Impact of Patient Subtype and Surgical Variables on Abdominoplasty Outcomes: A 12-Year Massachusetts General Hospital Experience

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 .

Outcomes of Abdominoplasty in Tumescent Local Anesthesia Combined with Subdural Anesthesia

BACKGROUND

Abdominoplasty is a common surgical procedure performed under general anesthesia, and although the use of TLA combined with subdural anesthesia has never been reported in abdominoplasty, it offers several benefits such as safe and effective local anesthesia and vasoconstriction. We outline our experience with the TLA technique for primary abdominoplasty over the last 7 years.

METHODS

From 2014 to 2021, TLA and subdural anesthesia have been used in primary abdominoplasty surgeries for 106 patients. The TLA solution consisted of 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) diluted in 1000 mL of 0.9% saline solution. The solution was then injected with a 2-mm cannula into the subcutaneous adipose tissue in the suprafascial plane. The subdural anesthesia was performed at intervertebral level L1-L2 using Ropivacaine 15/18 mg in 4 ml.

RESULTS

Patients aged from 32 to 75 years. The amount of tumescent solution infiltrated ranged between 500 and 1000 mL. Mean surgery time was 70 minutes, and recovery room time averaged at 240 minutes. Major complications related to the surgery were observed in 12.26% of patients, including eight hematomas and five seromas. Two patients experienced wound dehiscence, and no dystrophic scar formation was observed. Eventually, there was no need for a conversion to general anesthesia.

CONCLUSIONS

Tumescent local anesthesia combined with subdural anesthesia is a highly effective and safe method for performing abdominoplasty. This technique has proven to be an excellent choice for primary abdominoplasty, providing significant benefits to patients and surgeons alike due to its safe administration, precise pain management during and after surgery, and minimal postoperative side effects.

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 .

Does Concomitant Umbilical Hernia Repair Increase the Risk of Complications in Abdominoplasty? A Propensity Score Matched Analysis

BACKGROUND

Patients seeking cosmetic abdominoplasty often have umbilical hernias. Optimal management and safety of concomitant umbilical hernia repair with abdominoplasty is not well described.

OBJECTIVES

The goal of this study was to compare complication rates following abdominoplasty with or without umbilical hernia repair.

METHODS

A retrospective propensity score matched cohort study of patients who underwent an abdominoplasty at Massachusetts General Hospital was performed. Direct umbilical hernia repair was performed by making a fascial slit inferior or superior to the umbilical stalk. The fascial edges were approximated with up to three 0-Ethibond sutures (Ethicon, Raritan, NJ) from the preperitoneal or peritoneal space. Propensity score matching was used to adjust for confounding variables.

RESULTS

The authors identified 231 patients with a mean [standard deviation] age of 46.7 [9.7] years and a mean BMI of 25.9 [4.4] kg/m2. Nine (3.9%) had diabetes, 8 (3.5%) were active smokers, and the median number of previous pregnancies was 2. In total, 223 (96%) had a traditional abdominoplasty, whereas 8 (3.5%) underwent a fleur-de-lys approach. Liposuction was performed on 90%, and 45.4% underwent simultaneous breast or body contouring surgery. The overall complication rate was 6.9%. Propensity scores matched 61 pairs in each group (n = 122) with closely aligned covariates. There was no significant difference in total complication rates between abdominoplasty alone vs abdominoplasty with hernia repair. There were no cases of skin necrosis or umbilical necrosis in either group.

CONCLUSIONS

Performing umbilical hernia repair with abdominoplasty is safe when utilizing the technique reported in this series.

LEVEL OF EVIDENCE: 3

Patient-reported Outcomes of Scar Impact: Comparing of Abdominoplasty, Breast Surgery, and Facial Surgery Patients

Scarring negatively impacts patient mental health, causing worsened self-confidence, body image, and social interactions, as well as anxiety and depression. The objective of this study is to evaluate the scarring impact after facial surgery, breast surgery, and full abdominoplasty for symptoms, appearance, psychosocial health, career, and sexual well-being using validated patient-reported outcome measures.

[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.

TULUA Lipoabdominoplasty: Transversal Aponeurotic Plication, No Undermining, and Unrestricted Liposuction. A Multicenter Study of 845 Cases

BACKGROUND

TULUA (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar) is the acronym for a radically different lipoabdominoplasty, intended to add simplicity, improve vascular safety, and attain good results. Modifications are unrestricted liposuction, no flap detachment, massive transverse infraumbilical plication, umbilicus amputation, neoumbilicoplasty, diminished tension wound closure, and low transverse scar settlement. The objectives of this article are to describe the technique and analyze a multicenter experience.

METHODS

Sixty-eight plastic surgeons from 10 countries provided data for a retrospective review of 845 patients. Aesthetic results were scored by each surgeon using the Salles scale and analyzed in combination with complications to identify associations between patient and surgery characteristics.

