Complications in Body Contouring Procedures: An Analysis of 1797 Patients from the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program Databases

Comparing the safety and effectiveness of different liposuction techniques for lipedema

INTRODUCTION

Lipedema is a relatively common, frequently misdiagnosed, chronic condition that is often treated using liposuction when conservative therapies fail. Techniques such as traditional tumescent liposuction (TTL), power-assisted liposuction (PAL), and water-jet-assisted liposuction (WAL) are popular surgical interventions, although it is unclear how these techniques compare. This meta-analysis aimed to assess the efficacy and safety of liposuction in patients with lipedema.

METHODS

Relevant English lipedema studies published in PubMed from January 2003 to April 2023 were identified. Ten articles with post-operative outcomes and complications data were included (2 TTL, 5 PAL, 1 WAL, and 2 articles used PAL and WAL). Results were summarized using descriptive statistics, and a randomized effects model was used to evaluate heterogeneity.

RESULTS

A total of 2542 procedures in 906 patients were included. Combined outcomes for all techniques significantly improved pain, bruising, edema, tension, pressure sensitivity, cosmetic impairment, and general impairment (all P < 0.00001). TTL, PAL, and WAL led to significant improvements in pain reduction P = 0.0005), bruising, swelling, pressure sensitivity, or cosmetic impairment (all P < 0.05). However, WAL more effectively reduced tension and general impairment (all P < 0.005), but heterogeneity for these outcomes was high. Overall complication rates were low for the studies that used TTL (1.5%), PAL (4.0%), WAL (0%), and both PAL and WAL (2.3%).

CONCLUSION

Liposuction techniques, including TTL, PAL, and WAL, resulted in significant symptom improvement in patients with lipedema with a relatively low complication rate. WAL may potentially result in a more substantial reduction of tension and general impairment with fewer complications; however, only a single study performed this method of liposuction exclusively. To the best of our knowledge, this is the first meta-analysis investigating liposuction data in lipedema treatment.

Body Contouring Surgery After Bariatric Surgery Improves Long-Term Health-Related Quality of Life and Satisfaction With Appearance: An International Longitudinal Cohort Study Using the BODY-Q

OBJECTIVE

To examine health-related quality of life (HRQL) and satisfaction with appearance in patients who have undergone bariatric surgery (BS) with or without subsequent body contouring surgery (BCS) in relation to the general population normative for the BODY-Q.

BACKGROUND

The long-term impact of BS with or without BCS has not been established using rigorously developed and validated patient-reported outcome measures. The BODY-Q is a patient-reported outcome measure developed to measure changes in HRQL and satisfaction with appearance in patients with BS and BCS.

METHODS

Prospective BODY-Q data were collected from 6 European countries (Denmark, the Netherlands, Finland, Germany, Italy, and Poland) from June 2015 to February 2022 in a cohort of patients who underwent BS. Mixed-effects regression models were used to analyze changes in HRQL and appearance over time between patients who did and did not receive BCS and to examine the impact of patient-level covariates on outcomes.

RESULTS

This study included 24,604 assessments from 5620 patients. BS initially led to improved HRQL and appearance scores throughout the first postbariatric year, followed by a gradual decrease. Patients who underwent subsequent BCS after BS experienced a sustained improvement in HRQL and appearance or remained relatively stable for up to 10 years postoperatively.

CONCLUSIONS

Patients who underwent BCS maintained an improvement in HRQL and satisfaction with appearance in contrast to patients who only underwent BS, who reported a decline in scores 1 to 2 years postoperatively. Our results emphasize the pivotal role that BCS plays in the completion of the weight loss trajectory.

Patient Characteristics and Spending Among Individuals Undergoing Ambulatory Panniculectomy and Abdominoplasty in the US from 2016 to 2019

BACKGROUND

Abdominal contouring surgery can provide both functional and cosmetic benefits to patients with abdominal soft tissue laxity. Although these procedures have been studied in the inpatient setting, few studies describe abdominal contouring surgery in the ambulatory setting.

OBJECTIVE

The purpose of this analysis was to investigate patterns in patient demographics between functional panniculectomy and cosmetic abdominoplasty using national data from the last four years.

