An Evidence-Based Approach to Abdominoplasty:

Clinical Practice Patterns in Abdominoplasty: 16-Year Analysis of Continuous Certification Data from the American Board of Plastic Surgery

BACKGROUND

The authors evaluated trends in practice patterns for abdominoplasty based on a 16-year review of tracer data collected by the American Board of Plastic Surgery as part of the continuous certification process.

METHODS

To facilitate comparison of an equal number of patients over time, tracer data from 2005 to 2021 were split into an early cohort (EC) (from 2005 to 2014) and a recent cohort (RC) (from 2015 to 2021). Fisher exact tests and two-sample t tests were used to compare patient demographics, surgical techniques, and complication rates.

RESULTS

Data from 8990 abdominoplasties (EC, n = 4740; RC, n = 4250) were analyzed. RC abdominoplasties report a lower rate of complications (RC, 19%; EC, 22%; P < 0.001) and a lower rate of revision surgery (RC 8%; EC, 10%; P < 0.001). This has occurred despite the increased use of abdominal flap liposuction (RC, 25%; EC, 18%; P < 0.001). There has been a decline in the use of wide undermining (81% versus 75%; P < 0.001), vertical plication of the abdomen (89% versus 86%; P < 0.001), and surgical drains (93% versus 89%; P < 0.001). Abdominoplasty surgery is increasingly performed in an outpatient setting, with increased use of chemoprophylaxis for thrombosis prevention.

CONCLUSIONS

Analysis of these American Board of Plastic Surgery tracer data highlights important trends in clinical practice over the past 16 years. Abdominoplasty continues to be a safe and effective procedure with similar complication and revision rates over the 16-year period.

Occurrence and treatment of peripheral nerve injuries after cosmetic surgeries

Although non-invasive and minimally invasive aesthetic procedures increasingly dominate the cosmetic market, traditional plastic surgery remains the most effective improvement method. One of the most common complications in plastic surgery, peripheral nerve injuries, though has a low incidence but intrigued plastic surgeons globally. In this article, a narrative review was conducted using several databases (PubMed, EMBASE, Scopus, and Web of Science) to identify peripheral nerve injuries following cosmetic surgeries such as blepharoplasty, rhinoplasty, rhytidectomy, breast surgeries, and abdominoplasty. Surgery-related nerve injuries were discussed, respectively. Despite the low incidence, cosmetic plastic surgeries can cause iatrogenic peripheral nerve injuries that require special attention. The postoperative algorithm approaches can be effective, but the waiting and treatment processes can be long and painful. Preventive measures are undoubtedly more effective than postoperative remedies. The best means of preventing disease is having a good understanding of anatomy and conducting a careful dissection.

Evaluating Outcomes and Weight Loss After Panniculectomy

OBJECTIVE

The objective of this study was to evaluate long-term outcomes and weight loss after panniculectomy.

METHODS

A retrospective chart review study was performed on 225 consecutive patients who had undergone panniculectomy from 2002 and 2020. Demographic variables including smoking status, medical comorbidities, and prior history of weight loss/bariatric surgery were collected for 173 patients. Preoperative and postoperative body mass index (BMI) were calculated in addition to postoperative outcomes.

RESULTS

The study population was 85% female with a mean age of 57 years and an average follow-up of 3.9 years. Relevant comorbidities included obesity (88%), hypertension (65%), diabetes (37%), and smoking (8%), and the majority (53%) of patients had undergone prior bariatric surgery. The overall complication rate was 40%. Twenty percent of patients required reoperation or readmission, and 20% had minor complications addressed in an outpatient setting. Patients who had higher preoperative BMI experienced a significant long-term reduction in BMI. In addition, patients who did not undergo prior bariatric surgery tended to lose weight more often and by larger amounts than patients who had prior bariatric surgery (71.6% vs 57.6, P = 0.023). Complications were not uncommon and included infection (17%), delayed wound healing (16%), seroma (8%), and hematoma (3%). Patients who had prior bariatric surgery were at reduced risk of any complication (P = 0.012). Smoking increased the incidence of infection (38.5% of smokers vs 15.6% of nonsmokers, P = 0.039). Concomitant hernia repair increased the risk of overall complications (64.3% vs 35.9%, P = 0.003) and delayed wound healing (39.2% vs 11.7%, P < 0.001). In the subgroup of patients who did not lose weight, a panniculus weight greater than 5 kg was associated with an increased complication rate (61.5% vs 27%, P = 0.03).

