Comparison of Seroma Formation following Abdominoplasty with or without Liposuction:

Direct Subscarpal Lipectomy Combined With Liposuction in Abdominoplasty: An Analysis of Safety and Efficacy in 200 Consecutive Patients

BACKGROUND

Abdominoplasty procedures continue to evolve because combining techniques such as suction-assisted lipectomy or direct subscarpal lipectomy have proven to be powerful adjuncts to achieve optimal aesthetic results. However, concern has been expressed about combining techniques simultaneously given the potential to damage the vascularity of the abdominoplasty flap.

OBJECTIVES

The aim of this study was to assess the safety and efficacy of simultaneous direct subscarpal lipectomy combined with liposuction in abdominoplasty patients.

METHODS

A 4-year retrospective review of consecutive abdominoplasties (n = 200) performed by a single surgeon was conducted. Liposuction of the abdominal flap and flanks was performed in all patients. After raising the abdominoplasty flap, undermining was performed to just beyond the xyphoid, the lower rib margins superiorly, and the anterior axillary line laterally. Fat deep to Scarpa's fascia was then removed by direct tangential excision in all zones of the abdominal flap.

RESULTS

The patients had a mean age of 42.19 years and BMI of 28.10 kg/m2; the mean follow-up time was 7 months. Seroma occurred in 13 patients (6.5%), superficial wound dehiscence treated with local wound care in 16 patients (8%), hypertrophic scarring in 16 patients (8%), partial umbilical necrosis in 1 patient (0.5%), and partial umbilical epidermolysis in 6 patients (3%). No patients experienced major or minor full-thickness tissue loss. No patients needed reoperation.

CONCLUSIONS

Simultaneous direct excision of subscarpal fat with liposuction of the abdomen and flanks does not appear to subject any zone of the abdominoplasty flap to increased risks of vascular compromise. No flap necroses were observed. The technique described is safe and may provide superior abdominoplasty results.

LEVEL OF EVIDENCE: 3

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE III

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

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.

Machine Learning Prediction Algorithm for In-Hospital Mortality following Body Contouring

BACKGROUND

Body contouring is a common procedure, but it is worth attention because of concern for a variety of complications, and even the potential for death. As a result, the purpose of this study was to determine the key predictors following body contouring and create models for the risk of mortality using diverse machine learning (ML) models.

METHODS

The National Inpatient Sample database from 2015 to 2017 was queried to identify patients undergoing body contouring. Candidate predictors, such as demographics, comorbidities, personal history, postoperative complications, and operative features, were included. The outcome was in-hospital mortality. Models were compared by area under the curve, accuracy, sensitivity, specificity, positive and negative predictive values, and decision curve analysis.

RESULTS

Overall, 8214 patients undergoing body contouring were identified, among whom 141 (1.72%) died in the hospital. Variable importance plot demonstrated that sepsis was the variable with greatest importance across all ML algorithms, followed by Elixhauser Comorbidity Index, cardiac arrest, and so forth. The naive Bayes model had a higher predictive performance (area under the curve, 0.898; 95% CI, 0.884 to 0.911) among these eight ML models. Similarly, in the decision curve analysis, the naive Bayes model also demonstrated a higher net benefit (ie, the correct classification of in-hospital deaths considering a tradeoff between false-negatives and false-positives) compared with the other seven models across a range of threshold probability values.

CONCLUSION

The ML models, as indicated by this study, can be used to predict in-hospital death for patients at risk who undergo body contouring.

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.

EFFECTS OF DIEP FLAP-BASED BREAST RECONSTRUCTION ON RESPIRATORY FUNCTION

BACKGROUND

Breast reconstruction (BR) is an essential part of breast cancer treatment, and the DIEP flap is considered the gold standard reconstruction technique, which uses a free abdominal flap. Concerns have been raised regarding the effects of abdominoplasty on respiratory functions. This topic has not been addressed regarding donor-site closure of DIEP flaps. Our aim is to prospectively compare preoperative and postoperative spirometry in patients undergoing DIEP flap-based BR, investigating its impact on respiratory function.

MATERIALS AND METHODS

We enrolled 21 patients who received BR with DIEP flap in our institution, who underwent pulmonary function assessment by spirometry 1 month preoperatively and 1 year postoperatively. We assessed Forced Expiratory Volume in the first second (FEV1), Forced Vital Capacity (FVC), FEV1/FVC ratio, and Peak Expiratory Flow (PEF). Statistical analysis was performed using the paired samples test.

RESULTS

An improvement in the mean values of all 4 variables was found at 1 year from surgery. Namely, FEV1 improved by 0.1 L with a standard deviation (SD) of 0.39 L, FVC by 0.04 L with SD of 0.627, FEV1/FVC by 2.11 L with SD of 7.85 L, and PEF by 1.2 L with SD of 1.45 L. Only PEF was statistically significant [P = 0.001].

CONCLUSION

Our results suggest that DIEP flap BR does not negatively impact respiratory function. Although further knowledge is required, we confirm the possibility of considering the indication for abdominoplasty and DIEP flap reconstruction in patients with altered and reduced pulmonary function.

