation.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 .

Classic Versus Scarpa-sparing abdominoplasty: An infrared thermographic comparative analysis

BACKGROUND

Scarpa fascia preservation during abdominoplasty has been shown to have several clinical advantages. The mechanisms behind its efficiency have been the subject of several studies. Three theories have been proposed, relating to mechanical factors, lymphatic preservation, and improved vascularization. This study aimed to further investigate the possible vascular impact of Scarpa fascia preservation by using a thermographic analysis.

METHODS

A single-center prospective study was conducted, involving 12 female patients randomly and equally assigned to one of two surgical procedures: classic (Group A) and Scarpa-sparing abdominoplasty (Group B). Dynamic thermography was applied before and after surgery (one and six months), and two regions of interest (ROIs) were considered. The latter had the same location on every sample, and corresponded to areas where different surgical planes had been used. Static thermography was applied intraoperatively, and four ROIs were considered, located over Scarpa and over the deep fascia. The respective thermal data were analyzed.

RESULTS

The general characteristics of both groups were identical. Preoperative thermography demonstrated no differences between groups. Intraoperative higher thermal gradients between lateral and medial ROIs were observed in Group B (P = 0.037, right side). Dynamic thermography at one month demonstrated a trend for better thermal recovery and better thermal symmetry (P = 0.035, 1-min mark) in Group B. No other differences were found.

CONCLUSION

Dynamic thermography presented a better response when Scarpa fascia was preserved: stronger, faster, and more symmetric. Based on these results, improved vascularization may have a role in explaining the clinical efficiency of a Scarpa-sparing abdominoplasty.

Clinical Evaluation of 310 Abdominoplasties and Measurement of Scar Level

BACKGROUND

Most published studies on abdominoplasty focus on methods to reduce the risk of seromas. These methods include limited dissection (lipoabdominoplasty), quilting sutures, and preservation of the Scarpa fascia. Quantitative evaluation of the aesthetic result has been lacking.

METHODS

A retrospective study was undertaken of all patients undergoing abdominoplasty in the author's practice from 2016 to 2022. A full abdominoplasty was performed, usually with liposuction (87%). All patients were treated under total intravenous anesthesia without paralysis or prone positioning. A single closed suction drain was removed 3 or 4 days after surgery. All procedures were performed as outpatients. Ultrasound surveillance was used to detect any deep venous thromboses. No patient received chemoprophylaxis. The operating table was flexed, often to 90°. Deep fascial anchoring sutures were used to attach the Scarpa fascia of the flap to the deep muscle fascia. Measurements of the scar level were made at intervals after surgery up to 1 year.

RESULTS

Three hundred ten patients were evaluated, including 300 women. The mean follow-up time was 1 year. The overall complication rate, which included minor scar deformities, was 35.8%. Five deep venous thromboses were detected. There were no hematomas. Fifteen patients (4.8%) developed seromas that were successfully treated by aspiration. The mean vertical scar level 1 month after surgery was 9.9 cm (range, 6.1-12.9 cm). There was no significant change in scar level at subsequent follow-up times up to 1 year. By comparison, the scar level in published studies ranged from 8.6 to 14.1 cm.

DISCUSSION

Avoidance of electrodissection reduces tissue trauma that causes seromas. Flexed patient positioning during surgery and deep fascial anchoring sutures are effective in keeping the scar low. By avoiding chemoprophylaxis, hematomas can be avoided. Limiting the dissection (lipoabdominoplasty), preserving the Scarpa fascia, and adding quilting (progressive tension) sutures are unnecessary.

CONCLUSIONS

Total intravenous anesthesia offers important safety advantages. Avoiding electrodissection is effective in keeping seroma rates at a tolerable level (5%), and the scar low and more easily concealed. Alternative methods present disadvantages that may contribute to a suboptimal aesthetic result and require additional operating time.

Scarpa Fascia Preservation to Reduce Seroma Rate on Massive Weight Loss Patients Undergoing Abdominoplasty: A Comparative Study