CONCLUSIONS

Patients who underwent a panniculectomy tended to lose weight postoperatively, particularly those who had not undergone previous bariatric surgery. Complications were not uncommon, especially in patients with a smoking history. Prior bariatric surgery patients had a significant decrease in postoperative complications but tended to lose less weight after panniculectomy than those without prior bariatric surgery. Concomitant hernia repair put patients at an increased risk of complications.

The reverse lip design: a design for safe and effective abdominoplasty

Conventional abdominoplasty includes the removal of an ellipse-shaped section of abdominal tissue between the umbilicus and mons pubis. However, this method can result in tension of the undermined flap, especially in the midline. To address this problem, we present reverse lip design as a modified method that also has aesthetic advantages. The reverse lip design entails a longer lower flap edge while preserving the triangular tissue in the vascularly stable pubis area. These markings create an image of a reverse lip shape with a cleft at the bottom of the lower markings. After typical lipoabdominoplasty is performed, redundant waist tissues can easily be pulled inward and downward. The reverse lip design abdominoplasty demonstrated no complications and required no further revisions after the procedure. Patients were generally satisfied with the aesthetic improvements in their body shape. They were also able to return to their routine activities approximately 1 week after the operation while wearing a supporting undergarment. This modified abdominoplasty using the reverse lip design reduces low midline tension of the undermined abdominal flap while enhancing body aesthetics with a slimmer waistline, leading to higher patient satisfaction.

Post-bariatric body contouring surgery: analysis of complications in 180 consecutive patients

INTRODUCTION

bariatric surgery is the main treatment for cases of severe obesity and body contour surgery to correct body dysmorphia resulting from weight loss. However, these procedures are associated with a significant number of postoperative complications.

OBJECTIVE

this study aims to analyze complications in post-bariatric patients undergoing body contour surgeries and correlating them with the age and BMI of these patients.

METHODS

the current study is a retrospective study evaluating 180 consecutive patients undergoing body contour surgery after bariatric surgery within a period of three years (2014-2016). Data such as age, gender, Body Mass Index before bariatric and plastic surgeries, type of surgery performed and complications were collected, and correlated the age as well as the BMI of the patients in the pre-bariatric (PB) and pre-plastic (PP) periods with the complications presented.

RESULTS

of the 180 patients evaluated, 91.7% were females (n = 165), and the mean age was 46.3 ± 1.7 years. The most performed surgery was abdominoplasty (48.9%), followed by mammaplasty (21.1%). Some complications occurred in 26.1% of the patients with partial dehiscence (40.4%) and seroma (14.9%) being the most frequent. Patients who presented complications had a higher mean age (50.8 years) than those who presented with no complications, and major complications accounted for 2.7% of the sample.

CONCLUSIONS

a statistically significant number of surgeries progressed without complications and, when they occurred, there were minor complications in most of the sample. Complications were more frequent in older patients with some of them having a BMI over 30 Kg/m2.

The Addition of Partial or Circumferential Liposuction to Abdominoplasty Is Not Associated With a Higher Risk of Skin Necrosis

BACKGROUND

Combining abdominoplasty with liposuction is a common practice for optimal patient aesthetic outcomes. In the past, several practitioners have argued against liposuction due to the potential for vascular insufficiency, especially with central liposuction. Despite these concerns for flap damage with resultant necrosis, the incidence of this complication has not been comprehensively investigated.