Negative Pressure Wound Therapy in Postbariatric Lower Body Lift-A Method of Decreasing Postoperative Complications

BACKGROUND

Lower body lift procedure is one of the most common procedures in postbariatric surgery, which can be followed by postoperative complications that delay the healing time. The purpose of this study was to analyse whether the use of negative pressure wound therapy (NPWT) as a replacement for the classical drainage method would provide better postoperative results with fewer complications.

METHODS

The authors reviewed their experience with 46 consecutive patients that underwent lower body lift surgery from 2018 to 2021. They were divided into two groups: 23 of them received NPWT as drainage method and another 23 received classical active drains. We assessed the complication rates and types between the two groups to demonstrate the efficiency of NPWT as a support in the surgical protocol.

RESULTS

Forty-six patients were included in this study. Two equal groups formed by 23 patients were analysed for age, sex, type of weight loss, type of circumferential lower body lift, type of drainage, quantity of drainage, time of drain usance, postoperative complications, operation time, hospital stay and frequency of hospital visits. The group that received NPWT had a 26.08% rate of complications as compared with the drain group that had a 47.8% complication rate.

CONCLUSIONS

This study is performed as a comparison between negative pressure wound therapy and classical drainage method in lower body lift surgery, as a new method of reducing the postoperative complications. By achieving faster closure of large, undermining areas, it concludes in a lower risk of seroma or hematoma formation.

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 .

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Level of Evidence 3

The Global Prevalence of Seroma After Abdominoplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Abdominoplasty is one of the most common cosmetic surgeries performed worldwide. Seroma is also the most common local complication associated with abdominoplasty, which increases care costs, reduces patient satisfaction, and has serious complications for patients. Results of previous studies report different levels of seroma prevalence after abdominoplasty. The aim of this study is to standardize the statistics of the prevalence of seroma after abdominoplasty using meta-analysis.

METHODS

In this systematic review and meta-analysis study, data from studies conducted on the global prevalence of seroma after abdominoplasty was extracted using the keywords "Prevalence, Epidemiology, Complications, Abdominoplasty, Seroma, and Lipo abdominoplasty" in the databases of Science, Scientific Information Database, MagIran, Embase, Scopus, PubMed, Web of Science, and Google Scholar search engine without time limit until October 2020. The random-effects model was used to analyze the eligible studies, and the heterogeneity of the studies was investigated with the I² index. Data analysis was performed using Comprehensive Meta-Analysis software (Version 2).

RESULTS

In reviewing 143 studies (five studies related to Asia, 55 studies related to Europe, three studies related to Africa, and 80 studies related to the Americas) with a total sample size of 27834 individuals, the global prevalence of seroma after abdominoplasty was obtained as 10.9% (95% CI: 9.3-3.6.6%) and the highest prevalence of seroma was related to the Europe continent with 12.8% (95% CI: 10.15-3.9%). The results from meta-regression showed a declining trend in the global prevalence of seroma after abdominoplasty with an increase in the sample size, age of study participants, and the year of study (p < 0.05).

CONCLUSIONS

This study shows that the prevalence of seroma after abdominoplasty is high globally. Therefore, physicians and specialists must consider its importance and take the controlling and treatment measures seriously.

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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

Abdominal Body Contouring: Does Body Mass Index Affect Clinical and Patient Reported Outcomes?

BACKGROUND

Obese individuals are thought to be higher risk for complications after excisional abdominal body contouring (EAC) due to co-morbidities and significant tissue resection.

OBJECTIVES

We comparatively analyzed EAC patients with Body Mass Index (BMI) ≥35 kg/m² and BMI <35 kg/m² to highlight key differences in clinical and patient-reported-outcomes (PROs).

METHODS

Patients ≥18 years-old undergoing EAC by a single surgeon from 01/2018-01/2020 were identified and separated into cohorts based on BMI (<35 and ≥35 kg/m²). Patients were excluded if they had a cosmetic abdominoplasty without history of bariatric surgery or massive weight loss, or if they had <1000 gs of tissue resected. Clinical outcomes and PROs using the BODY-Q were comparatively analyzed.

RESULTS

70 total patients with median BMIs of 30[26-32] and 41[37-45] kg/m² in each cohort, were identified. Patients with BMI ≥35 kg/m² were more likely to have higher ASA (P<0.01) and use of incisional negative pressure wound devices (P = 0.042). Alternatively, they were less likely to have had concurrent liposuction (P = 0.05). There were no differences in development of an SSO, SSI or SSOpi (P>0.05) between cohorts. Multivariate logistic regression showed that BMI ≥35 kg/m², iNPWD and liposuction were not associated with the development of complications. PROs demonstrated improvement in multiple domains despite BMI.

CONCLUSION

There was no association with BMI ≥35 kg/m² and the development of complications within our cohort. We encourage preoperative weight loss when possible, however these procedures can be performed safely with acceptable outcomes even in individuals who are obese and/or require extensive tissue removal.

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

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

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

Efficacy of Progressive Tension Sutures without Drains in Reducing Seroma Rates of Abdominoplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Abdominoplasty using progressive tension sutures (PTS) without drains has been reported to lower seroma risk. However, evidence regarding the reproducibility of PTS drainless abdominoplasty in lowering seroma risk is inconsistent and limited to a few studies.

OBJECTIVES

The purpose of this review and meta-analysis was to assess the efficacy of PTS without drains in reducing seroma rates associated with abdominoplasty.