(1) Background: An increasing number of patients undergo bariatric surgery and seek body contouring surgery after massive weight loss (MWL). Abdominoplasty itself is associated with a high complication rate in these patients, particularly due to seroma formation. Scarpa fascia preservation (SFP) has been proven to be an efficient method of reducing seroma rates. We aimed to evaluate the possible benefits of SFP on massive weight loss patients comparatively. (2) Methods: This is a single-center retrospective comparative study encompassing 202 MWL patients operated between 2009 and 2019 at Turku University Hospital. Patients included in the study had a preoperative weight loss greater than 30 kg. Of them, 149 went through traditional abdominoplasty and 53 abdominoplasties with SFP. The primary outcome measure was seroma occurrence, while secondary outcomes included drainage amount, hospital stay, surgical site occurrence, and need for blood transfusion. (3) Results: The only statistically significant difference between groups on patients' demographics was the sex ratio, favoring females in the control group (43:10, 81% vs. 130:19, 87%, p = 0.018). SFP significantly reduced seroma occurrence (9.4% vs. 26.2%, p = 0.011) and decreased mean drainage duration (3.7 ± 2.4 vs. 5.3 ± 3.2 days, p = 0.025). There was a trend towards lower drainage output (214.1 ± 162.2 mL vs. 341.9 ± 480.5 mL, p = 0.060) and fewer postoperative days on ward in the SFP group. Other complication incidences did not differ between the groups. The multivariable analysis did not show any significant factor for seroma formation or surgical site occurrence. (4) Conclusions: Preserving Scarpa fascia on MWL patients may result in decreased seroma occurrence and a shorter time to drain removal.

Retrospective Analysis of Predictive Factors for Complications in Abdominoplasty in Massive Weight Loss Patients

INTRODUCTION

Ex-obese patients present with redundancy of abdominal skin and soft tissue due to massive weight loss (MWL). The plastic surgeon can restore the body shape through body contouring procedures. Hence the need to adequately direct patients to body contouring by identifying suitable candidates exists. Our work aims to retrospectively analyze the abdominoplasty complications in our case series to identify associated risk factors and evaluate the effect of combined procedures on abdominoplasty outcomes.

MATERIALS AND METHODS

We retrospectively investigated predictive factors of abdominoplasty procedure complications on 213 MWL patients who received abdominoplasty with and without rectus sheath plication, abdominal liposuction, and other body contouring procedures. We identified risk and protective factors with univariate and multivariate regression analysis. Furthermore, we assessed the impact of additional procedures on the complication rates.

RESULTS

The overall complication rate was 49.8% (26.8% minor complications; 23% major complications). The delayed wound healing rate was 27.7%, and the revision surgery rate was 25.8% (14.7% early revision; 14.2% late revision). These results were compared with literature reports. Several negative predictors emerged as non-modifiable (advanced age, diabetes mellitus, surgical mode of weight loss) or modifiable (preoperative obesity and body mass index (BMI); active smoking; preoperative anemia; use of fibrin glue or quilting sutures). Performing rectus sheath plication improved most of the outcomes. Liposuction of hypochondriac regions and flanks led to increased safety and reduced the risk of surgical dehiscence and delayed wound healing, in contrast to epimesogastric liposuction. The other combined body contouring procedures did not worsen the outcomes, except for poor scarring.

CONCLUSION

Our findings encourage us to continue associating rectus sheath plication, liposuction, and other body contouring surgeries with abdominoplasty. We emphasize the importance of proper patient selection, particularly with regard to anemia, before body contouring surgery in the interests of offering safe surgery and satisfactory results. Further studies are needed to investigate how the optimal BMI cut-off and abstinence from smoking (in terms of time) before surgery reduce postoperative complications.

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 https://www.springer.com/journal/00266 .

Morphea After Liposuction Ultrasonography

Liposuction is a common aesthetic procedure; however, to date, liposuction has not been linked to morphea. The aim was to review cases with a history of liposuction that presented active morphea lesions in the same surgery regions and were confirmed by ultrasound and histology. A retrospective descriptive analysis of the clinical, ultrasonographic, and pathology database took place (2014-2020). Eleven patients met the criteria. Ultrasound supported the diagnosis, and the ultrasonographic signs of activity in these cases matched the features described in the literature in 100% of cases. In summary, morphea may appear after liposuction and ultrasound can support its early detection.

Changes in the Pattern of Superficial Lymphatic Drainage of the Abdomen after Abdominoplasty

BACKGROUND

The changes in the pattern of lymphatic drainage of the superficial abdominal wall after abdominoplasty are still unknown. These changes may increase the risk of numerous complications, including seroma formation. Depending on the alterations, the manual lymphatic drainage technique should be modified in postoperative patients. The aim of this study was to map the pattern of lymphatic drainage of the superficial infraumbilical abdominal wall after abdominoplasty.

METHODS

Twenty women with indications for abdominoplasty were selected in the Plastic Surgery Division of the Federal University of São Paulo. Intradermal lymphoscintigraphy with dextran 500-99m-technetium was performed in 20 female patients in the preoperative phase and 1 and 6 months after abdominoplasty to evaluate superficial lymphatic drainage of the abdominal wall.