OBJECTIVES

The authors therefore examined the incidence of necrotic complications, including skin and fat necrosis as well as partial/total flap loss, in patients who underwent abdominoplasty alone (AA) or abdominoplasty with partial or circumferential liposuction (APCL).

METHODS

Literature searches were performed in PubMed/Medline and Embase with no query limits. For the systematic review, data from the studies were extracted into a form including primary author, publication year, study design, number of AA and APCL patients, abdominal zone(s) treated with liposuction, average lipoaspirate volume, follow-up time, necrotic complications, and revision procedures. A meta-analysis was separately performed for 13 studies that included patients who underwent both AA and APCL.

RESULTS

The overall rate of necrotic complications was lower in the APCL group (0.39%) compared with the AA group (1.01%). The incidence of necrotic complications was low for all patients, with a pooled partial flap loss rate of 0.24% and a pooled skin necrosis rate of 0.23%. The forest plots revealed that patients who underwent APCL do not face a higher risk of skin necrosis or revision compared with those who underwent AA.

CONCLUSIONS

Performing APCL is a safe combined procedural approach and can confer added benefits of improved patient satisfaction and aesthetic outcomes.

LEVEL OF EVIDENCE: 4

TULUA Lipoabdominoplasty: No Supraumbilical Elevation Combined With Transverse Infraumbilical Plication, Video Description, and Experience With 164 Patients

BACKGROUND

TULUA (transverse plication, undermining halted at umbilicus, liposuction [without restrictions], umbilicoplasty with a skin graft, and abdominoplasty with low transverse scar localization) is a fundamentally different lipoabdominoplasty technique intended to reduce the risk of vascular compromise, correct wall laxity through a unique plication, allow freedom in choosing the umbilical position, reduce tension on closure, and keep the final scar low.

OBJECTIVES

The objectives of this article were to describe the TULUA technique and its variations, delineate the indications and contraindications, show the expected results, and determine its safety profile.

METHODS

A series of 164 patients is presented. The technique's basic tenets were (1) infraumbilical wide transverse plication; (2) no undermining above the umbilicus; (3) unrestricted liposuction, including the supraumbilical tissues; (4) umbilical amputation and neoumbilicoplasty in the ideal position with a skin graft; and (5) low transverse scar placement. Complications were recorded and tabulated. Results were evaluated utilizing Salles' and the author's graded scales.

RESULTS

Scores averaged 9.4 out of 10 on the Salles' scale and 5.6 out of 6 on the author's scale, demonstrating adequate correction of the abdominal contour and the wall and skin laxity, with properly placed scars and umbilici, and without compensatory epigastric bulging. Overall, 20% of the patients experienced a complication: 9.7% experienced a delay in either the healing or graft take of the umbilicus, 0.6% developed skin necrosis, 0.6% experienced a wound dehiscence, 2.4% had an infection, and 4.9% developed a seroma.

CONCLUSIONS

The TULUA lipoabdominoplasty technique was found to improve abdominal wall laxity and aesthetics to a degree that is similar to traditional abdominoplasty, based on the evaluated parameters. The complications associated with the procedure are within the range of other abdominoplasty techniques, and the technique potentially has a reasonable safety profile with less risk of vascular compromise.

LEVEL OF EVIDENCE: 4

Evidenced-Based Approach to Abdominoplasty Update

The following publication was compiled as an evidence-based update for plastic surgeons performing abdominoplasty from a review of the published literature on that subject between January 2014 and February 2017. It is an overview of various aspects of abdominoplasty including preoperative patient assessment, variations and advances in both surgical and anesthetic technique, patient safety, and outcomes. It is intended to serve as an adjunct to previously published evidence-based reviews of abdominoplasty.