METHODS

PubMed, EMBASE, and Cochrane databases were searched with no restrictions for randomized controlled trials (RCTs) and observational studies in which the number of patients who experienced postoperative seroma was indicated. The keywords included ''progressive tension sutures,'' ''quilting sutures,'' "drain," and "abdominoplasty.'' Review Manager software (RevMan, version 5.3) was utilized to compute the pooled effect estimate using a random-effects Mantel-Haenszel model. The outcomes were expressed as odds ratios (OR) and 95% confidence intervals (CI). Subgroup analysis was conducted based on whether abdominoplasty was combined with liposuction.

RESULTS

Five studies were included (one RCT and four retrospective studies) involving a total of 1255 adult patients. Patients who underwent abdominoplasty using PTS without drains experienced a significantly lower rate of postoperative seroma compared to those with drains (D) only (OR, 0.36; 95% CI, 0.19-0.70; P = 0.002; I² = 9%). There was no significant difference in postoperative seroma rates between the PTS and PTS + D groups (OR, 1.03; 95% CI, 0.30-3.54; P = 0.96; I² = 0%). The data analysis for the subgroup that included liposuction showed that compared with the use of drain only, PTS were associated with a significantly reduced number of seromas (OR, 0.24; 95% CI, 0.11-0.49; P = 0.0001; I² = 0%).

CONCLUSION

Abdominoplasty using PTS without drain and combined with liposuction was effective in reducing seroma rates. Additional RCTs with larger sample sizes and better comparability are needed to confirm the safety and effectiveness of the drainless abdominoplasty technique using progressive tension sutures.

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 .

Plastic Surgery Complications: A Review for Emergency Clinicians

The number of aesthetic surgical procedures performed in the United States is increasing rapidly. Over 1.5 million surgical procedures and over three million nonsurgical procedures were performed in 2015 alone. Of these, the most common procedures included surgeries of the breast and abdominal wall, specifically implants, liposuction, and subcutaneous injections. Emergency clinicians may be tasked with the management of postoperative complications of cosmetic surgeries including postoperative infections, thromboembolic events, skin necrosis, hemorrhage, pulmonary edema, fat embolism syndrome, bowel cavity perforation, intra-abdominal injury, local seroma formation, and local anesthetic systemic toxicity. This review provides several guiding principles for management of acute complications. Understanding these complications and approach to their management is essential to optimizing patient care.

Abdominoplasty with Scarpa Fascia Preservation: Randomized Controlled Trial with Assessment of Scar Quality and Cutaneous Sensibility

BACKGROUND

Scarpa fascia preservation during abdominoplasty has been shown to reduce complications associated with the traditional technique. As an extension of a previously published randomized controlled trial, this study aims to clarify whether preservation of Scarpa fascia during abdominoplasty has an influence on scar quality or sensibility recovery.

METHODS

This was a single-center clinical trial, involving 160 patients randomly assigned to one of two surgical procedures: classic full abdominoplasty (group A) and abdominoplasty with preservation of Scarpa fascia (group B). Patients were later convoked to assess scar quality and abdominal cutaneous sensibility. Scar quality was evaluated through the Patient and Observer Scar Assessment Scale. Cutaneous sensibility was measured on the upper and lower abdomen, using light touch, Semmes-Weinstein testing (5.07/10-g monofilament), and a 25-gauge needle.

RESULTS

A total of 99 patients (group A, 54 patients; group B, 45 patients) responded to contact, with a mean follow-up time of 44 months. Concerning scar quality, Patient and Observer Scar Assessment Scale scores were similar between groups. On the upper abdomen, there was a statistically significant difference between groups on cutaneous sensibility, on the examination with the Semmes-Weinstein 5.07/10-g monofilament (group A, 79.6 percent; group B, 93.3 percent; p = 0.046) and pain (group A, 90.7 percent; group B, 100 percent; p = 0.044). No statistically significant differences were found between groups on the lower abdomen. A considerable proportion of patients (two-thirds) still presented sensibility alterations in the subumbilical area 3½ years after abdominoplasty.

CONCLUSION

Scarpa fascia preservation during abdominoplasty does not influence scar quality, but it improves sensibility recovery in the supraumbilical area.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Abdominoplasty after bariatric surgery: comparison of three different techniques

BACKGROUND

Abdominoplasty after massive weight loss is not a cosmetic procedure. The aim of this study was to compare three different techniques for postbariatric abdominoplasty.

METHODS

All postbariatric patients that have undergone abdominoplasty from January 2013 to December 2016 were included in the study. Patients were divided into 3 groups: subjects who underwent standard procedure were allocated ingroup A; those cases performed using a synthetic glue were assigned to group B; cases performed with an energy device were inserted in group C. Operative time, length of stay and complications were recorded.

RESULTS

Seventy-one abdominoplasties were performed in the selected period. Mean operative time was shorter (P<0.01) in group C (94.3±2.7 minutes) than in group A (112.1±16.8 minutes) and in group B (121±13.2 minutes). Mean length of stay was significantly reduced (P<0.01) in group C (2.4±0.7) when compared to group A (3.5±0.6 days) and group B (3.1±0.5 days). Bleeding occurred in 21 (29.5%) patients (15 in group A, 4 in groupB, 3 in group C; P<0.01). Seroma was detected in 22(30.9%) subjects (14 in group A, 2in group B, 6 in group C; P<0.01). Wound dehiscence and umbilical necrosis were recorded in 7 (9.9%) and 9 (12.6%) patients respectively, without statistical differences.