RESULTS

Of the patients, 95.5 percent were female, 19.7 percent were obese, 35.6 percent had prior scars, 10.4 percent had undergone previous abdominoplasty, 6.5 percent were postbariatric, and 6.6 percent were smokers. One patient had a kidney transplant, and 16.5 percent had comorbidities. Surgery characteristics varied widely, being on average as follows: lipoaspirate, 2967 ml; resection, 1388 g; and surgical time, 3.9 hours; 46.5 percent were not hospitalized. Averaged results were 8.68 of 10 points, besides adequate positioning and proportion of scar and umbilicus, without epigastric compensatory bulging (4.97 of 6 points). Overall complications were 16.2 percent, mostly seroma (8.8 percent); vascular-related complications (i.e., necrosis, wound dehiscence, and infection) constituted 2.7 percent. There were no fatalities. The logistic regression model demonstrated that smoking and obesity duplicate the risk of complications; if age older than 60 years is added, the risk of complication increases seven to nine times. Reported indications were multiple; however, pathologic diastasis was excluded.

CONCLUSION

TULUA lipoabdominoplasty is a new reproducible procedure with good quantified results and an acceptable complication rate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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 Effect of Obesity, Bariatric Surgery, and Operative Time on Abdominal Body Contouring Outcomes

BACKGROUND

Abdominal body contouring procedures are associated with the highest rates of complications among all aesthetic procedures. Patient selection and optimization of surgical variables are crucial in reducing morbidity and complications.

OBJECTIVES

The purpose of this single-institution study was to assess complication rates, and to evaluate BMI, operative time, and history of bariatric surgery as individual risk factors in abdominal body contouring surgery.

METHODS

A retrospective chart review was performed of all patients who underwent abdominoplasty, circumferential lower body lift, fleur-de-lis panniculectomy (FDL), and circumferential FDL between August 2014 and February 2020. Endpoints were the incidence of venous thromboembolism, bleeding events, seroma, infection, wound complications, and reoperations. Univariate statistical analysis and multivariate logistic regressions were performed. Covariates in the multivariate logistic regression were BMI, procedure time, and history of bariatric surgery.

RESULTS

A total of 632 patients were included in the study. Univariate analysis revealed that longer procedure time was associated with infection (P = 0.0008), seroma (P = 0.002), necrosis/dehiscence (P = 0.01), and reoperation (P = 0.002). These associations persisted following multivariate analyses. There was a trend toward history of bariatric surgery being associated with minor reoperation (P = 0.054). No significant increase in the incidence of major reoperation was found in association with overweight or obese patient habitus, history of bariatric surgery, or prolonged procedure time. BMI was not found to be an individual risk factor for morbidity in this patient population.

CONCLUSIONS

In abdominal body contouring surgery, surgery lasting longer than 6 hours is associated with higher incidence of seroma and infectious complications, as well as higher rates of minor reoperation.

LEVEL OF EVIDENCE: 4

Abdominoplasty in the Massive Weight Loss Patient: Are Aesthetic Goals and Safety Mutually Exclusive?

Background

The goals of abdominoplasty in massive weight loss (MWL) patients are often functional, with a greater emphasis on safety than on aesthetic rejuvenation. As important as functional improvements and safety are, however, there may be room for increasing the aesthetic potential of abdominoplasties in these patients.

Objectives

To determine the safety of the pursuit of aesthetic goals for abdominoplasty in MWL patients.

Methods

This is a retrospective study examining 910 consecutive female patients consisting of 3 groups: postpartum (n = 718), dietary MWL (n = 65), and bariatric MWL (n = 127). All patients were approached with a well-defined set of aesthetic goals which were pursued as needed and as feasible.

Results

The utilization of aesthetic abdominoplasty components was similar in all groups, supporting the assertion that the groups were subjected to a similar aesthetic emphasis. Logistic regression showed that a history of bariatric MWL was an independent risk factor for multiple complications (odds ratio 2.738, P = 0.014) and that elevated body mass index (BMI), smoking, diabetes, and age were likewise independent risk factors for complications. Propensity score-matched case-control pairs showed that bariatric MWL patients were more likely than dietary MWL patients to experience multiple complications (9.52% vs 0%, P = 0.031).

Conclusions

Bariatric MWL patients but not dietary weight loss patients seem to have a higher risk than postpartum patients. Other comorbidities (elevated BMI, smoking, diabetes, and age) seem to be more important predictors of complications than MWL status. Select MWL patients can likely be approached with an emphasis on aesthetic goals, without increasing risks as compared with the postpartum population.

Level of Evidence: 2

Post-Bariatric Abdominoplasty: Analysis of 406 Cases With Focus on Risk Factors and Complications

BACKGROUND

Post-bariatric patients present a surgical challenge within abdominoplasty because of residual obesity and major comorbidities. In this study, we analyzed complications following abdominoplasty in post-bariatric patients and evaluated potential risk factors associated with these complications.