METHODS

Using the Nationwide Ambulatory Surgery Sample, we analyzed outpatient abdominal contouring procedures between 2016 and 2019. Encounters with a CPT 15830 were included. Procedures with ICD Z41.1 or CPT 15847 modifiers were defined as cases of cosmetic abdominoplasty.

RESULTS

A weighted estimate of 95,289 encounters were included, with 66,531 (69.8%) functional panniculectomy and 28,758 (30.2%) cosmetic abdominoplasty procedures. Among patients with a history of bariatric surgery (23.8%; 95% CI, 22.3-25.4%), there was a 28.5% (4,866 in 2016 vs 6,254 in 2019) increase in panniculectomy and abdominoplasty. Compared with individuals who underwent cosmetic abdominoplasty, individuals who underwent functional panniculectomy were more racially diverse, had more comorbidities, and were more likely to be from low-income backgrounds.

CONCLUSIONS

Rates of abdominal contouring surgery in the ambulatory setting have increased in recent years especially among individuals with previous bariatric surgery. There are important demographic and clinical differences between patients who underwent functional panniculectomy and cosmetic abdominoplasty including primary payer, comorbidities, and racial identity.

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 .

Interplay of Oblique Flankplasty with Vertical Medial Thighplasty

After 25 years' experience, the authors present the senior author's current integration of lower body lift with vertical medial thighplasty. Mostly, oblique flankplasty with lipoabdominoplasty (OFLA) has replaced the traditional transverse posterior lower body lift and abdominoplasty due to improved esthetics and lower rate of complications. OFLA proceeds either immediately or as a first stage to the medially based reduction of thighs. L-vertical medial thighplasty, facilitated by excision site liposuction and scalpel assisted skin avulsion, is our preferred complimentary operation for predictable results and low rate of complications.

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.

Cryolipolysis: A promising nonsurgical technique for localized fat reduction

BACKGROUND

Cryolipolysis, also known as fat freezing, is a nonsurgical technique specialized for localized fat reduction. Utilizing targeted cold exposure to adipose tissue, cryolipolysis devices induce cellular apoptosis in adipocytes while sparing surrounding tissues, resulting in the selective disruption of fat cells and subsequent removal of damaged cells by macrophages. A reduction of the fat layer produces a noninvasive cosmetic benefit that provides an accessible alternative to liposuction. Objective and subjective measurements have demonstrated significant reduction in fat volume and high patient satisfaction rates. Cryolipolysis has been proven to be safe with minimal adverse effects. However, further research is needed to fully understand the mechanism of cryolipolysis and its efficacy in different treatment areas. This paper aims to provide a comprehensive overview of cryolipolysis, including its mechanism of action, indications, contraindications, adverse effects, results and outcomes, safety profile, and areas requiring further research.

METHODS

Our primary phase of literature review consisted of a PubMed search looking for all published literature around cryolipolysis. We employed a review approach that examined over 30 papers with the key search terms of "cryolipolysis," "fat-freezing," "cosmetic dermatology," "body contouring," "adverse effects," "adipocyte apoptosis," "Coolsculpting®," "cold panniculitis," and "localized fat reduction." We then analyzed each paper, extracting relevant information to gain a multidimensional understanding of cryolipolysis to provide a comprehensive review.

CONCLUSION

Cryolipolysis, with its ability to target and reduce localized adipose tissue, has emerged as a promising nonsurgical technique in the field of body contouring. It offers patients a valuable option for achieving their desired fat reduction without the need for a lengthy recovery period or major surgery. Cryolipolysis has shown to reduce the number of adipocytes in the treated area, a phenomenon that can be objectively quantified through various means, including fat caliper measurements, ultrasound assessments, and 3D imaging, or subjectively observed through patient satisfaction rates, clinical observations, and investigator assessments. In addition to its effectiveness in reducing localized adipose tissue, cryolipolysis also holds potential in the area of skin tightening. Preliminary studies suggest that cryolipolysis may have a positive impact on skin elasticity and tightening. Further investigation of this mechanism is needed to provide a better understanding of its potential in achieving optimal cosmetic outcomes for patients. By combining the benefits of fat reduction and skin tightening, cryolipolysis has the potential to offer a comprehensive nonsurgical solution for body contouring.