CONCLUSIONS

Both synthetic glue and energy device improve outcomes of postbariatric abdominoplasties. The glue reduces rates of bleeding and seroma. The energy deviceimproves intraoperative hemostasis and shortens operative time.

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

Clinical outcome of patients undergoing abdominoplasty after massive weight loss

BACKGROUND

Abdominoplasty is one of the most commonly performed surgical procedures to reshape the body contour in patients who have undergone massive weight loss.

OBJECTIVES

This study was undertaken to assess the clinical outcome, complication rates, and risk factors for complications of patients undergoing abdominoplasty after massive weight loss.

SETTING

University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.

METHOD

Clinical outcome was retrospectively analyzed in 121 patients, who underwent abdominoplasty. The retrospective analysis included demographic data of patients, such as sex, age, body mass index (BMI), and pre-existing illnesses. Moreover, postoperative complications including seroma, hematoma, wound infection, and tissue necrosis were analyzed.

RESULTS

In our study cohort, the median age was 43.7 years, the median weight was 94.7 kg, and the median BMI was 32.3 kg/m². The majority of included patients were women (70.3%). Death occurred in none of the patients. Among individuals, wound infection occurred in 3.3%, tissue necrosis in 1.7%, seroma in 7.4%, and hematoma in 3.3% of patients during the postoperative course. Reoperations were necessary in 2 patients (1.7%) due to postoperative bleeding and tissue necrosis of the navel. Tissue necrosis was significantly more often seen in a subset individual with type 2 diabetes (P = .006). Moreover, the rate of reoperations was significantly higher in patients with pre-existing cardiovascular illnesses compared with cardiovascular healthy patients (P = .036). Multivariate analysis analyzing risk factors for postoperative complications, including sex, age, BMI, diabetes, pulmonary disease, and cardiovascular disease, revealed strong independent relevance for type 2 diabetes (P = .024).

CONCLUSIONS

We found that abdominoplasty is a safe operative procedure. In addition, the risk for complications is significantly increased in the subgroup of diabetic patients and patients with cardiovascular diseases.

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.

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.

Abdominoplasty in the Obese Patient: Risk versus Reward

BACKGROUND

The incidence of obesity is on the rise worldwide. Many surgeons elect not to perform abdominoplasty on patients with a high body mass index, fearing an increased risk of perioperative complications. In this study, the authors compare the outcomes of obese and nonobese patients who underwent abdominoplasty.

METHODS

A retrospective chart analysis was performed on all patients who underwent abdominoplasty by a single surgeon from 2009 to 2016. Complication rates were compared in obese and nonobese patients. Patients were excluded if they did not undergo a full abdominoplasty, underwent a combined surgical procedure, or underwent liposuction in an area outside of the abdomen or flanks at the time of the abdominoplasty.

RESULTS

A total of 83 patients were included: 62 nonobese and 21 obese patients. The obese group had a higher average body mass index (34. 9 kg/m versus 25.1 kg/m; p < 0.001). Follow-up time was similar (310 days versus 265 days; p = 0.468). No significant differences were seen with regard to perioperative seroma formation (14.2 percent versus 22.5 percent; p = 0.419)), wound dehiscence (9.5 percent versus 11.29 percent; p = 0.822), hematoma formation (4.7 percent versus 1.6 percent; p = 0.438), or surgical-site infection (9.5 percent versus 8.0 percent; p = 0.835). No instances of venous thromboembolism were observed.

CONCLUSIONS

Abdominoplasty, with or without concurrent liposuction, in obese patients, is a safe and effective procedure with similar perioperative complication rates as the nonobese patient population. No significant differences were observed in perioperative complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

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.

The Effect of Smoking in the Cosmetic Surgery Population: Analysis of 129,007 Patients

Background

Smoking has been associated with several postoperative adverse outcomes across multiple surgical disciplines, but the literature is limited for aesthetic surgical procedures.

Objectives

To compare complication rates between smokers and nonsmokers undergoing common cosmetic procedures, identify specific cosmetic procedures where smoking increases the risk of complications, and evaluate smoking as an independent risk factor for major complications following aesthetic surgery.

Methods

A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Smoking was evaluated as a risk factor for major complications requiring emergency room visit, hospital admission, or reoperation within 30 days after surgery. Multivariate regression analysis was performed controlling for the effects of age, gender, body mass index, type of surgical facility, type of procedure, and combined procedures.

Results

Of the 129,007 patients, 10,621 (8.2%) were smokers. All procedures examined, except breast augmentation, were more frequently performed in the nonsmoker cohort. Overall major complications were similar between smokers and nonsmokers (2.0% vs 1.9%, P = 0.57). In univariate analysis, surgical site infections (0.6% vs 0.5%, P = 0.04) were significantly higher among smokers, but suspected venous thromboembolism (0.2% vs 0.1%, P = 0.01) was significantly higher among nonsmokers. Notably, smokers had a higher risk of major complications after body procedures (2.9% vs 1.0%, P = 0.01), as well as thigh lifts (23.8% vs 3.6%, P < 0.01) and male breast surgery (3.7% vs 1.4%, P = 0.03). In multivariate analysis, smoking was found to be an independent predictor of surgical site infections (relative risk 1.61, P < 0.01).