OBJECTIVES

The authors sought to determine the complications and risk factors following abdominoplasty in post-bariatric patients.

METHODS

A retrospective study of patients who underwent abdominoplasty was performed from January 2009 to December 2018 at our institution. Variables analyzed were sex, age, body mass index (BMI), smoking, surgical technique, operative time, resection weight, drain output, and complications.

RESULTS

A total of 406 patients were included in this study (320 female and 86 male) with a mean age of 44.4 years and a BMI of 30.6 kg/m2. Abdominoplasty techniques consisted of traditional (64.3%), fleur-de-lis technique (27.3%), and panniculectomy without umbilical displacement (8.4%). Overall complications recorded were 41.9%, the majority of these being wound-healing problems (32%). Minor and major complications were found in 29.1% and 12.8% of patients, respectively. A BMI value of ≥30 kg/m2 was associated with an increased risk for wound-healing problems (P = 0.001). The frequency of total complications was significantly related to age (P = 0.007), BMI (P = 0.004), and resection weight (P = 0.001). Abdominoplasty technique tended to influence total complications.

CONCLUSIONS

This study demonstrates in a fairly large sample of post-bariatric patients (n = 406) that abdominoplasty alone can be performed safely, with an acceptable complication rate. Age, BMI, and resection weight are shown to be significant risk factors for total complications. The role of surgical technique needs to be evaluated further.

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.

Safety of Lipoabdominoplasty Versus Abdominoplasty: A Systematic Review and Meta-analysis

BACKGROUND

Lipoabdominoplasty is a powerful operation to maintain a youthful physique for aging people, improve body contouring, and remove excess skin caused by massive weight loss. Nonetheless, it is controversial to combine abdominoplasty and liposuction because of the potential for vascular damage of the abdominal flap and increased complications. The purpose of this article was to determine the complication rates of lipoabdominoplasty compared with traditional abdominoplasty.

METHODS

PubMed, EMBASE, and Cochrane databases were searched through July of 2018. Study results were analyzed utilizing a fixed random effects model. The outcomes were expressed as relative risk (RR) and 95% confidence interval. Subgroup analyses were conducted based on complications.

RESULTS

Overall, 17 trials enrolling 14,061 adult patients were searched. Of these patients, 577 (4.1%) developed seroma; 113 (0.8%) experienced hematoma; 783 (5.6%) experienced wound infection, dehiscence, or fat necrosis; 35 (0.2%) developed deep venous thrombosis; and 110 (0.7%) experienced scar deformity. A forest plot revealed fewer complications in the lipoabdominoplasty group than in the traditional abdominoplasty group (RR = 0.85; 95% CI 0.74-0.97; p = 0.017). Subgroup analysis showed that the lipoabdominoplasty group had a lower incidence of hematoma (RR = 0.56; 95% CI 0.36-0.86; p = 0.009) and seroma (RR = 0.69; 95% CI 0.57-0.85; p = 0.000).

CONCLUSIONS

Lipoabdominoplasty is a valuable tool to perfect body shape. This meta-analysis showed no evidence that it was associated with higher rates of 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 .

Risk Factors for Undergoing Elective Abdominal Contouring Surgery Shortly After Hospitalization

BACKGROUND

Having posthospital syndrome (PHS) at the time of an elective surgery increases the risk of postoperative adverse outcomes. The purpose of this article was to identify incidence and risk factors for having PHS at the time of abdominal contouring surgeries.

METHODS

Insurance claims from the Truven MarketScan Databases were used to identify patients who underwent outpatient abdominoplasty, liposuction, or panniculectomy between April 2010 and August 2015. Patients were presumed to have PHS if they were hospitalized within 90 d before surgery. Incidence rates of having PHS were calculated for patient groups defined by demographic data and comorbidities. Statistical inference based on adjusted odds ratios was used to evaluate the association of potential risk factors with PHS. A nonparametric regression method was used to demonstrate nonlinear effects of patient covariates on the risk of PHS.

RESULTS

This study included 18,947 patients who underwent abdominal contouring; 77% were female, and the mean age was 48.7 y (SD = 14.7). Six percent (n = 1045) of patients had PHS at the time of surgery. A significantly stronger association with PHS (P < 0.001) was observed in patients with deep venous thrombosis (adjusted odds ratio = 3.56), Elixhauser score > 8 (3.28), and smokers (2.16). Age was found to have a piecewise linear effect on PHS, with odds increasing by 2.1% per year over the age of 45 y.

CONCLUSIONS

Older patients have an increased risk of undergoing abdominal contouring surgery in a deconditioned state. Screening at-risk populations for PHS would help identify patients who need rehabilitation before operative intervention.

[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.