A Prospective, Matched Comparison of Health-Related Quality of Life in Bariatric Patients following Truncal Body Contouring

BACKGROUND

Massive weight loss after bariatric surgery can lead to excess skin associated with functional and aesthetic sequelae. Access to the benefit provided by body contouring procedures may be limited by insurance approval, which does not consider health-related quality of life. The aim of this study was to quantify the benefit in health-related quality of life for patients who undergo body contouring procedures after massive weight loss.

METHODS

Patients evaluated for postbariatric body contouring procedures were systematically identified and prospectively surveyed using the BODY-Q. Health-related quality-of-life change for each functional scale was compared between those who underwent body contouring procedures (operative group, preoperatively versus postoperatively) and those who did not (nonoperative group, preoperatively versus resurvey) using t tests. Propensity score matching allowed the authors to balance baseline demographics, comorbidities, physical symptoms, and risk factors between cohorts.

RESULTS

Fifty-seven matched patients were analyzed (34 operative versus 23 nonoperative). No significant difference in age, body mass index, time between surveys, or preoperative BODY-Q scores existed between cohorts. The surgical group demonstrated a significant improvement in 10 out of 11 BODY-Q functional scales. The nonoperative group realized no improvements and, in the interim, had a significant deterioration in four BODY-Q scales.

CONCLUSIONS

Postbariatric body contouring procedures represent a critical and final step in the surgical weight loss journey for patients and are associated with significant improvements in health-related quality of life. Further deterioration in psychosocial and sexual health-related quality of life occurs in patients who do not undergo body contouring procedures following bariatric surgery. This study provides prospective comparative data that validate the field's standard intervention and justification for insurance approval.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

The Age Factor in Postbariatric Body Contouring Surgery Outcome

BACKGROUND

Increasing life expectancy will likely lead greater numbers of older patients to seek postbariatric body contouring plastic surgery. The impact of age on body contouring plastic surgery outcome is undetermined.

METHODS

A retrospective cohort study of 317 postbariatric body contouring plastic surgery cases was performed. Patient demographics and operative and postoperative data were collected. Patients were categorized into three age groups, and univariate analysis examined group differences. Multivariate logistic regression analysis assessed independent associations between age and surgical outcome measures.

RESULTS

Patients 60 years and older had a higher mean preoperative body mass index (30.8 ± 3.6 kg/m2, p < 0.001) and higher rates of hypertension (48.9 percent, p < 0.001), dyslipidemia (38.3 percent, p < 0.001), and diabetes mellitus (17 percent, p = 0.012) compared to the younger age groups. They also sustained significantly higher complication rates (any minor complications, p = 0.004; minor surgical site infections, p = 0.005; minor hematomas, p = 0.007; any major complications, p < 0.001; major surgical-site infections, p < 0.001; and major dehiscence, p < 0.001). Increasing age was a significant risk factor for any major complications (p = 0.005), reoperation (p = 0.02), and readmission (p = 0.001). Age greater than or equal to 60 years was a significant risk factor solely for readmission (OR, 3.32; p = 0.03).

CONCLUSIONS

Increasing age was a risk factor for adverse postoperative outcome in postbariatric body contouring plastic surgery patients; however, age greater than or equal to 60 years in and of itself was an independent risk factor for readmission only. These findings may aid plastic surgeons in patient consultation and in decision making regarding suitable candidates for these procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Circumferential Lipobrachioplasty Is a Safe Procedure

BACKGROUND

Excess fat and skin in the upper arms have become troublesome with aging and especially after the advancement in methods of weight reduction. Arm contouring procedures can be divided into three groups: those dealing with skin redundancy, those dealing with the lipodystrophy, and a combination of both. This study tries to find an answer to the debate about the safety of simultaneous circumferential liposuction and brachioplasty.

METHODS

Sixty-two patients (49 women and 13 men) were operated on by simultaneous circumferential suction-assisted lipectomy followed by brachioplasty. Preoperative and postoperative arm circumferences and outcomes (including complications and patient satisfaction) were evaluated starting at least 6 months after the procedure.