RESULTS

Before surgery, all patients presented with abdominal lymphatic drainage toward the inguinal lymph nodes. One and 6 months after abdominoplasty, only 15 percent exhibited the same drainage pathway. Drainage toward the axillary lymph node chain occurred in 65 percent of the patients, 10 percent displayed a drainage pathway toward both the axillary and inguinal lymph nodes, and lymphatic drainage was indeterminate in 10 percent of the cases.

CONCLUSIONS

A significant change in lymphatic drainage pathway occurred in the infraumbilical region after abdominoplasty. The axillary drainage path was predominant after the operation, in contrast to the inguinal path observed in the preoperative period. However, 35 percent of cases exhibited alternative drainage. No significant changes were documented between 1 and 6 months postoperatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Seromas: How to Prevent and Treat Them-a 20-Year Experience

Seromas are a common complication in plastic surgery. In this article, the authors describe their approach to the prevention and treatment of seromas and include a discussion of the evolution of their techniques. They provide specific technical details for many body contouring operations, including abdominoplasty, belt lipectomy, brachioplasty, and thighplasty. Many of the authors' techniques question the traditional dictums of plastic surgery, and they hope to encourage others to consider novel techniques for the treatment and prevention of seromas.

LEVEL OF EVIDENCE: 4

Defining Internal Tissue Closure: High-Resolution Ultrasound Evaluation of Interi-A Novel Internal Tissue Closure System

Background

Seroma remains a leading postsurgical complication in plastic surgery. Conventional drains are ineffective in clearing blood and fluid and closing down surgical spaces. The Interi (Internal Closure System, IC Surgical, Grand Rapids, MI) is comprised of a novel branching internal manifold attached to a self-contained portable pump with a higher, consistent, continuous negative pressure, may reduce this long-standing issue. In addition, high-resolution ultrasound (HRUS) has emerged as an ideal tool to visualize structures, fluid collections, and seromas internally.

Objectives

This study evaluates Interi in full abdominoplasty patients utilizing HRUS to evaluate Interi's ability to evacuate blood and fluid, hold internal tissues together and document, for the first time, what internal tissue healing actually looks like radiographically.

Methods

An IRB approved, Contract Research Organization reviewed retrospective study evaluated consecutive patients undergoing full abdominoplasty utilizing Interi from July 2020 through March 2021 by three plastic surgeons. HRUS visualized and confirmed the presence or absence of fluid collections and healing tissue planes during the postoperative process. Study data and all adverse events were recorded, with HRUS images reviewed by investigators and confirmed by an independent radiologist.

Results

Seventy-one Interi patients were enrolled. Mean age was 43 (range: 21-74) and BMI was 28. Seroma was confirmed clinically and through HRUS in 3/71 patients, and was associated with either clot (2) or failure to activate system (1). Interi's ability to eliminate fluid and approximate/hold surgical tissue planes together was confirmed with HRUS. No other major complications, including abscess, hematomas, or flap necrosis were observed.

Conclusions

This novel Internal Tissue Closure System effectively evacuated blood and fluid, approximated and maintained closure of internal tissue planes in abdominoplasty patients, allowing for primary tissue healing and internal wound closure to occur. Healing tissue planes and any fluid present are easily identified on HRUS visualizing actual internal tissue healing with a simple, widely available radiographic scan.

Level of Evidence 3

The Internal Negative-Pressure Wound Control System: A Paradigm Shift for Promoting Deep Space Healing in Complex Surgically Created Wounds

This article introduces a new technology to minimize seroma and promote more predictable healing in surgically created deep space wounds. Its novel design internalizes the delivery of a continuously generated high negative pressure (-125 mmHg) throughout the surgically created space by means of a multibranched Manifold. In a small prospective cohort case study of 24 patients undergoing full abdominoplasty, all patients underwent placement of this device, which was removed 7 days postoperatively. Results at 30 days revealed no evidence of wound-healing problems, no clinical seroma, and no device malfunction. The internalization of a constant negative-pressure wound therapy provided by this system has the potential to significantly reduce clinical seroma, and to produce more consistent apposition of interfaces in deep tissue spaces in complex wounds seen in plastic surgery and other surgical disciplines.

Predicting lipoabdominoplasty complications with infrared thermography: a delta-R analysis

The diagnosis of the main complications resulting from lipoabdominoplasty has not yet been standardized. Infrared thermal imaging has been used to assess possible complications, such as necrosis and changes in micro- and macro-circulation, based on perforator mapping techniques, among others. The objective of this study was to present two clinical cases involving thermal imaging monitoring of the healing process of lipoabdominoplasty in the immediate postoperative evaluation and its preliminary results. Infrared thermography was performed 24 hours after the operation and on postoperative days 5, 25, and 27. In clinical case 1, it was found that the delta-R (∆TR)-defined as the difference in minimum temperature between the highest and lowest points in the SA3 region (caution suction area) following the classification established by Matarasso-was 0.4°C at 24 hours after surgery and decreased to 0.1°C on a postoperative day 5. There were no complications in this case. In contrast, in clinical case 2, the ∆TR was 1.7°C at 24 hours after surgery (upon hospital discharge) and remained high, at 2.2°C, on postoperative day 5. A higher ∆TR was found in the second patient, who developed necrosis of the surgical wound. The ∆TR thermal index may be a new tool for predicting possible complications, complementing the clinical evaluation and therapeutic decision-making.

