Abdominoplasty Flap Elevation in a More Superficial Plane: Decreasing the Need for Drains:

Abdominoplasty after massive weight loss. Safety preservation fascia technique and clinical outcomes in a large single series-comparative study

Introduction

Weight loss after bariatric surgery causes very important modifications to the patient's silhouette. Abdominal fat and skin excess reduction are associated with several complications. The most frequent are seroma and hematoma whereas major complications, such as pulmonary embolism, are less frequent. This study aimed to describe our technical procedure for abdominoplasty in patients with massive weight loss after bariatric surgery.

Methods

In total, 196 patients were included. All patients who underwent abdominoplasty classic (group A) and abdominoplasty with the preservation and lift of Scarpa fascia (group B) and with umbilical transposition between May 2018 and May 2021 were included. Patients with concomitant correction of ventral hernia were excluded. Demographic and operative data were analyzed according to comorbidities and postoperative complications.

Results

There were 160 (81.6%) women. The mean age was 43.6 years; the mean weight was 86.7 kg; and the mean BMI was 28.6 kg/m2. Five patients (2.5%) presented postoperative seroma. Four patients (2%) presented partial dehiscence/skin necrosis one of them requiring a revision. Finally, 26 patients presented a postoperative complication, with an overall incidence of 12.6%. The average postoperative hospital stay was 3.6. The rates of seroma were significantly higher in men, patients with a BMI > 30 kg/m2, and aged >50 years.

Conclusion

Preserving Scarpa Fascia during surgical post-bariatric patient procedures reduces the seroma formation and the scar complication and reduces the tension of the inguinal-pubic region with correction of our deformation after weight loss. Improves reducing the drain and reducing seroma incidence suction and hospital stay.

Postbariatric Abdominoplasty: A Comparative Study on Scarpa Fascia Preservation Versus Classical Technique

BACKGROUND

Abdominoplasties performed with Scarpa Fascia preservation, improve recovery and reduce complications, particularly seroma. Bariatric patients who experience massive weight loss frequently seek body contouring procedures and represent a high-risk group. This study aimed to evaluate the effects of abdominoplasty with Scarpa Fascia preservation versus the classical technique in a bariatric population.

METHODS

A retrospective observational cohort study was performed between March 2015 and March 2021 in 65 postbariatric patients who underwent a classic full abdominoplasty (group A, N = 25) or a similar procedure except for the preservation of Scarpa fascia (group B, N = 40). Total and daily drain output, time until drain removal, long drainers (≥ 6 days), length of hospital stay, emergency department visit, readmission to the hospital, reoperation, local and systemic complications were the outcomes evaluated.

RESULTS

Group B had a 3-day reduction in time until drain removal (p < 0.001), a 62.6% reduction of total drain output (p < 0.001) and a 3-day reduction in the length of the hospital stay (p < 0.001). Long drainers (≥ 6 days) were highly reduced (from 56.0% in group A to 7.5% in group B) (p < 0.001). There was a lower incidence of liquid collections in group B, with a 66.7% reduction in seroma incidence.

CONCLUSIONS

Abdominoplasty with Scarpa Fascia preservation improves recovery by reducing drain output, allowing earlier drain removal and reducing long periods with suction drains. It also reduces hospital stay and seroma incidence. This technique modifies the high-risk postbariatric patient in such a major way that he behaves like a nonbariatric.

LEVEL OF EVIDENCE II

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 .

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 .

Abdominoplasty with Scarpa Fascia Preservation: A Systematic Review and Meta-analysis

BACKGROUND

Scarpa fascia preservation has been proposed to minimize complications associated with conventional abdominoplasty, but its efficacy is unclear. The purpose of this article is to determine the influence of preserving scarpa fascia on reducing postabdominoplasty complications.

METHODS

A comprehensive search of Medline Ovid, PubMed, Web of Science, and the Cochrane CENTRAL databases was conducted from the inception till June 2021. Eligible studies were prospective controlled studies investigating postoperative complications after scarpa fascia preservation following abdominoplasty. Stata 15.1 software was used for the meta-analysis.