Conclusions

Smoking is an independent risk factor of major surgical site infections following aesthetic surgery. Body procedures, as well as thigh lifts and male breast surgery, have higher complication rates in smokers.

Level of Evidence 2

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 .

Use of a Lysine-Derived Urethane Surgical Adhesive as an Alternative to Progressive Tension Sutures in Abdominoplasty Patients: A Cohort Study

BACKGROUND

Fluid accumulation is a common complication after abdominoplasty procedures, and is typically managed by the placement of post-surgical drains. Progressive tension sutures (PTS) have been shown to be an effective approach to reduce the dead space by point-wise mechanical fixation, allowing for drain-free procedures. Lysine-derived urethane surgical adhesive provides an alternative approach for mechanical fixation and reduction of dead space, and may reduce surgery time compared to PTS.

OBJECTIVES

This prospective, controlled, single center clinical study compared progressive tension suture wound closure technique without drains (control) to tissue adhesive wound closure technique without drains (test) during abdominoplasty surgery. The objective was to determine if lysine-derived urethane surgical adhesive is an effective alternative to PTS for drain-free abdominoplasty procedures.

METHODS

Patients undergoing abdominoplasty who met the established inclusion/exclusion criteria were consented and enrolled in the study. Ten PTS (control) cases were performed, followed immediately by 10 tissue adhesive (test) cases.

RESULTS

Surgeries were completed over an 8-month period. No statistical differences were identified between the two groups with regard to age, BMI, dissection surface area or flap weight. No clinical seroma formation was observed in either group. In the control (PTS) group, two patients developed small areas of dermal closure suture abscess requiring removal of suture material. One control patient developed drainage and fat necrosis thought to be related to PTS above the incision and later required a scar revision. One tissue adhesive patient developed hypertrophic scars of both her breast reduction and abdominoplasty scars requiring additional treatment.

CONCLUSIONS

Lysine-derived urethane surgical adhesive was applied in less time than PTS, even after accounting for holding pressure for 5 minutes. The tissue adhesive provided four times the number of attachment points compared to PTS, although the significance of this is not clear. Based on these results, the use of lysine-derived urethane surgical adhesive was found to be a safe and effective alternative to PTS to reduce seroma formation in drain-free abdominoplasty procedures.

LEVEL OF EVIDENCE 2

Is There a Limit? A Risk Assessment Model of Liposuction and Lipoaspirate Volume on Complications in Abdominoplasty

BACKGROUND

Combining liposuction and abdominoplasty is controversial because of concerns for increased complications and potential for vascular compromise of the abdominoplasty flap. Also, the lipoaspirate volume in abdominoplasty is regulated in some areas to as little as 500 ml when performed with abdominoplasty. This study measures abdominoplasty complication rates when performed with and without trunk liposuction, and evaluates the effect of lipoaspirate volume on complications.

METHODS

Abdominoplasty and liposuction of the trunk procedures were identified in the Tracking Operations and Outcomes for Plastic Surgeons database. Multivariate regression models determined the effect of liposuction with abdominoplasty on complications compared with abdominoplasty alone and determined the effect of liposuction volume on complications.

RESULTS

Eleven thousand one hundred ninety-one patients were identified: 9638 (86.1 percent) having abdominoplasty with truncal liposuction and 1553 (13.9 percent) having abdominoplasty alone. Overall complication rates were 10.5 percent and 13.0 percent, respectively. Combined liposuction and abdominoplasty was independently associated with a reduced risk of both overall complications (p = 0.046) and seroma (p = 0.030). Given existing laws limiting liposuction volume to 500 or 1000 ml in combination with abdominoplasty, each of these thresholds was evaluated, with no effect on complications. Surprisingly, increasing liposuction volume was not independently associated with an increased risk of any complication.

CONCLUSIONS

When done by board-certified plastic surgeons, abdominoplasty with truncal liposuction is safe, with fewer complications than abdominoplasty alone. Regulations governing liposuction volumes in abdominoplasty are arbitrary and do not reflect valid thresholds for increased complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Can drains be avoided in lipo-abdominoplasty?

Context:

Seroma formation is a common complication after lipoabdominoplasty. Conventionally, drains have been placed to prevent seroma; however, there are problems with drains, namely, pain, compromised mobilisation, breakage, tissue irritation and infection. Strategies to prevent seroma, such as the use of glue or quilting sutures have all been attempted with variable and unpredictable benefit.

Aims:

The author extrapolated the experience with own liposuction protocols to lipoabdominoplasty and began doing away with drains from the year 2006 onwards unless absolutely indicated. Incidence of complications is evaluated here.

Settings and Design:

This retrospective study is the report of our experience with 204 lipoabdominoplasties performed since 2006 upto December 2016.

Subjects and Methods:

Consecutive abdominoplasty patients were evaluated for seroma formation, wound dehiscence till suture removal. Nuances of operative details that helped avoid drains were contemplated.

Results:

Only one patient who had drainless abdominoplasty had seroma formation and wound dehiscence.