Does Abdominoplasty Add Morbidity to Incisional Hernia Repair? A Randomized Controlled Trial

Background Abdominoplasty is considered an operation linked to a considerable rate of morbidity. The convenience of simultaneously performing an incisional hernia repair and an abdominoplasty remains controversial. Methods A total of 111 patients were randomized prospectively to compare isolated incisional hernia repair and hernia repair when combined with abdominoplasty. Primary end points were in-hospital stay and early morbidity. Secondary end points were late morbidity, recurrences, and quality of life. Patients were followed-up for 24 months. Results Duration of the surgical procedure differed significantly between both groups (39 vs 85 minutes, P < .001) and postoperative hospital stay (2.5 vs 3.5 days; P < .001). No statistically significant differences in early or late morbidity between both groups were detected. The perceived quality of life for patients was higher in the combined surgery group (P < .001) that in the isolated hernia repair group. Conclusions Postoperative in-hospital stay and early and late morbidity do not differ significantly between isolated incisional hernia repair and simultaneous hernia repair with abdominoplasty, but associated abdominoplasty provides a higher quality of life when indicated.

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.

Safely combining abdominoplasty with aggressive abdominal liposuction based on perforator vessels: technique and a review of 300 consecutive cases

BACKGROUND

There continues to be controversy about performing abdominoplasty concurrently with abdominal liposuction. The concern is that liposuction on the already vascularly compromised abdominal flap will lead to increased complications and flap necrosis. The central abdomen is supplied by the epigastric system. If perforator vessels from this system are spared, the blood supply to the abdomen can be spared and liposuction should be able to be safely performed on the elevated abdominal flap. The purpose of this study was to evaluate the safety of abdominoplasty with concurrent abdominal liposuction when a perforator vessel is spared.

METHODS

A standard abdominoplasty was performed, sparing one or two perforator vessels from the deep superior epigastric artery system. A retrospective chart review of 300 consecutive patients who underwent abdominoplasty surgery combined with concurrent abdominal liposuction was performed. Complications, total volume of abdominal liposuction, and results were reviewed.

RESULTS

The overall complication rate was 17.3 percent (52 patients). Sixteen percent (48 patients) suffered minor complications and 1.3 percent (four patients) suffered major complications.

CONCLUSIONS

Abdominoplasty can be combined safely with concurrent abdominal liposuction when a perforator vessel is spared. The combination of concurrent liposuction with abdominoplasty showed no increase in complication rates when a perforator vessel was spared. The perforator vessels are located consistently in a 2-cm radius located 4 cm from the midline and 6 cm from the subcostal margin. The potential advantages of abdominoplasty with concurrent liposuction include a better postoperative cosmetic result.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Abdominoplasty-related nerve injuries: systematic review and treatment options

BACKGROUND

Abdominoplasty is a common cosmetic procedure; nerve injury is an underexplored risk of the procedure.

OBJECTIVE

The authors review existing literature to examine the incidence and treatment of nerve injuries after abdominoplasty procedures and provide a treatment algorithm based on their results.

METHODS

A search of the literature on MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews was undertaken. After full-text review, 23 articles met our criteria. Any mentions of nerve injury, including references to a lack of nerve injury, were documented. All data were pooled for analysis. From our combined data, we calculated the risks of postabdominoplasty nerve injury by dividing the total number of nerve injuries by the total number of patients.

RESULTS

Pooled data showed that 1.94% of patients sustained specific nerve injury, and 1.02% of patients sustained permanent injury after abdominoplasty. In addition, 7.67% experienced decreased sensation, 1.07% reported chronic pain, and 0.44% reported temporary weakness or paralysis. Nerves directly injured were the lateral femoral cutaneous (1.36% of patients) and iliohypogastric (0.10%) nerves. Nerves injured from surgical positioning were the brachial plexus (0.10%), musculocutaneous (0.10%), radial (0.05%), sciatic (0.19%), and common peroneal (0.05%) nerves.