RESULTS

The meta-analysis included seven studies with 682 abdominoplasty patients. Abdominoplasty with scarpa fascia preservation could significantly reduce incidence of seroma (OR = - 1.34, 95% CI = - 2.09 - - 0.59, P < 0.05), length of hospital stay (SMD = - 1.65; 95% CI = - 3.50-0.20; P = 0.08), time to drain removal (SMD = - 3.64; 95% CI = - 5.76 - - 1.52; P < 0.05), and total drain output (SMD = - 401.60; 95% CI = - 593.75 - - 209.44; P < 0.05) compared with that of conventional abdominoplasty. However, it failed to achieve a statistically significant reduction in hematoma (OR=- 1.30, 95% CI = - 2.79-0.18, P = 0.08), infection (OR = - 1.03; 95% CI = - 2.17-0.12; P = 0.08), skin necrosis (OR = 0.63; 95% CI = - 1.20-2.45; P = 0.50), and wound dehiscence (OR = 0.28; 95% CI = - 0.28-0.83; P = 0.33). The seroma incidence rate was lower when a scalpel was utilized for dissection rather than electrocautery (3% (95% CI = 1-7%) versus 11% (95% CI = 5-18%)).

CONCLUSIONS

Preservation of scarpa fascia during abdominoplasty might reduce the likelihood of postoperative seroma, length of hospital stay, time to drain removal, and total drain output. However, it did not significantly affect the incidence of hematoma, infection, skin necrosis, and 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 .

Final 24-hour Drain Output and Postoperative Day Are Poor Indicators for Appropriate Drain Removal

Drains are used in plastic surgery to remove excess fluid while ameliorating complications. However, there is a paucity of evidence supporting guiding parameters on when to discontinue a drain. The aim of our study was to determine whether two of the most common parameters, drain volume 24 hours before removal or postoperative day, are valid indicators for drain removal.

Abdominoplasty without Drains or Progressive Tension Suturing

BACKGROUND

Over the years, the techniques of performing abdominoplasty have been modified and altered. Some of these modifications include progressive tension suturing and preservation of sub-Scarpa fat. These alterations have been done to decrease the risk of postoperative seroma and hematoma formation. Abdominoplasty, without the use of drains, is well documented in the literature. Here, the authors describe that raising superficial flaps (in the sub-Scarpa fat plane) will reduce seroma formation risk. As a result, the use of drains and tension suturing can be avoided altogether.

METHODS

A retrospective study was conducted from January 2015 to January 2018. The data of patients were extracted from admission files and operative notes. All the procedures were done under general anesthesia using the same operative technique by a single surgeon at the same institute. This article describes the operative technique used, observations, and result in comparison to the literature.

RESULTS

A total of 100 patients were included in the study for over three years; 89% were females, and the average age was 40 years, with a mean BMI of 25.1 kg/m². Liposuction was performed concomitantly in 56 patients, and rectus plication was done in 47. The overall complication rate was 14%, with the incidence of seroma and hematoma formation being 6% and 2%, respectively. This is comparable to the incidence found in the literature. The average hospital stay was 1.7 days, and the patients were followed for up to 6 months.

CONCLUSION

Abdominoplasty, when performed in superficial planes with preservation of sub-Scarpa fat, is safe in terms of improved flap vascularity and beneficial in reducing the risk of seroma and hematoma formation. It can be safely performed without drains or progressive tension suturing and reduces the operative time required, patient discomfort, and hospital-stay period.

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 .

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.

[Abdominoplasties: Do we still need to drain in 2021?]

OBJECTIVE

The purpose of this study was to consider the use of drainage when performing an abdominoplasty with regards to postoperative complications for two groups of patients.

PATIENTS AND METHOD

From January 1st 2017 to December 31th 2019, 215 patients underwent an abdominoplasty in our institution. In this retrospective, comparative, single institution study, patients were divided into two groups: "drainage" D (n=162) when suction completed abdominoplasty, "no drainage" ND (n=53) when suction didn't completed abdominoplasty. Early and distant complications were retrieved for each group and compared.

RESULTS

There was no significant difference between the two groups concerning the occurrence of seroma postoperatively (8% of patients in group D and 11.3% of patients in group AD). The drainage group D experienced more seroma's punctures (2,3± 1,0) and the mean of punctured fluid was higher (386,5ml±350,4ml) compared to the no drainage group ND (1,3+- 0,5 number of punctures with a mean punctured fluid of 165,8mL± 224,2mL). The mean hospital stay was shorter for group ND (2,9± 1,8 days) than for group D (4,4+- 1,7 days), P<0,0001.

CONCLUSION

Performing an abdominoplasty with quilting suture but drainless doesn't seem to increase postoperative complications statistically. The authors recommend, under the guise of a quilting suture, not to systematically drain the abdominoplasties and to reserve this technique for patients at risk of complications (high BMI, significant weight loss and co-morbidities).

Hernio-abdominoplasty with or without Scarpa's Fascia Preservation for Ventral Hernia and Abdominal Wall Deformity

Scarpa’s fascia preservation plays a great role in decreasing the volume of wound drainage and reducing seroma after abdominoplasty. This study aimed to assess the role of Scarpa’s fascia preservation in patients with ventral hernias associated with abdominal wall deformity who underwent concomitant hernio-abdominoplasty in terms of early and late postoperative outcome and quality of life.