Fibrin Sealant Artiss Compared to Progressive Tension Sutures With Stratafix in the Management of Wound Drainage Following Post-Bariatric Body-Contouring Surgery

Background

Post-bariatric body-contouring surgery is one of the most rapidly growing areas in plastic surgery. One of the most common complications following post-bariatric body-contouring surgery is seroma. There are a number of approaches to reducing wound drainage and seroma formation. A promising strategy to reduce these complications is to develop effective methods for reducing dead space between the tissue layers.

Methods

We conducted a retrospective trial assessing the use of human fibrin sealant Artiss in comparison to progressive tension sutures (PTS) with Stratafix, a bidirectional barbed suture device in patients undergoing post-bariatric body-contouring surgery. Thirty-six patients for abdominoplasty or lower-body-lift were evaluated. Treatment patients underwent procedure with fibrin sealant applied to adapt the tissue layers. Control patients underwent an identical procedure but with PTS. Primary outcome measures included total wound drainage and time to drain removal.

Results

The use of Artiss in abdominoplasty was associated with a mean drain volume that was significantly higher and more days that were needed to remove all drains compared to the PTS group. In body-lift, the mean drain volume and number of days needed to remove all drains tended to be higher when using Artiss compared to the PTS group.

Conclusion

The use of Artiss in post-bariatric body-contouring surgery did not decrease the rate of seromas and the length of time required for post-surgical drains when compared to PTS.

Local Triamcinolone Treatment Affects Inflammatory Response in Seroma Exudate of Abdominoplasty Patients: A Randomized Controlled Trial

BACKGROUND

As the leading complication of abdominoplasty, seroma formation might represent an inflammatory process in response to surgical trauma. This prospective randomized trial investigated whether local administration of the antiinflammatory agent triamcinolone could prevent seroma accumulation.

METHODS

Weekly and cumulative seroma volumes were compared between the study groups A, B, and C over a 4-week follow-up (group A, with drain, without triamcinolone; group B, without drain, without triamcinolone; group C, without drain, with triamcinolone). Aspirated seroma samples were analyzed by enzyme-linked immunosorbent assay for selective inflammatory mediators.

RESULTS

Triamcinolone significantly reduced cumulative seroma volume (n = 60; mA 845 ± SDA 578 ml, mC 236 ± SDC 381 ml, p = 0.001). The most accentuated suppressive effect of triamcinolone was observed shortly after the treatment (week 1) (mA1 616 ± SDA1 457 ml, mB1 153 ± SDB1 161 ml, mC1 22 ± SDC1 44 ml, pA1/C1 < 0.001, pB1/C1 = 0.014). Local triamcinolone administration resulted in a differential concentration of interleukin-6 (IL-6) and matrix metalloproteinase-9 (MMP-9 (week 1) in seroma exudate as measured by enzyme-linked immunosorbent assay (mIL-6A1 1239 ± SDA1 59 pg/ml, mIL-6C1 848 ± SDC1 80 pg/ml, p < 0.001; mMMP-9A1 2343 ± SDA1 484 pg/ml, mMMP-9C1 376 ± SDC1 120 pg/ml, p = 0.001).

CONCLUSIONS

Local administration of 80 mg of triamcinolone reduced postabdominoplasty seroma accumulation significantly. Under triamcinolone treatment, suppressed levels of IL-6 and MMP-9 in seroma fluid were observed. Notably, inflammatory marker suppression correlated clinically with a decrease in seroma accumulation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Predictors for Prolonged Drain Use Following Autologous Breast Reconstruction

BACKGROUND

 Surgical drains are routinely used following autologous reconstruction, but are often cited as the leading cause of peri-operative discomfort. This study defined routine drain use duration and assessed the risk factors for prolonged breast and abdominal drain use during microvascular breast reconstruction, measures which have never previously been defined.

METHODS

 Patients who underwent an abdominal microvascular free flap were included. Demographics, comorbidities, and operation-related characteristics were retrospectively collected in a prospectively maintained database. Statistical analysis utilized chi-square independent t-test, and linear regression analyses.