CONCLUSIONS

Although our results showed a low incidence of postabdominoplasty nerve injury, the lasting impact on affected patients' quality of life can be significant. Appropriate and timely treatment by a multidisciplinary team is critical to optimize patient outcomes. Better reporting of nerve injuries in future studies of abdominoplasty will provide more accurate information about the incidence and consequences of these injuries.

LEVEL OF EVIDENCE

4.

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.

A study of postural changes after abdominal rectus plication abdominoplasty

PURPOSE

Factors such as body masses and humour are known to influence human posture. Abdominoplasty, which causes a sudden change in body masses, significantly improves body image and self-esteem. The aim of this study was to assess postural changes after abdominoplasty by studding the position and orientation through space of the body and the centre of pressure.

METHODS

Patients affected by excess abdominal skin and/or significant abdominal muscular anterior wall laxity due to undergo an abdominoplasty were enrolled. Posture was evaluated both before and for 1 year after surgery by quantifying the centres of mass, using the Fastrak™ system, and the centre of pressure, using stabilometry. The Wilcoxon signed-rank sum test was used to compare changes.

RESULTS

Forty-six patients were enrolled. A retro-positioning of the pelvis with a compensatory advancement of the head and shoulders, confirmed by the baropodometric analysis, was evident in the early post-operative period. The biomechanical system subsequently stabilized, achieving a state of equilibrium 1 year after surgery.

CONCLUSIONS

We believe that the change in posture following abdominoplasty is a consequence of both surgery (changes in body masses) and psychological factors that influence posture. Indeed, redundant abdominal skin and abdominal muscular anterior wall weakness are often associated with kyphosis since patients try to hide what they consider to be a source of embarrassment. The discovery of a new body image eliminates dissatisfaction, reduces anxiety and increases self-esteem, which provide psychological and physical benefits that improve the quality of life.

Body contouring

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. List patient selection factors for body lift surgery. 2. Describe operative approaches for brachioplasty, upper body lift, abdominoplasty, lower body lift, and thigh lift. 3. Identify complications and pitfalls related to body lifting and describe how to avoid them.

SUMMARY

The author discusses the preoperative assessment, surgical treatment plan, postoperative management, outcomes, and possible complications for a comprehensive spectrum of body-contouring surgical procedures. Preoperative planning includes medical history and physical examination, along with an open discussion with the patient. Surgical procedures for brachioplasty, upper back lift, abdominoplasty, lower back lift, gluteal augmentation and thigh lift are discussed. Postoperative management pearls are shared, as well as pitfalls to be avoided.

DIEP flap donor site versus elective abdominoplasty short-term complication rates: a meta-analysis

BACKGROUND

Although over the past decade the DIEP flap has emerged as one of the preferred choices for autologous breast reconstruction and the donor-site closure has much in common with the standard abdominoplasty technique, reports on comparisons of the complication rates between DIEP and elective abdominoplasty patients are not currently available. The purpose of this study was to compare DIEP donor-site and elective abdominoplasty short-term complications rates, in support of surgical choices.

METHODS

Searches of MEDLINE and CENTRAL for English language articles on DIEP and elective abdominoplasty (EA) published from January 1999 through December 2009 identified 33 studies that met the inclusion criteria and included 3,937 patients. A random-effects model was used to calculate the average complication rate in the literature.

RESULTS

The rate of seroma/hematoma in EA (16.1%, 95% confidence interval [CI] = 12.2-20.9%) was approximately four times the rate in DIEP flap patients (3.7%, 95% CI = 1.5-8.8%) was found from analyzing the data under a random-effects model. No substantial differences in the rates of infection, abdominal/umbilical necrosis, or wound dehiscence/delayed healing between the two series of patients were detected.

CONCLUSIONS

This meta-analysis reveals that DIEP donor-site complication rates were comparable to those in elective abdominoplasty, and, the rate of seroma in DIEP is an even lower than that of one of the most performed procedures in plastic surgery. We argue that patients presenting for a DIEP flap should be informed about this interesting comparison.