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

The use of plasmakinetic cautery compared to conventional electrocautery for dissection of abdominal free flap for breast reconstruction: single-centre, randomized controlled study

Background

The plasmakinetic cautery is a surgical dissection instrument that combines scalpel-like cutting precision with electrocautery-like haemostasis properties, and operates at lower temperatures (40-170 °C) than conventional electrocautery (200-350 °C). The aim of this study is to evaluate the clinical benefits of using plasmakinetic cautery in abdominal free flap dissection for breast reconstruction.

Methods

Forty women undergoing abdominal-based microsurgical breast reconstruction (DIEP/MS-TRAM) were randomized to plasmakinetic cautery (n=20) or conventional electrocautery (n=20) for dissection of the abdominal free flap. Total abdominal wound drainage volume/duration, operation time and complications such as seroma and haematoma were examined.

Results

Age, body mass index, type of reconstruction and abdominal flap weight were similar in both groups. Mean abdominal drainage volume was (279±262) mL in conventional electrocautery group and (294±265) mL in plasmakinetic cautery group (P=0.853). Plasmakinetic cautery group mean drainage duration (4.3±2.2 days) was no difference compared to conventional diathermy group (3.8±2.0 days, P=0.501). Mean operation time in the conventional electrocautery group and plasmakinetic cautery group was 157±50 vs. 174±70 min respectively (P=0.195). There was more seroma detected in the conventional electrocautery group compared to plasmakinetic cautery group at days 7, 14 and 42 post-operation, but this was not statically significant. 2 haematomas in conventional diathermy group and 1 haematoms in the plasmakinetic cautery group required evacuation.

Conclusions

This study demonstrates that there are no significant differences between the use of plasmakinetic cautery and conventional electrocautery for abdominal free flap dissection.

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.

Lymphostasis and Hemostasis in Body-Contouring Surgery Using a Polysaccharide Based Hemostat (4DryField PH)

Background:

Following liposuction, abdominoplasty is the most frequent body-contouring intervention in the world. The transection of small blood vessels in large areas and subsequent bleeding is a viable risk during this procedure. The resulting microvascular bleedings should be stopped thoroughly to reduce the probability of related complications. In this prospective, monocentric, randomized study, the efficacy of the polysaccharide-based hemostat 4DryField PH (4DF) (PlanTec Medical, Lueneburg, Germany) is examined in classic abdominoplasty and lower body lift after Lockwood.

Methods:

For this prospective, monocentric, randomized study, 40 patients underwent surgery for both interventions. Twenty patients received an abdominoplasty, and 20 patients underwent a body lift. In each group, 10 patients have been treated with 4DF, whereas 10 have been served as the untreated control group.

Results:

4DF had neither a beneficial nor a negative effect on necessity of drainages, drainage volume and duration, length of hospital stay or frequency of postoperative seromas, wound healing disturbances, and infections, independent of surgical intervention. Patients in the 4DF group, however, had more individual risk factors, and required extended surgical interventions that might mask primary outcome results.

Conclusions:

This is the first prospective, monocentric, randomized study on 4DF in body-contouring surgery. The use of 4DF did not lead to a better postoperative outcome regarding hemostasis and lymphostasis. Potential benefits need further evaluation in high-volume studies.

Ligasure impact™might reduce blood loss, complications, and re-operation occurrence after abdominoplasty in massive-weight-loss patients: A Comparative Study

Background and Aims:

The most effective dissection technique for raising the flap in abdominoplasty is still controversial, particularly in high-risk massive-weight-loss patients. LigaSure Impact™vessel-sealing system (Medtronic, Dublin, Ireland) is an energy device commonly used among different surgical specialties to reduce morbidity and implement outcomes. The aim of this study was to investigate the effectiveness of LigaSure Impact in abdominoplasty compared with the conventional techniques, diathermia.

Material and Methods:

Patients underwent primary abdominoplasty after massive weight loss at a single center from 1 January 2008 to 31 May 2015 and were retrospectively reviewed. A total of 94 patients eligible for the study were divided into two groups on basis of the dissection technique: LigaSure Impact group (29 patients) and the conventional technique group (65 patients). Total intraoperative blood loss was the primary endpoint. Duration of the operation, perioperative complications and re-operation were recorded as secondary endpoints.