Conclusions:

We found that (a) 'toilet liposuction', (a term the author would like to introduce) (b) multilayer wound closure without tension, (c) avoidance of gliding surfaces d) continuous use of pressure garment for 4 days post-operative and (e) reducing the amount of infiltration are the key factors in avoidance of collections and thus seroma formation. If such a technique is diligently followed, desired results are obtained; yet there is no need to insert drains in most patients. Reducing the need of drains permits early ambulation and better patient comfort without seroma and other complications.

Seroma Rates Are Not Increased When Combining Liposuction With Progressive Tension Suture Abdominoplasty: A Retrospective Cohort Study of 619 Patients

BACKGROUND

Several studies have demonstrated that progressive tension sutures (PTS) reduce seroma. Many fear that adding liposuction to abdominoplasty will increase seroma rates and avoid drainless abdominoplasty when performing concomitant liposuction.

OBJECTIVES

We sought to identify whether liposuction increases seroma in PTS and non-PTS abdominoplasty.

METHODS

In this retrospective study, 619 patients underwent abdominoplasty between 2009 and 2017, of which 299 patients had drainless abdominoplasty with PTS and 320 had drain-based abdominoplasty. We compared complications among PTS patients with and without liposuction and among drain-based abdominoplasty patients with and without liposuction.

RESULTS

Demographics were similar between PTS and drain patients and between liposuction and nonliposuction PTS. Mean liposuction volume with PTS was 1592 ± 1048 mL. Seroma in the PTS group was found to be 2.6%, which is consistent with previous data. PTS without liposuction had a rate of seroma of 6.67% compared to a rate of 2.2% with liposuction; these rates were not significantly different (P = 0.20). A total of 207 patients had drain-based abdominoplasty with liposuction, and 113 had it without liposuction. Seroma with liposuction was 9.17% and without liposuction was 6.19%, although these differences were not significant (P = 0.52). PTS lipoabdominoplasty had less seroma compared with drain-based lipoabdominoplasty (P = 0.01).

CONCLUSIONS

Liposuction was performed in 80% of the patients, and patients with lipoabdominoplasty were not at a higher risk of seroma, in the drain group or the PTS group. More patients may allow validation that liposuction may actually be protective with PTS. Regardless, there is no increase in seroma with the addition of liposuction to PTS drainless abdominoplasty.

LEVEL OF EVIDENCE 3

Aesthetic Surgical Procedures in Men: Major Complications and Associated Risk Factors

BACKGROUND

The number of men undergoing cosmetic surgery is increasing in North America.

OBJECTIVES

To determine the incidence and risk factors of major complications in males undergoing cosmetic surgery, compare the complication profiles between men and women, and identify specific procedures that are associated with higher risk of complications in males.

METHODS

A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Gender specific procedures were excluded. Primary outcome was occurrence of a major complication in males requiring emergency room visit, hospital admission, or reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for major complications including age, body mass index (BMI), smoking, diabetes, type of surgical facility, type of procedure, and combined procedures.

RESULTS

Of the 129,007 patients, 54,927 underwent gender nonspecific procedures, of which 5801 (10.6%) were males. Women showed a higher mean age (46.4 ± 14.1 vs 45.2 ± 16.7 years, P < 0.01). Men had a higher BMI (27.2 ± 4.7 vs 25.7 ± 4.9 kg/m2, P < 0.01), and were more likely to be smokers (7.1% vs 5.7%, P < 0.01) when compared to women. Men demonstrated similar overall major complication rates compared to women (2.1% vs 2.1%, P = 0.97). When specific complications were analyzed further, men had higher hematoma rates, but lower incidence of surgical site infection. Additionally, major complications after abdominoplasty, facelift surgery, and buttock augmentation were noted to preferentially affect males. On multivariate analysis, independent predictors of major complications in males included BMI (RR 1.05), hospital or ambulatory surgery center procedures (RR 3.47), and combined procedures (RR 2.56).

CONCLUSIONS

Aesthetic surgery in men is safe with low major complication rates. Modifiable predictors of complications included BMI and combined procedures.

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.

Cosmetic Liposuction: Preoperative Risk Factors, Major Complication Rates, and Safety of Combined Procedures

BACKGROUND

Liposuction is among the most commonly performed aesthetic procedures, and is being performed increasingly as an adjunct to other procedures.

OBJECTIVES

To report the incidence and risk factors of significant complications after liposuction, and to determine whether adding liposuction to other cosmetic surgical procedures impacts the complication risk.

METHODS

A prospective cohort of patients who underwent liposuction between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications requiring emergency room visit, hospital admission, or reoperation within 30 days of the operation. Univariate and multivariate analysis evaluated risk factors including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, and combined procedures.

RESULTS

Of the 31,010 liposuction procedures, only 11,490 (37.1%) were performed as a solitary procedure. Liposuction alone had a major complication rate of 0.7% with hematoma (0.15%), pulmonary complications (0.1%), infection (0.1%), and confirmed venous thromboembolism (VTE) (0.06%) being the most common. Independent predictors of major complications included combined procedures (Relative Risk (RR) 4.81), age (RR 1.01), BMI (RR 1.05), and procedures performed in hospitals (RR 1.36). When examining specifically other aesthetic procedures performed alone or with liposuction, combined procedures had a higher risk of confirmed VTE (RR 5.65), pulmonary complications (RR 2.72), and infection (RR 2.41), but paradoxically lower hematoma risk (RR 0.77) than solitary procedures.