RESULTS

 One hundred forty-nine patients comprising 233 breast flaps were included. Average breast and abdominal drain duration were 12.9 ± 3.9 and 17.7 ± 8.2 days, respectively. Prolonged breast and abdominal drain duration were defined as drain use beyond the 75^th percentile at 14 and 19 days, respectively. Multivariable regression revealed hypertension was associated with an increased breast drain duration by 1.4 days (p = 0.024), axillary dissection with 1.7 days (p = 0.026), African-American race with 3.1 days (p < 0.001), Hispanic race with 1.6 days (p = 0.029), return to the OR with 3.2 days (p = 0.004), and each point increase in BMI with 0.1 days (p = 0.028). For abdominal drains, each point increase in BMI was associated with an increased abdominal drain duration by 0.3 days (p = 0.011), infection with 14.4 days (p < 0.001), and return to the OR with 5.7 days (p = 0.007).

CONCLUSION

 Elevated BMI, hypertension, and axillary dissection increase risk for prolonged breast drain requirement in autologous reconstruction. African-American and Hispanic populations experience prolonged breast drain requirement after controlling for other factors, warranting further study.

Dissection Technique for Abdominoplasty With Scarpa Fascia Preservation: Comparative Study on Avulsion Technique Versus Diathermocoagulation

BACKGROUND

Many strategies have been developed to lower the high complication rate associated with a full abdominoplasty. The dissection technique may have a role to achieve this goal.

OBJECTIVES

The present study compared 2 different dissection techniques to perform a full abdominoplasty with Scarpa fascia preservation: avulsion technique and electrodissection.

METHODS

A retrospective observational cohort study was performed in 2 health institutions from January 2005 to January 2019. A total of 251 patients were involved: 122 patients submitted to abdominoplasty employing the avulsion technique (Group A) and 129 with diathermocoagulation (coagulation mode) (Group B). The latter was further divided into group B1 (57 patients with device settings according to surgeon's preferences) and B2 (72 patients with a specific regulation aiming at minimal tissue damage). Several variables were analyzed: population characteristics, time of hospital stay, time to drain removal, total and daily drain output, emergency department visits, readmission, reoperation, and local and systemic complications.

RESULTS

The general characteristics of both groups did not statistically significantly differ except for previous abdominal surgery. The diathermocoagulation group had a significantly lower length of hospital stay and time to drain removal. Moreover, these advantages were maximized when electrocautery was conducted with a specific low-voltage setting as significant differences were found. The other outcomes were identical.

CONCLUSIONS

Limiting the extension of electrodissection with the avulsion technique did not present any advantage. Utilizing diathermocoagulation (coagulation mode) during a full abdominoplasty with Scarpa fascia preservation, especially when it is aimed at minimal tissue damage, reduces patients' time with drains.

LEVEL OF EVIDENCE: 3

Treatment of rectus diastasis: should the midline always be reinforced with mesh? A systematic review

BACKGROUND

Two main trends are described for the treatment of diastasis recti: plication versus midline mesh reinforcement. Indications for these procedures have not been clearly described. This study reviewed the outcomes in the treatment of rectus diastasis with plication versus mesh by the assessment of durability, complications, and patient-reported outcomes.

MATERIALS AND METHODS

A systematic review of literature on the treatment of diastasis recti was performed searching through PubMed, Embase, Web of Science, and Cochrane databases. This resulted in 53 eligible articles and predefined inclusion criteria led to the selection of 24 articles. Primary outcomes included recurrence and perioperative complications and secondary outcomes were defined as patient satisfaction, chronic pain, and quality of life.

RESULTS

A total of 931 patients were surgically treated for rectus divarication (age range: 18 - 70 years). The most frequently noted comorbidity was obesity and 10.6 percent were smokers. Recurrence was reported in 5 percent of the patients. The most frequent complication was seroma (7 percent), followed by abdominal hypoesthesia (6 percent), and surgical site infection (2 percent). Chronic pain was reported in 4 percent of the patients. Satisfaction was assessed subjectively in the majority of patients and was generally rated as high. Follow-up period ranged from 3 weeks to 20 years.

CONCLUSIONS

Durability, safety, and high patient satisfaction support surgical correction of rectus diastasis and could not favor a treatment method. Inter-rectus distance could not be identified as the indicator for technique, which emphasizes that other factors might add to the entity of abdominal wall protrusion more than previously thought.