Results:

Baseline characteristics were well balanced between the groups. Significant differences were found in intraoperative blood loss favoring LigaSure Impact group (259.6 ± 198.8 mL vs 377.9 ± 190.0 mL, p = 0.004) and blood transfusion rates (13.8% vs 35.4%, p = 0.047). In contrast, operative time was significantly longer in LigaSure Impact group (168.6 ± 121.2 vs 179.7 ± 57.6 min, p = 0.005), while a tendency to shorter hospital stay was found in LigaSure Impact group (3.6 ± 1.1 days vs 4.6 ± 3.2 days, p = 0.081). Overall complications occurrence, Clavien–Dindo grade II (24.1% vs 55.4%) and grade III (13.8% vs 30.8%) complications were significantly lower in LigaSure Impact group (respectively, p = 0.005, p = 0.007, p = 0.016). Late (>30 days) re-operation rate was significantly lower in the LigaSure Impact group (6.9% vs 27.70%, p = 0.0028). Specific wound complications showed no significant difference.

Conclusion:

LigaSure Impact vessel-sealing system may be beneficial in improving abdominoplasty outcomes in massive-weight-loss patients because it might reduce blood loss, need for transfusions, complications, and re-operations.

Evaluation of the Number of Progressive Tension Sutures Needed to Prevent Seroma in Abdominoplasty with Drains: A Single-Blind, Prospective, Comparative, Randomized Clinical Trial

BACKGROUND

Seroma formation has become the most reported complication after abdominoplasties. In 2000, progressive tension sutures (PTS) were described and reported to be associated with a seroma rate of 0.1%. Surgeons worldwide use PTS to prevent seroma; however, there are discrepancies in the number of PTS commonly used, starting from five up to 35 sutures. The absence of standardization may cause a lack of seroma prevention, increased surgical time, and general hesitation to perform the technique.

OBJECTIVE

To determine whether 11 PTS are sufficient to prevent seroma in abdominoplasties.

METHODS

We performed a single-blind, prospective, comparative, randomized clinical trial of 63 healthy patients from January to December 2017. Patients were divided into groups: group 1, classic abdominoplasty without the use of PTS and drains; group 2, abdominoplasty with the use of 11 PTS and drains; and group 3, abdominoplasty with the use of 22 PTS and drains. The duration of the surgical technique, presence of clinical seroma, number of aspirations, and days to drain removal were evaluated. The Cochran-Armitage, Fisher exact, Kruskal-Wallis, and t tests were used in the statistical analyses.

RESULTS

PTS reduced the rate of seroma formation to 3.5%. Results showed that there is a benefit in using 11 PTS instead of 22 PTS because using more sutures led to an increased surgical time (30 min vs. 13 min) and possible complications. Compared to patients with PTS, those without PTS underwent more seroma aspirations and delayed drain removal.

CONCLUSIONS

Eleven PTS should be used in classic abdominoplasties.

LEVEL OF EVIDENCE I

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

Abdominoplasty with "Scarpa Fascia" preservation: Case Report

INTRODUCTION

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

PRESENTATION OF CASE

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

DISCUSSION

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

CONCLUSION

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

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

BACKGROUND

Seroma is the most common complication of abdominoplasty. Certain modifications to abdominoplasty may reduce the risk of seroma.

OBJECTIVES

The authors evaluated the incidence of seroma for 3 abdominoplasty techniques: preservation of Scarpa's fascia, placement of progressive tension (or quilting) sutures, and application of fibrin glue.

METHODS

In this systematic review and meta-analysis, the Cochrane Library, MEDLINE, Embase, and the International Clinical Trials Registry Platform (World Health Organization) were searched to identify studies of patients who underwent abdominoplasty with seroma as a potential "outcome." RevMan 5.3 was utilized for data management, statistical analyses, and graph preparation.

RESULTS

Fifteen studies (1824 total patients) met the criteria for inclusion in this review. The overall risk of bias was high, mainly owing to the nonrandomized nature of most studies. Abdominoplasty with preservation of Scarpa's fascia or placement of progressive tension sutures was associated with a significantly reduced incidence of seroma compared with that of standard abdominoplasty (P < 0.0001 and P < 0.0002, respectively). Abdominoplasty with application of fibrin glue was similar to standard abdominoplasty in terms of seroma development.

CONCLUSIONS

Placement of progressive tension sutures or preservation of Scarpa's fascia during abdominoplasty may reduce the likelihood of postoperative seroma. Application of fibrin glue has no impact on seroma formation.

LEVEL OF EVIDENCE

2.