CONCLUSIONS

Liposuction performed alone is a safe procedure with a low risk of major complications. Combined procedures, especially on obese or older individuals, can significantly increase complication rates. The impact of liposuction on the risk of hematoma in combined procedures needs further investigation.

LEVEL OF EVIDENCE 2

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.

Prevention of Seroma Formation Following Abdominoplasty: A Systematic Review and Meta-Analysis

Background

With seroma formation being the most common complication of abdominoplasty, multiple surgical strategies have been proposed to lower the seroma rate, yet their effectiveness is unclear.

Objectives

The objective of this systematic review and meta-analysis was to comprehensively summarize and quantify the effects of preventive surgical measures for seroma in patients undergoing abdominoplasty.

Methods

A predetermined protocol was used. An electronic search in MEDLINE, Scopus, the Cochrane Library, and CENTRAL electronic databases was conducted from inception to June 2016. This search was supplemented by a review of reference lists of potentially eligible studies and a manual search of key journals in the field of plastic surgery. Eligible studies were prospective controlled studies, which investigated prevention of seroma formation and reported on seroma rate. Secondary outcomes were rate of hematoma, wound dehiscence, infection, reoperation and hospital readmission, time to drain removal, total drain output, and length of hospital stay.

Results

The meta-analysis included nine studies with 664 abdominoplasty patients. Seroma rate was 7.5% in the prevention group and 19.5% in the control group with the odds ratio (95% confidence interval) being 0.26 (0.10-0.67), P = .006, favoring the prevention group. Similar results were also revealed for infection rate, time to drain removal, and length of hospital stay. Subgroup analysis showed that preservation of Scarpa's fascia, tissue adhesives and, possibly, progressive tension sutures reduce, independently, seroma formation.

Conclusions

This meta-analysis provides strong evidence that the use of certain preventive measures during abdominoplasty, compared to conventional procedure, reduces seroma formation.

Level of Evidence 2

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.

Effect of Tissue Adhesives on Seroma Incidence After Abdominoplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Tissue adhesives (TAs) are widely utilized in abdominoplasty to reduce postoperative seroma. However, current literature regarding TAs in abdominoplasty is limited to small studies and the findings of single institutions.

OBJECTIVES

The authors reviewed the current literature regarding the effects of TAs on seroma formation and other endpoints following abdominoplasty, and summarized the types of TAs and application techniques that have been described to date.

METHODS

A systematic review of the Medline, Embase, Web of Science, and Cochrane databases was conducted to identify randomized controlled trials (RCTs) in which the numbers of patients who experienced seroma after abdominoplasty were indicated. The Cochrane Collaboration's tool for assessing risk of bias was applied.

RESULTS

Seven studies were included in a descriptive review, 5 of which were RCTs. Data from the 5 RCTs were pooled for a meta-analysis. Patients who received TAs following abdominoplasty had a similar incidence of seroma compared with patients who did not receive TAs. However, the total drainage volume was significantly lower for patients who received TAs.

CONCLUSIONS

There is a paucity of high-quality evidence to support the delivery of TAs to prevent seroma formation after abdominoplasty. Well-designed RCTs are needed to assess with confidence the overall effects of TAs in abdominoplasty.

LEVEL OF EVIDENCE

2 Therapeutic.

The use of a fibrin glue with a low concentration of thrombin decreases seroma formation in postbariatric patients undergoing circular abdominoplasty

BACKGROUND

The serum collection under the abdominal flap is the most common complication after a lipo-abdominoplasty. The frequency of seroma increases further among obese patients, who have achieved massive weight loss after bariatric surgery. The purpose of this study is to demonstrate the effectiveness of fibrin glues with a low concentration of thrombin in reducing seroma formation after a lipo-abdominoplasty.

METHODS

Thirty patients, that had achieved a significant weight loss after an intervention of laparoscopic adjustable gastric banding (LAGB), underwent a circular lipo-abdominoplasty at our bariatric surgery department. Patients were divided into two groups of 15 subjects each: group A underwent traditional surgery; in group B, we applied a slow-clotting variant of fibrin glue (ARTISS, Baxter) under the abdominal flap. All subjects were evaluated clinically using an ultrasound device on postoperative day 15. We considered positive for seroma, those cases with a liquid collection greater than 20 cc.

RESULTS

The groups were homogeneous for age, BMI, male/female ratio, and diabetic or smoker patients. The mean hospital stay was significantly longer in group A than in group B. We found eight cases of serum collection >20 cc in group A and only one case in group B. Hematoma, umbilicus necrosis, and surgical site infection occurred in both groups, but overall complication rate was lower in group B.

CONCLUSIONS

The use of a fibrin glue with a low concentration of thrombin could be useful during wound closure and may decrease seroma formation in postbariatric patients undergoing lipo-abdominoplasty.

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.

Use of Quilting Sutures During Abdominoplasty to Prevent Seroma Formation: Are They Really Effective?