RESULTS

Only two patients (3.2 percent) developed small areas of wound dehiscence that healed after repeated dressing and an extended period of compression garment use. One patient (1.6 percent) complained of hypertrophic scarring, which was managed by local compression and silicone sheets. The average reduction in mid arm circumference was 9 cm (range, 5 to 14 cm). Approximately 95.2 percent of the patients in the study are highly satisfied, and 4.8 percent reported a mild degree of satisfaction.

CONCLUSIONS

Simultaneous circumferential arm liposuction followed by brachioplasty addresses both the lipodystrophy and arm ptosis in a single hospital admission. This combination does not increase the complication rate. The results are highly satisfactory to the patients. According to the results of this study, circumferential arm lipobrachioplasty is considered to be a safe, efficient, reliable, and feasible procedure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE: 4

Quality of Life and Complications in the Morbidly Obese Patient following Post-Bariatric Body Contouring

BACKGROUND

With a growing obesity epidemic, an increasing number of patients are seeking body contouring procedures (BCP). The aim of this study was to assess the association of morbid obesity (BMI > 40 kg/m2) with both clinical and health-related quality of life (H-RQOL) outcomes following BCP.

METHODS

Patients evaluated for post-bariatric BCP at a large academic hospital by one surgeon were retrospectively identified. Patients were surveyed using the BODY-Q^© during initial and postoperative visits. Demographic, clinical, operative characteristics, and surgical outcomes data were extracted. BODY-Q domain scores were compared between morbidly obese (MO) and non-morbidly obese (NMO). The absolute change in HR-QOL scores for MO and NMO was also compared.

RESULTS

Overall, 59 patients were included (MO 72.9% vs. NMO 27.1%). The median age was 50 years old (Interquartile range [IQR] ± 17); the majority were non-Hispanic (89.8%), non-diabetic (81.4%), non-smokers (67.8%). Assessment of surgical site occurrences, reoperations, and the complication composite outcome revealed no statistical differences between groups (p >0.05). MO patients showed lower net improvement in three HR-QOL domains: satisfaction with body (median 30 [IQR ± 53] vs. 65 [IQR ± 54]; p = 0.036), body image (median 39 [IQR ± 55] vs. 52 [IQR ± 44]; p = 0.025), and social function (median 12 [IQR ± 18] vs. 19 [IQR ± 35]; p = 0.015).

CONCLUSION

Post-bariatric BCP can be safely performed in the MO patient without increased risk of complication. However, the benefit of truncal BCP is less in MO as it pertains to specific QOL domains: satisfaction with body, body image, and social function.

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 .

A New Surgical Approach to Body Contouring

BACKGROUND

The success of body contouring surgery will largely depend on the correct choice and performance of the technique, and utilization of the necessary scientific measures. Thus, this study sought to highlight the combination and evolution of the abdominoplasty-assisted liposuction technique, while individualizing each case for the patient's benefit.

METHOD

We present a series of 188 cases from the past 3 years (2017-2019), using our modification to the surgical technique: performing 360-degree liposuction first, and then abdominoplasty in the same surgical time. We show our aesthetic results, surgical time, and complications, so as to compare them with the literature.

RESULTS

Of the 188 cases, 184 were women (97.9%) and 4 were men (2.1%). In 11 cases (5.8%), we recorded 4 hours as a minimum surgical time and 8 hours in 16 cases (8.5%) as a maximum time. Regarding complications, hematomas were recorded in 1 case (0.5%) as the least frequent complication and seromas in 18 cases (9.6%) as the most frequent complication. The aesthetic results, although not objectively measurable, are flattering for both the patient and the surgeon, as shown by documented evidence (photographs) before and after surgery.

CONCLUSIONS

Our study supports favorable results. Modification of this technique has resulted in outstanding body contouring surgery. We hope this procedure can be reproduced because of its few complications and the pleasant results it yields.

The Potential Impact of Plastic Surgery Expertise on Body Contouring Procedure Outcomes

BACKGROUND

With the increasing demand for body contouring procedures in the United States over the past 2 decades, more surgeons with diverse specialty training are performing these procedures. However, little is known regarding the comparative outcomes of these patients.

OBJECTIVES

The purpose of this study was to compare outcomes of body contouring procedures based on the specialty training of the surgeon.

METHODS

Data from the American College of Surgeons National Surgical Quality Improvement Program (2005-2015) were reviewed for all body contouring procedures. Patients were stratified by surgeon training (plastic surgery [PS] vs general surgery [GS]). Descriptive statistics and regression analyses were used to evaluate differences in outcomes.