Managing Complications in Abdominoplasty: A Literature Review

Background

Abdominoplasty, with or without liposuction, is among the most frequently performed aesthetic procedures. Its main objective is to improve the body contour by means of excising redundant skin and fat tissue. Although abdominoplasty is considered a safe procedure with high satisfaction rates, intraoperative and postoperative complications can become a challenge for the surgical team. The aim of this article is to offer a synopsis of the most common complications arising after abdominoplasty, along with evidence-based guidelines about how to prevent and treat them.

Methods

A systematic MEDLINE search strategy was designed using appropriate Medical Subject Headings (MeSH) terms, and references were scanned for further relevant articles.

Results

According to the published case series, local complications are considerably more common than complications with systemic repercussions. Approximately 10% to 20% of patients suffer a local complication following abdominoplasty, while fewer than 1% suffer a systemic complication. Prevention and management strategies are critically discussed for complications including seroma, haematoma, infection, skin necrosis, suture extrusions, hypertrophic scars, neurological symptoms, umbilical anomalies, deep venous thrombosis and pulmonary thromboembolism, respiratory distress, and death.

Conclusions

The complications of abdominoplasty vary in severity and in the impact they have on the aesthetic outcomes. Recommendations for prevention and management are based on various levels of evidence, with a risk of observer bias. However, most complications can be treated appropriately following the current standards, with satisfactory results.

Efficacy and Safety of Scarpa Fascia Preservation During Abdominoplasty: A Systematic Review and Meta-analysis

INTRODUCTION

Scarpa fascia preservation might be a promising approach to reduce seroma and other complications after abdominoplasty. However, the results remained controversial. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of scarpa fascia preservation in patients with abdominoplasty.

METHODS

PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials and clinical controlled trials assessing the effect of scarpa fascia preservation versus control (without scarpa fascia) during abdominoplasty were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcomes were seroma and hematoma/bleeding. Meta-analysis was performed using random-effect model.

RESULTS

Four studies involving 630 patients were included in the meta-analysis. Overall, compared with the control group, scarpa fascia preservation was associated with a significant reduced seroma (OR 0.16; 95% CI 0.06-0.43; P = 0.0004), time until drain removal (std. mean difference = -0.92; 95% CI -1.31 to -0.54; P<0.00001;), drain output (std. mean difference = -0.92; 95% CI -1.38 to -0.45; P = 0.0001), and hospital stay (std. mean difference = -0.93; 95% CI -1.48 to -0.39; P = 0.0008), but it failed to alter hematoma/bleeding (OR 0.46; 95% CI 0.09-2.38; P = 0.36), infection (OR 0.38; 95% CI 0.11-1.25; P = 0.11), and suture rupture (OR 0.67; 95% CI 0.12-3.73; P = 0.65) in patients with abdominoplasty.

CONCLUSIONS

Scarpa fascia preservation was associated with a significant decreased seroma, time until drain removal, drain output, and hospital stay, but could not change hematoma/bleeding, infection and suture rupture following abdominoplasty. Scarpa fascia preservation should be recommended during abdominoplasty.

LEVEL OF EVIDENCE II

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 .

Drainless Abdominoplasty Using Barbed Progressive Tension Sutures

We describe our current technique of drainless abdominoplasty using barbed progressive tension sutures. The perioperative management and detailed steps of procedure are outlined, including indications for concomitantly performing liposuction and repair of diastasis of the rectus abdominis muscles. This approach reliably improves abdominal contour, minimizes complications, and is straightforward to learn and perform.

Decrease in Seroma Rate After Adopting Progressive Tension Sutures Without Drains: A Single Surgery Center Experience of 451 Abdominoplasties Over 7 Years

BACKGROUND

Abdominoplasty is a common aesthetic procedure in the United States. Pollock and Pollock described their progressive tension technique in 2000 and published a series of 597 patients in 2012 of their experience. The reported seroma rate in the literature ranges from 2% to 26% with drains and 0.1% to 4% with progressive tension sutures (PTS) without drains.

OBJECTIVES

Given these data, we decided to use PTS and forego drains in abdominoplasty. Here we present our experience with the transition.

METHODS

This is a retrospective chart review of 451 abdominoplasties performed at our outpatient surgery center over a 7-year period (2009-2015). We gathered data on patient demographics, concomitant liposuction, and complications and length of follow up.

RESULTS

Five main differences were examined in PTS vs traditional abdominoplasty using drains groups. These included rate of seroma, wound complication, scar revision, hematoma, and follow up. We found a decreased rate of seroma in the PTS group, 2% vs 9%. Wound complications were similar. Scar revision was slightly higher in the PTS group at 17% vs 10% in traditional abdominoplasty, this association had a P value of .048. The rates of hematoma were similar (0% vs 1%). The mean follow up was 6 months in PTS and 9 months in traditional abdominoplasty. Addition of liposuction did not increase the rate of seroma.