Bilateral paraspinal muscle flap closure technique for reduction of wound complications from posterior thoracolumbar spinal fusion: results of a series of 716 patients

OBJECTIVE

Wound complications such as surgical site infection (SSI) and dehiscence are among the most common complications of thoracolumbar spinal fusion surgery and are particularly prevalent in patients with risk factors such as obesity, diabetes, smoking, malignancy, and multilevel and/or revision procedures. A specialized wound closure technique with muscle flap mobilization, which reduces tension at the wound edges and increases the bulk of vascularized tissue in the midline, can be employed as a salvage procedure to manage wound complications. The authors evaluated the effectiveness of prophylactic muscle flap closure for reducing SSI in patients with risk factors for wound complications who undergo thoracolumbar fusion surgery.

METHODS

A retrospective review of thoracolumbar fusion surgeries over a 15-year period was conducted in a group of patients at risk for wound complications to compare outcomes of patients who underwent prophylactic muscle flap closure with outcomes of patients who had conventional wound closure. Patients were selected for specialized closure based upon a protocol adopted during the study period. Patients were excluded if they had active infections or underwent tubular retractor-mediated decompression and did not have open surgery with a midline incision.

RESULTS

Of 716 patients, wound closure was performed in 455 patients using conventional closure and in 261 using muscle flap closure. There were no significant differences in the ratios of male to female patients, with 251 men and 204 women with conventional closure and 133 men and 128 women with muscle flap closure, but the muscle flap patients were older than the conventional closure patients, with mean ages of 65.2 versus 62.9 years (p < 0.005). Indications for surgery in the muscle flap group and the conventional group, respectively, were metastatic disease in 44 (17%) and 32 (7%) patients; trauma in 10 (4%) and 14 (3%) patients; and degenerative disease, including spondylolisthesis, spondylolysis, and stenosis, in 207 (79%) and 409 (90%) patients, with more muscle flap patients having metastasis (p < 0.00001). Patients having muscle flaps had significantly higher rates of diabetes, smoking, and revision surgery, and a higher mean BMI and number of operative levels. The serum albumin level was slightly lower in the muscle flap group (p < 0.047). The wound infection rate was significantly lower in the muscle flap group (0.4%) compared with the conventional closure group (2.4%) (p < 0.033).

CONCLUSIONS

Prophylactic muscle flap closure significantly lowers the rate of SSI in patients undergoing thoracolumbar spinal fusion who harbor risk factors for wound complications, with even fewer infections seen than in a group of patients without similar risk factors. Given the success of the technique, consideration of wider use for thoracolumbar fusion cases, even those without a high level of complexity, may be warranted.

Management of abdominal wall recurrent subfascial seroma after pelvic surgery

Seroma is a serous fluid collection that accumulates in dead spaces, where tissue was attached to something before surgery. Abdominal seroma formation is a quite common complication after breast reconstruction with abdominal’s flaps or after an abdominoplasty procedure. The most frequently used method for decreasing early seroma frequency are the use of closed suction drains, ultrasonic dissection and sharp dissection, use of fibrine, and use of clip or ligation of vessels during the surgery. The management strategies consist of non-operative management, percutaneous drainage, or surgical drainage. With this paper we report a case of a subfascial seroma of the abdominal wall occurred in a 41 years old patient after laparotomy surgery for a voluminous pelvic serocele. (www.actabiomedica.it)

Impact of Lipo-Body Lift Compared to Classical Lower Body Lift on Postoperative Outcome and Patient's Satisfaction: A Retrospective Study

INTRODUCTION

Lately, the growing number of bariatric procedures performed each year led to an increasing demand for lower trunk reconstruction. Our team previously described the lipo-body lift (LBL) technique into lower duration of drainage and therefore seromas and other complications. In this study, we compared the classical body lift (CBL) technique to the LBL procedure.

MATERIALS AND METHODS

All patients who underwent a LBL or CBL after massive weight loss between November 2012 and October 2017 were included. Surgery outcome parameters were collected as well as patient satisfaction through a satisfaction score realized at least after 1 year postoperative. Comparisons between CBL and LBL were conducted to assess the surgery's safety and the patient's satisfaction.

RESULTS

A total of 130 patients were included, 61 patients who had a LBL were compared to 69 patients who had a CBL. The mean patient age was 39.64 ± 9.97 (21-66) years old, the mean body mass index before plastic surgery was 26.83 ± 3.08 kg/m² (19.83-32.69), and the average weight loss was 53.40 ± 17.37 kg. The two groups had comparable preoperative data. Duration of drainage and hospital stay was significantly lower in the LBL group than in the CBL (p < 0.0001 and p < 0.0001, respectively). Surgical outcomes were comparable between groups as well as patient satisfaction scores.

CONCLUSION

Lipo-body lift allows early discharge of the patient by reducing the duration of drainage without increasing the risk for complications. In our opinion, this technique should be used for type 1 and 2 patients with no contraindication for abdominal liposuction.

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.