BACKGROUND

Abdominoplasty surgery is one of the most popular cosmetic procedures performed in plastic surgery. As with any surgical procedure, it is associated with risks and complications, primarily that of seroma formation. Quilting sutures are a recent development in abdominoplasty surgery that aim to prevent the incidence of seroma.

OBJECTIVES

The aim of this article was to assess the effectiveness of quilting suturing in the prevention of seroma formation.

METHODS

In our retrospective clinical study, 414 female patients underwent abdominoplasty surgery with liposculpture contouring. The patients were divided in to three groups. The first group, comprising of 100 patients, were fitted with two drains postoperatively and no quilting sutures. The second group of 226 patients underwent quilting suturing in addition to receiving two drains. And the final group of 88 patients also underwent quilting suturing, but received only one drain. Post-operative seroma diagnosis was confirmed with the presence of clinical signs and symptoms.

RESULTS

The data was analysed using Fisher's exact test. With P < .000, we rejected our null hypothesis that there is no difference in results between the procedure with sutures and that without sutures. We calculated that the probability of having seroma with sutures to be <0.02. In contrast, abstinence from quilting sutures resulted in a 12% risk of seroma formation.

CONCLUSIONS

The use of quilting sutures is a significantly effective measure for the prevention of seroma formation.

LEVEL OF EVIDENCE

4 Therapeutic.

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.

Minimising complications in abdominoplasty: An approach based on the root cause analysis and focused preventive steps

Significant complications still occur after abdominoplasty, the rate varies widely in different series. This variation suggests that there is a lot of scope for improvement. This paper reviews the various complications and also the technical improvements reported in the last 20 years. The root cause of each complication is analysed and preventive steps are suggested based on the literature and the author's own personal series with very low complication rates. Proper case selection, risk stratified prophylaxis of thromboembolism, initial synchronous liposuction, flap elevation at the Scarpa fascia level, discontinuous incremental flap dissection, vascular preservation and obliteration of the sub-flap space by multiple sutures emerge as the strongest preventive factors. It is proposed that most of the complications of abdominoplasty are preventable and that it is possible to greatly enhance the aesthetic and safety profile of this surgery.

Ligating perforators in abdominoplasty reduces the risk of seroma

BACKGROUND

Seroma formation, a common complication of abdominoplasty, can cause patient discomfort and inconvenience. This study aimed to compare seroma rates after ligation and diathermy of large abdominal perforating vessels during abdominoplasty.

METHODS

Consecutive patients undergoing abdominoplasty with epigastric undermining between 2004 and 2011 were studied. Body mass index (BMI), age at operation, smoking history, preoperative weight loss, operative details, perioperative fluid infiltration, concomitant abdominal liposuction, ligation of perforators by clips, suture or diathermy, use of quilting sutures, weight of tissue removed, postoperative drainage, inpatient stay, and seroma rates were recorded. Statistical analysis was undertaken using the unpaired t test, Fisher's exact test, the Mann-Whitney U test, and Kendall's tau-b test.

RESULTS

The study included 90 patients. The incidence of seroma was significantly lower among the patients who had perforators ligated (4/60, 6.7%) than among those who had diathermy (10/30, 33%) (p=0.002, Fisher's exact test). Seroma formation was significantly associated with a higher BMI, (27.45 vs. 25.16 kg/m2; p=0.025, t test) but not with preoperative weight loss. Postoperative fluid drainage did not differ significantly between ligated and diathermied perforators (p=0.716 Mann-Whitney U test).

CONCLUSIONS

Use of ligation by clip or suture rather than by diathermy to ablate large abdominal perforators significantly reduced the incidence of seroma among abdominoplasty patients.

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 .

[Complications and level of satisfaction after dermolipectomy and abdominoplasty post-bariatric surgery]

BACKGROUND

Body contouring surgery is in high demand following the increase in bariatric surgery. But these types of procedures are associated with high complication rates that cause long hospital stays and have a negative effect on patient satisfaction. The purpose of this study is to identify predictors of complications in order to optimize outcomes in these patients and find a relationship between complication rate and satisfaction.

MATERIAL AND METHODS

Out of a group of 175 post-bariatric patients, 72 patients underwent body contouring surgery following massive weight loss from 2003-2008. They were reviewed retrospectively for demographic data, pre- and postoperative weight status, co-morbidities and complications and reoperation rate. Patient satisfaction was evaluated.

RESULTS

a)

COMPLICATIONS

The overall complication rate was 45.8%. The most frequent were seromas (23.6%); infection (13.9%), bleeding (11.1%), hematoma (6.9%) (needing transfusions [6.9%]), skin necrosis (6.9%) and umbilical necrosis (4.2%). A total of 8 patients required reoperation (11.1%). b) Satisfaction rating: 1) very satisfied: 51.4%, 2) satisfied: 31.9%, 3) dissatisfied: 8.3%, 4) very dissatisfied: 8.3%. c) The presence of complications was significantly associated with patients' satisfaction, reoperation rate and longer hospital stays (P<.001).

CONCLUSIONS

Post operative complications were frequent. No predictors could be found to prevent these complications and optimize patient selection and appropriate timing of surgery. Patients with complications had a significantly higher reoperation rate, longer hospital stay and more dissatisfaction. The patients' satisfaction was negatively influenced by complication occurrence and not by the aesthetic results.