CONCLUSIONS

PTS without drains significantly decreased the seroma rate in our practice. Our experience adds to the mounting evidence that surgeons should consider using the PTS technique and abandon the use of drains in abdominoplasty. A well powered, multicenter, randomized controlled study is needed in order to definitively lay this question to rest.

LEVEL OF EVIDENCE

4 Therapeutic.

Analysis of Extended Deep Fat Pad Excision in Abdominoplasty

BACKGROUND

Because abdominoplasty flap's major vascularization is suprafascial, some surgeons perform excision of the deep fat pad below Scarpa's fascia to achieve a better abdominal contour and balance the lower abdominal projection above and below the scar. The dimensions of this excised adipose flap and its correlations to both the classic abdominoplasty flap and patient biometrics have not been studied yet and are the aim of this article. Short-term complication outcomes are also reported.

METHODS

We performed a prospective case series study, operating 74 consecutive women using an otherwise standard abdominoplasty technique, and recorded patient variables, flap dimensions, and complications.

RESULTS

Average values are as follows: BMI, 27.35 kg/m; total flap weight, 1868 g; adipose flap weight, 157 g (corresponding to 9% extra flap weight); adipose flap height, 7.2 cm; and preserved infraumbilical deep fat pad thickness, 7.7 mm. Statistical analysis of correlations between variables was performed.

CONCLUSIONS

Increased patient weight, umbilical perimeter, BMI, and width of the operative specimen can be used to predict a heavier extra adipose flap. The extra fat excision is safe, preventing inadvertent invasion of the abdominoplasty flap's suprafascial plane that can happen with liposuction. No flap necroses were observed. The use of this technique may prove useful to achieve a slimmer abdominal contour and harmonize it with the pubic region.

A Prospective, Randomized, Multicenter Trial Assessing a Novel Lysine-Derived Urethane Adhesive in a Large Flap Surgical Procedure without Drains

OBJECTIVE

To evaluate the safety and effectiveness of a lysine-derived urethane adhesive as a noninvasive alternative to closed suction drains in a commonly performed large flap surgical procedure.

METHODS

One hundred thirty subjects undergoing abdominoplasty at five centers were prospectively randomized to standard flap closure with surgical drains (Control group) or a lysine-derived urethane adhesive (Treatment group) without drains. The primary outcome measured was the number of post-operative procedures, including drain removals (as the event marking the use of a surgical drain) and needle aspirations. Secondary endpoints included total wound drainage, cumulative days of treatment, and days to drain removal. A patient questionnaire evaluating quality of life measures was also administered.

RESULTS

Subjects in the Treatment group required significantly fewer post-operative procedures compared to the Control group (1.8 ± 3.8 vs. 2.4 ± 1.2 procedures; p < 0.0001) and fewer cumulative days of treatment (1.6 ± 0.4 vs. 7.3 ± 3.3; p < 0.0001). A procedure to address fluid accumulation was required for only 27.3 % of the subjects in the Treatment group versus 100 % of Control group, which by study design required the use of drains. The mean duration of use of indwelling surgical drains for the Control group was 6.9 ± 3.3 days. All fluid collections treated with percutaneous aspiration were resolved and there were no unanticipated adverse events.

CONCLUSION

The results of the study support that the use of a lysine-derived urethane adhesive is a safe and effective alternative to drains in patients undergoing a common large flap surgical procedure.

Analysis of Complications in Postbariatric Abdominoplasty: Our Experience

Abdominoplasty is one of the most popular body-contouring procedures. It is associated with a significant number of complications: the most common ones are seroma, hematoma, infection, wound-healing problems, and skin flap necrosis. From January 2012 to December 2014, 25 patients (18 women and 7 men) (mean age: 51 years) underwent abdominoplastic surgery at the Plastic Surgery Section, Department of Surgical Sciences, University of Parma, Italy. All patients reported a weight loss between 15 kg and 47 kg. All of the of 25 patients were included in the study; minor and major complications were seen in 17 (68%) and 8 (32%) patients, respectively. The percentage of complications in our patients was as follows: 9 patients with seroma (36%); 4 patients with wound dehiscence with delayed wound healing (16%); 3 cases with hematoma (12%); 2 patients with postoperative bleeding (8%); 1 patient (4%) with an umbilical necrosis; 1 patient (4%) with a deep vein thrombosis; 3 patients with infected seroma (12%); and 2 patients with wound infection (8%). There were no cases of postoperative mortality. The aim of this study is to analyze our complications in postbariatric abdominoplasty.