Liposuction

Seroma following liposuction (especially mega-sessions; more than 5 L) is a common complication that causes much distress to the surgeon and the patient. This will eventually affect the overall satisfaction and patient’s experience regarding liposuction. If not detected promptly, seromas can impair the results.

Advanced Age Is a Risk Factor for Complications Following Abdominal Panniculectomy

BACKGROUND

Widespread adoption of bariatric surgery in the treatment of obesity has led to greater numbers of patients seeking panniculectomy, including aged patients, who represent a rapidly growing proportion of the U.S population. Although the quality of life and functional benefits of abdominal panniculectomy have been established, its safety in patients 65 years and older has not been evaluated.

METHODS

The American College of Surgeons National Surgical Quality Improvements (ACS-NSQIP) database was used to identify patients undergoing panniculectomy between 2010 and 2015. Age 65 years and older was the risk factor of interest, and primary outcomes included 30-day wound complications, overall complications, reoperation, readmission, and mortality. Multivariate regression was performed to control for confounders.

RESULTS

Review of the database identified 7030 patients who underwent abdominal panniculectomy. When stratified by age, 6455 (91.8%) of patients were younger than 65, and 575 (8.2%) were 65 or older. Multivariate regression analysis demonstrated that age over 65 was a significant independent risk factor for wound complications (OR = 1.81; 95% CI 1.35-2.42; p < 0.001) and all complications (OR = 1.46; 95% CI 1.15-1.87; p = 0.002). BMI, smoking, diabetes, and partial or total dependence were also identified as significant independent risk factors for wound and all complications.

CONCLUSION

Our analysis demonstrates that advanced age is an independent risk factor for wound and overall complications following abdominal panniculectomy. These results highlight the importance of preoperative evaluation and optimization of modifiable preoperative risk factors as well as close postoperative follow-up for safe outcomes in patients 65 and older.

Effects of hydrochlorothiazide on drainage volume and seroma formation in deep inferior epigastric perforator flap breast reconstruction: Randomized controlled trial

BACKGROUND

Seroma is a recognized complication encountered at the reconstructed breast and donor site after abdominal-based breast reconstruction. Seroma is caused by lymphatic channel disruption and the formation of a large space between the deep fascia during flap elevation. Surgical techniques to preserve the lymphatics and secure the closure of the donor site can reduce seroma formation. This study investigated the safety and effectiveness of the diuretic hydrochlorothiazide at reducing interstitial fluid accumulation and seroma formation during deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

Sixty patients with breast cancer who underwent skin- or nipple-sparing mastectomy and DIEP flap reconstruction were enrolled between August 2016 and June 2017. The patients were randomly assigned to receive either 25 mg per day of hydrochlorothiazide from the second to the twentieth day after surgery (treatment) or no diuretic (control). The clinicopathological characteristics, drainage time, and drainage volume were statistically compared between the two groups.

RESULTS

The average total drainage volume at the donor site was 291 mL in the treatment group and 434 mL in the control group (p = 0.003). The differences in body mass index and flap weight between the two groups were not statistically significant (p = 0.879 and p = 0.963, respectively). No hypotension or electrolyte imbalance was noted during the follow-up.

CONCLUSIONS

Intake of 25 mg per day of hydrochlorothiazide tablets effectively reduced the total abdominal drainage volume and removal time of indwelling drains. However, the adverse effects should be further investigated in a large population and multiracial cohort before using hydrochlorothiazide for seroma prevention.

Serum Concentrations and Pharmacokinetics of Tranexamic Acid after Two Means of Topical Administration in Massive Weight Loss Skin-Reducing Surgery

Supplemental Digital Content is available in the text.

Background:

Topical administration of tranexamic acid to reduce bleeding is receiving increasing attention, as it is inexpensive, simple, and possibly beneficial in most surgery. Concerns regarding potential systemic adverse effects such as thromboembolic events and seizures may prevent general use of tranexamic acid. Although serum concentrations after topical application are assumed to be low, proper pharmacokinetic studies of tranexamic acid after topical application are lacking.

Methods:

The authors have investigated systemic absorption of tranexamic acid after two means of topical administration in patients undergoing abdominoplasty after massive weight loss: a bolus of 200 ml of 5 mg/ml into the wound cavity versus moistening the wound surface with 20 ml of 25 mg/ml. Twelve patients were recruited in each group. Serum concentrations achieved were compared with those after administration of 1 g as an intravenous bolus to arthroplasty patients. Serial blood samples for tranexamic acid analysis were obtained for up to 24 hours.