RESULTS

A total of 11,658 patients were included; 9502 PS cases and 2156 GS cases. Most were women (90.4%), aged 40 to 59 (52.7%) and white (79.5%). Compared with PS patients, GS patients were more likely to be obese (61.4% vs 40.6%), smokers (13.6% vs 9.8%), and with ASA classification ≥3 (35.3% vs 18.6%) (all P < 0.001). Abdominal contouring procedures were the most common (76%) cases. Multivariate regression revealed that compared with PS cases, those performed by GS practitioners were associated with increased wound and infectious complications (adjusted odds ratio [aOR], 1.81; 95% confidence interval [CI], 1.44-2.27), reoperation (aOR, 1.85; 95% CI, 1.31-2.62), and predicted mean length of stay (1.12 days; 95% CI, 0.64-1.60 days).

CONCLUSIONS

The variable outcomes in body contouring procedures performed by PS compared with GS practitioners may imply procedural-algorithmic differences between the subspecialties, leading to the noted outcome differential.

LEVEL OF EVIDENCE: 2

A Comparison of Common Plastic Surgery Operations Using the NSQIP and TOPS Databases

Both the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and the American Society of Plastic Surgeons Tracking Operations and Outcomes for Plastic Surgeons (TOPS) databases track 30-day outcomes.

Methods

Using the 2008-2016 TOPS and NSQIP databases, we compared patient characteristics and postoperative outcomes for 5 common plastic surgery procedures. A weighted TOPS population was used to mirror the NSQIP population in clinical and demographic characteristics to compare postoperative outcomes.

Results

We identified 154,181 cases. Compared with NSQIP patients, TOPS patients were more likely to be younger (47.9 versus 50.0 years), have American Society of Anesthesiologists class I-II (92.1% versus 74.6%), be outpatient (66.0% versus 49.3%), and be smokers (18.7% versus 11.7%). TOPS had extensive missing data: body mass index (40.6%), American Society of Anesthesiologists class (34.9%), diabetes (39.3%), and smoking status (37.2%). NSQIP was missing <1% of all shared categories except race (15.6%). The entire TOPS cohort versus only TOPS patients without missing data had higher rates of dehiscence (5.1% versus 3.5%) and infection (2.1% versus 1.7%). TOPS versus NSQIP patients had higher dehiscence rates (5.1% versus 1.0%) but lower rates of return to the operating room (3.1% versus 6.6%), infection (2.1% versus 3.0%), and medical complications (0.3% versus 2.2%). Nonweighted and weighted TOPS cohorts had similar 30-day outcomes.

Conclusions

NSQIP and TOPS populations are different in characteristics and outcomes, likely due to differences in collection methodology and the types physicians using the databases. The strengths of each dataset can be used together for research and quality improvement.

Surgical Site Infection Risk Factor Analysis in Postbariatric Patients Undergoing Body Contouring Surgery: A Nested Case-Control Study

BACKGROUND

Surgical site infections (SSIs) following body-contouring plastic surgery pose a significant burden on patients and caregivers, possibly leading to undesired surgical outcomes. Surgical site infection incidence following body-contouring plastic surgery ranges from 2% to 7%, but is estimated much higher among postbariatric massive weight loss (MWL) patients.

OBJECTIVE

The aim of this study was to evaluate SSI rate, risk and protective factors among postbariatric MWL patients following body-contouring plastic surgery.

METHODS

This was a nested case-control study of MWL patients who underwent body-contouring plastic surgery at the Department of Plastic Surgery at Assaf Harofeh Medical Center, between 2007 and 2014. Data were obtained from medical records. Surgical site infection was defined according to the Centers for Disease Control and Prevention criteria. Logistic regression was conducted to assess independent risk factors for SSIs.

RESULTS

From a cohort of 172 patients, 86 were included in the study. Surgical site infection rate was 20% (n = 17). Significant SSI risk factors included lifetime maximal weight and lifetime maximal body mass index (P = 0.039 and P = 0.002, respectively), body mass index loss prior to surgery (P = 0.032), estimated blood loss during surgery (P = 0.002), and gynecomastia repair procedure (P = 0.038). Independent SSI-associated factors included thigh lift procedure (odds ratio, 4.66; 95% confidence interval, 1.13-19.28) and preoperative antimicrobial prophylaxis (odds ratio, 0.04; 95% confidence interval, 0.03-0.61).