The no-drain, no-quilt abdominoplasty: a single-surgeon series of 271 patients

BACKGROUND

Recent innovations in abdominoplasty include progressive tension "quilting" sutures or Scarpa fascia preservation to limit the risk of seromas and hematomas. No-drain abdominoplasty with progressive tension sutures has been well documented. The authors describe outcomes in patients undergoing abdominoplasty with a modified surgical technique (including sub-Scarpa fascia fat preservation) and no use of drains or progressive tension sutures-the "no-drain, no-quilt" abdominoplasty.

METHODS

A retrospective, single-surgeon (A.A.Q.), single-site analysis of all abdominoplasty patients from 2003 to 2012 was performed. Data were extracted from paper case notes. All patients underwent surgery carried out under general anesthesia. The operative technique and postoperative regimen are described.

RESULTS

Two hundred seventy-one patients were identified over the 10-year period. Patients had a mean age of 45 years and mean body mass index of 27, and 98 percent were women. Concomitant abdominal liposuction was undertaken in 61 percent of all patients (165 of 271). Twenty-one patients (7.7 percent) had a seroma and five patients (1.8 percent) had a hematoma. Seven patients (2.6 percent) required a return to the operating room to manage complications, and 24 (8.9 percent) required elective revision. Patients were admitted for an average of 1.7 days, and mean follow-up was 6.2 months.

CONCLUSIONS

Abdominoplasty can be performed safely without drains or quilting sutures/progressive tension sutures. Benefits are discussed in terms of the potential for reduced intraoperative time (compared with progressive tension sutures), and reduced patient discomfort and inpatient stay (compared with drain use). The authors demonstrate low complication and elective revision rates in their series.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Defining the lymphatic system of the anterior abdominal wall: an anatomical study

BACKGROUND

Studies describing recent abdominoplasty modifications have reported a decreased incidence of seroma, attributed to preservation of abdominal lymphatics. However, there are limited anatomical data to support this hypothesis. The authors sought to characterize the lymphatic architecture of the abdominal wall and provide a conceptual basis for further refinement of abdominoplasty techniques.

METHODS

Fifteen tissue samples from five patients undergoing abdominoplasty were sectioned and analyzed. Slides were stained with hematoxylin and eosin, CD31, and D2-40 and assessed by a pathologist and a plastic surgeon for the presence and number of lymphatics. Results were reported as mean percentage of lymphatic-specific antibody per analyzed area.

RESULTS

Lymphatic vessels were observed in the dermis, superficial fascia, and loose areolar tissue but not in deep or superficial fat. The highest concentration was in the dermis (mean, 82.6 percent; range, 69 to 89.2 percent). The Scarpa fascia contained 9.4 percent of lymphatics (range, 7.0 to 11.4 percent), whereas the loose areolar tissue at the specimen base contained an average of 7.9 percent (range, 2.6 to 19.5 percent). These lymphatics were consistently located in the deepest third, with the Scarpa fascia lying an average of 34 percent of the total tissue thickness above muscle fascia. Lymphatic prevalence did not increase in specimens near the superficial epigastric vessels.

CONCLUSIONS

Abdominoplasty flap lymphatics are most common in the dermis, with a significant proportion (approximately 17 percent) also appearing near fascial layers. This confirms the presence of deep lymphatic channels that could potentially be preserved during abdominoplasty or lipoabdominoplasty.

Lipoabdominoplasty without drains or progressive tension sutures: an analysis of 100 consecutive patients

BACKGROUND

Subcutaneous surgical drains are commonly used in abdominoplasties to prevent seromas but are not tolerated well by patients and add additional discomfort after the procedure. The lipoabdominoplasty modification may create a more favorable surgical field to reduce the need for surgical drains without increasing seroma formation.

OBJECTIVES

The goal of this review was to determine if surgical drains can be completely eliminated in lipoabdominoplasty procedures without an increased risk of seromas.

METHODS

The authors conducted a retrospective chart review of 100 consecutive standard, extended, and circumferential lipoabdominoplasty patients done by a single surgeon with at least a 3-month follow-up period.

RESULTS

Seroma was identified in 5% of patients, hematoma and abscess each in 2% of patients, and granuloma, cellulitis, and delayed wound healing each in 1% of patients.

CONCLUSIONS

The use of discontinuous undermining with liposuction, limited direct undermining in the midline, preservation of a thin layer of fibrofatty tissue on the superficial abdominal wall fascia, and targeted surgical site compression can eliminate the need for surgical drains without increasing seroma rates.