Results:

After intravenous administration, the peak serum concentration was 66.1 ± 13.0 µg/ml after 6 ± 2 minutes. Peak serum concentration after topical moistening was 5.2 ± 2.6 µg/ml after 80 ± 33 minutes, and in the topical bolus group, it was 4.9 ± 1.8 µg/ml after 359 ± 70 minutes. Topical moistening resulted in homogenous and predictable absorption across the individuals included, whereas topical bolus administration caused variable and unpredictable serum concentrations.

Conclusion:

Topical administration of tranexamic acid in patients undergoing abdominoplasty results in low serum concentrations, which are highly unlikely to cause systemic effects.

Sub-Scarpa's Lipectomy in Abdominoplasty: An Analysis of Risks and Rewards in 723 Consecutive Patients

BACKGROUND

During the course of performing abdominoplasties, a plastic surgeon will encounter a certain body habitus characterized by a thick, tethered, and excessively redundant upper skin flap. Often these patients also demonstrate diffuse and substantial fascial laxity. One approach to this problem involves direct thinning and release of the flap by resection of the sub-Scarpa's fat pad. In theory, this resection should be safe from a flap perfusion standpoint. However, the safety of the sub-Scarpa's resection has not been completely documented.

OBJECTIVES

The author sought to assess the safety and efficacy of sub-Scarpa's lipectomy in abdominoplasty.

METHODS

A total 723 patients were retrospectively examined and divided into 2 groups: those with (Group B) and those without (Group A) a sub-Scarpa's lipectomy component to the abdominoplasty. Because of differences in the baseline characteristics between the 2 groups, data analysis was performed with a logistic regression model and with propensity score matching.

RESULTS

The sub-Scarpa's lipectomy technique allowed for substantial thinning of the flap: the average weight of the resected fat pad was 411 g. Wide undermining allowed for substantial fascial correction, and excellent results were obtainable even in challenging cases. The sub-Scarpa's lipectomy group did not demonstrate an increase in either minor (<5 cm2) or major (>5 cm2) flap necrosis. However, there was a statistically significant increase in fat necrosis and seroma formation in Group B compared with Group A. In both groups, an increasing body mass index was a risk factor for fat necrosis and major flap necrosis.

CONCLUSIONS

The implementation of a sub-Scarpa's lipectomy during abdominoplasty is a useful technique to consider for selected abdominoplasty candidates. The risks of minor and major flap loss do not seem to be increased compared to the standard abdominoplasty, but the risks of fat necrosis and seroma formation may be greater.

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.

[Research progress of abdominoplasty]

Objective

To summarize the research progress of abdominoplasty.

Methods

The literature related to abdominoplasty in recent years was reviewed and the evolution of this surgical method and related surgical techniques were summarized.

Results

By removing excess skin adipose tissue from abdominal wall and strengthening loosening muscle fascia system, the abdominal wall contour can be improved by abdominoplasty. With the development of liposuction, selective flaps undermining, progressive tension sutures, and Scarpa fascia retention, the trauma and complications of abdominoplasty are significantly reduced, and better aesthetic result is achieved.

Conclusion

At present, the incidence of abdominoplasty complication is still the highest among cosmetic surgeries, and further exploration is needed to reduce complications and improve aesthetic effects.

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.

The Bidirectional, Absorbable, No-Drain Abdominoplasty

This article outlines the author's technique, and the concepts of Bidirectional, Absorbable, No-Drain Abdominoplasty (BAND-Abdominoplasty). The attendant advantages and disadvantages are reviewed in the context of a retrospective, 5-year, single surgeon series. 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 .

Chronic Encapsulated Seroma Persisting for Three Years after Abdominoplasty and a Successful Surgical Solution

Abdominoplasty is listed among five most common esthetic surgical procedures in the Western World. Despite all efforts, abdominoplasty bears a high risk of complications. We observed a 39-year-old-woman with previous classical abdominoplasty performed elsewhere three years ago. Clinical examination demonstrated a swollen and tense abdominal mass. Laboratory findings were normal. Clinical examination was completed by abdominal ultrasonography which demonstrated both, a significant fluid volume in this area and a dense fibrous “capsule”. The diagnosis was a late or chronic encapsulated seroma with a thick pseudocapsule or “bursa”. We performed a revision abdominoplasty with a standard supra-fascial dissection. Surgical resection of infra-umbilical flap containing skin, subcutaneous tissue and capsulectomy were performed under general anaesthesia. A new umbilicus was created attaching small skin flaps in the muscular fascia. No drains were used. We observed no seroma formation. Follow up after six and ten months was unremarkable. The fibrous pseudocapsule of chronic seroma results in different degrees of deformities, abdominal scar deviation and asymmetry. Surgical capsulectomy combined with revision abdominoplasty with preservation of Scarpa’s fascia and placement of progressive tension sutures resulted in being effective and leads an esthetic outcome without seroma recurrence.