CONCLUSIONS

Although not required by current guidelines for body-contouring plastic surgery, preoperative antimicrobial prophylaxis in our study demonstrated a significant protective effect against SSIs. Further research may reveal its true contribution to SSI prevention in body-contouring plastic surgery.

Outcome of Body-Contouring Procedures After Massive Weight Loss

BACKGROUND

With the increased popularity of bariatric surgery, the demand for body-contouring procedures is growing. Associated with these procedures are a number of complications due to different risk factors and patients' characteristics. The aim of this study was to assess the outcome of body-contouring procedures and correlate it to possible risk factors.

METHODS

The study included a collective of 112 patients who underwent 157 body-contouring procedures. Patients' characteristics, risk factors, and complications have been recorded. Three groups were formed based on the type of surgical procedure to perform correlations of BMI, weight of resected tissue, and length of hospital stay using Spearman's rank test. Correlations between patients' risk factors and complication occurrence were analyzed with Fisher's exact test.

RESULTS

The most common procedure patients underwent was the classic abdominoplasty (n = 53). A significant correlation was found between preoperative BMI and weight of resected tissue in abdominoplasties (rho = 0.69), Fleur-de-Lis abdominoplasties (rho = 0.64), and body lifts (rho = 0.60). There was a significant correlation between weight of resected tissue and length of hospital stay (rho = 0.53) and preoperative BMI and length of hospital stay (rho = 0.4) as well. There was no significant correlation between patients' comorbidities or smoking status and the postoperative complication rate. The mean weight of resected tissue was higher in patients with than without complications requiring surgical revision.

CONCLUSIONS

The relevance of risk factors commonly believed to have an influence on postoperative complications should be revised. The weight of resected tissue has an influence on complication.

Challenging the Surgical Axiom: Albumin Level Does Not Reliably Predict Development of Wound Complications in Patients Undergoing Body Contouring

INTRODUCTION

Hypoalbuminemia has traditionally been associated with a poor nutritional status and subsequent high incidence of postoperative wound complications in surgical patients. Recent evidence, however, suggests that traditional nutritional markers are inadequate in predicting postoperative morbidity.

OBJECTIVE

To test the hypothesis that preoperative albumin levels are not associated with adverse outcomes in patients undergoing body contouring.

METHODS

All patients undergoing body contouring from 2015 to 2017 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Demographics, comorbidities, and wound classification were extracted from the database. The independent predictors of developing wound complications were identified. Logistic regressions were used to identify the impact of albumin on outcomes.

RESULTS

During the study period, 4496 patients were identified. Wound complications developed in 202 patients (4.5%). Increasing body mass index, history of diabetes mellitus, American Society of Anesthesiologists classification, history of prior open wound, and tobacco use were independently associated with the development of postoperative complications. Albumin levels were not associated with the development of wound complications. Similarly, albumin levels were not associated with the need for a repeated operation, with readmission, or with the total hospital length of stay.

CONCLUSION

Albumin values were not associated with wound complications or need for reoperation in patients undergoing body contouring. Further research is warranted.

Modified Treatment Algorithm for Pseudogynecomastia After Massive Weight Loss

BACKGROUND

Pseudogynecomastia is the increased aggregation of fatty tissue in the area of the male breast with resultant female appearance. Two forms can appear: pseudogynecomastia after massive weight loss (pseudogynecomastia obese [PO]) and pseudogynecomastia, which is caused only by adipose tissue (pseudogynecomastia fat). For PO, only the Gusenoff classification with corresponding operative treatment options exists. However, this classification is limited by the fact that it underestimates the extensive variability of residual fat tissue and skin excess, both crucial factors for operative planning. For this reason, we propose a modification of the treatment algorithm for the Gusenoff classification based on our results to achieve more masculine results.