Dissection Technique for Abdominoplasty: A Prospective Study on Scalpel versus Diathermocoagulation (Coagulation Mode)

Background:

The purpose of this study was to evaluate the effect of the dissection technique on outcomes and complications after a full abdominoplasty, comparing 2 different techniques used to raise the abdominal flap: the steel scalpel and the diathermocoagulation device on coagulation mode.

Methods:

A prospective study was performed at a single center from January 2009 to December 2011 of patients submitted to abdominoplasty with umbilical transposition. Two groups were identified: group A, abdominoplasty performed with steel scalpel/knife; and group B, abdominoplasty performed with diathermocoagulation on coagulation mode. Several variables were determined: general characteristics, time until drain removal, daily and total volume of drain output, length of hospital stay, operative time, readmission, reoperation, emergency department visits, and local and systemic complications.

Results:

A total of 119 full abdominoplasties were performed in women (group A, 39 patients; group B, 80 patients). There were no statistically significant differences between groups with respect to general characteristics, except for body mass index, comorbidities, and weight of the surgical specimen; there were no differences for operative time, systemic complications, hematoma, and necrosis incidence. The scalpel group had a highly significant reduction of 54.56% on total drain output, and a 2.65 day reduction on time to drain removal and no reported cases of seroma or healing problems (difference of 81.25% and 90.00%, respectively, between the 2 groups).

Conclusions:

Performing abdominal dissection with scalpel had a beneficial effect on patient recovery, as it reduced time requested for drain removal, total drain output, and incidence of seroma and wound healing problems.

Decreasing cesarean section surgical site infection: an ongoing comprehensive quality improvement program

This report illustrates how the "plan-do-study-act" method of continuous quality improvement can be effective in reducing surgical site infection after cesarean delivery.

Prospective clinical study of 551 cases of liposuction and abdominoplasty performed individually and in combination

BACKGROUND

Despite the popularity of these procedures, there are limited published prospective studies evaluating liposuction and abdominoplasty. Lipoabdominoplasty is a subject of recent attention. Several investigators have recommended alternative techniques that preserve the Scarpa fascia in an effort to reduce complications, particularly the risk of seromas.

METHODS

Over a 5-year period, 551 consecutive patients were treated with ultrasonic liposuction alone (n = 384), liposuction/abdominoplasty (n = 150), or abdominoplasty alone (n = 17). In lipoabdominoplasties, the abdomen and flanks were first treated with liposuction. A traditional flap dissection was used for all abdominoplasties. Scalpel dissection was used rather than electrodissection. A supine "jackknife" position was used in surgery to provide maximum hip flexion, allowing a secure deep fascial repair.

RESULTS

The complication rate after liposuction was 4.2% vs 50% for patients treated with an abdominoplasty. Approximately half of the abdominoplasty complications were minor scar deformities, including widened umbilical scars (17.3%) that were revised. The seroma rate after abdominoplasties was 5.4%; there were no seromas after liposuction alone.

CONCLUSIONS

Lipoabdominoplasty may be performed safely, so that patients may benefit from both modalities. The seroma rate is reduced by avoiding electrodissection, making Scarpa fascia preservation a moot point. A deep fascial repair keeps the abdominoplasty scar within the bikini line. Deep venous thrombosis and other complications may be minimized with precautions that do not include anticoagulation.

Scarpa fascia preservation during abdominoplasty: randomized clinical study of efficacy and safety

BACKGROUND

Scarpa fascia preservation has been suggested as a way of reducing complications associated with conventional abdominoplasty. A prospective randomized study was conducted to evaluate the effect on results and complications of preserving the Scarpa fascia during a full abdominoplasty.

METHODS

This was a single-center study conducted from August of 2009 to February of 2011. Patients were assigned randomly to one of two procedures: classic full abdominoplasty (group A) or a similar type of abdominoplasty except for the preservation of the Scarpa fascia and the deep fat compartment in the infraumbilical area (group B). Four surgeons were involved in the study. Several variables were determined: general characteristics, time to suction drain removal, total volume of drain output, length of hospital stay, systemic complications, local complications, and aesthetic result.

RESULTS

A total of 160 full abdominoplasties were performed in women (group A, 80 patients; group B, 80 patients) equally divided by the four involved surgeons. There were no statistically significant differences between groups with respect to general characteristics, complications (except for the seroma rate), and aesthetic result. The Scarpa fascia preservation group had a highly significant reduction of 65.5 percent on the total drain output, 3 days on the time to drain removal, and 86.7 percent on the seroma rate.

CONCLUSION

Preservation of the Scarpa fascia during an abdominoplasty had a beneficial effect on patient recovery, as it reduced the total drain output, time to drain removal, and seroma rate without compromising the aesthetic result.