MATERIALS AND METHODS

A total of 43 male patients with PO were included in this retrospective study (grade 1a, n = 1; grade 1b, n = 1; grade 2, n = 17; grade 3, n = 24). Forty-two mastectomies with a free nipple-areola complex (NAC) transposition (grades 2 and 3) and 1 with a subcutaneous mastectomy (grade 1a) with periareolar lifting were performed. A retrospective chart review was performed to obtain data regarding age, body mass index, body mass index loss, weight loss, reason for weight loss, comorbidities, nicotine, and additional procedures, postoperative sensitive on the NAC transplants and complications.

RESULTS

None of the free-nipple grafts were lost. Forty (95%) of 42 patients with mastectomy had a resensitivity on the NAC.

CONCLUSIONS

For pseudogynecomastia, the treatment algorithm of the Gusenoff classification should be modified and adapted according to our recommendations to achieve more optimal masculine results.

Comparative analysis on the effect of low-thermal plasma dissection device (PEAK PlasmaBlade) versus conventional electro surgery in post-bariatric body-contouring procedures: A retrospective randomised clinical study

Postoperative wound-healing problems are relatively high in post-bariatric body-contouring procedures, partly because of electrosurgery and the associated thermal tissue damage. This study is a retrospective randomised evaluation of the effect of a low-thermal plasma dissection device (PEAK PlasmaBlade, Medtronic, Minneapolis, Minnesota) in comparison with conventional electrosurgery. A total of 24 patients undergoing upper arm or medial thigh lifting were randomised to PEAK PlasmaBlade on one side and to monopolar electrosurgery on the other side of the same patient. Wounds of 10 patients were examined histologically for acute thermal injury depth. Significantly lower total volume of drain output (61,1 ± 70,2 mL versus 95,1 ± 176,0 mL; P = .04) was found on the PEAK PlasmaBlade side compared with the electrosurgery side. Furthermore, the PEAK PlasmaBlade side showed fewer seromas (no case of seroma versus three seromas in the electrosurgery group) and less thermal damage (40% versus 70%; P = .26). Acute thermal injury depth from the PEAK PlasmaBlade was less than from monopolar electrosurgery (425 ± 171 μm versus 686 ± 1037 μm; P = .631). PEAK PlasmaBlade appears to be superior to traditional monopolar electrosurgery for post-bariatric body-contouring procedures because it demonstrated less tissue damage, lower total volume of drain output, and fewer postoperative seromas resulting in faster wound healing.

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.

Scoping Review of the National Surgical Quality Improvement Program in Plastic Surgery Research

Background

The National Surgical Quality Improvement Program (NSQIP) is a robust, high-quality surgical outcomes database that measures risk-adjusted 30-day outcomes of surgical interventions. The purpose of this scoping review is to describe how the NSQIP is being used in plastic surgery research.

Methods

A comprehensive electronic literature search was completed in PubMed, Embase, MEDLINE, and CINAHL. Two reviewers independently reviewed articles to determine their relevance using predefined inclusion criteria. Articles were included if they utilized NSQIP data to conduct research in a domain of plastic surgery or analyzed surgical procedures completed by plastic surgeons. Extracted information included the domain of plastic surgery, country of origin, journal, and year of publication.

Results

A total of 106 articles met the inclusion criteria. The most common domain of plastic surgery was breast reconstruction representing 35% of the articles. Of the 106 articles, 95% were published within the last 5 years. The Plastic and Reconstructive Surgery journal published most of the (59%) NSQIP-related articles. All of the studies were retrospective. Of note, there were no articles on burns and only one study on trauma as the domain of plastic surgery.

Conclusion

This scoping review describes how NSQIP data are being used to analyze plastic surgery interventions and outcomes in order to guide quality improvement in 106 articles. It demonstrates the utility of NSQIP in the literature, however also identifies some limitations of the program as it applies to plastic surgery.

Risk Factors for Undergoing Elective Abdominal Contouring Surgery Shortly After Hospitalization

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of Posthospital Syndrome on Health Care Utilization After Abdominal Contouring Surgery

BACKGROUND

Posthospital syndrome (PHS) is a transient condition after acute hospitalizations when patients are physiologically deconditioned. The objective of this study was to determine if having PHS at the time of abdominal contouring surgery increased the incidence of postoperative adverse medical events.

METHODS

We conducted a retrospective cohort study of patients enrolled in the MarketScan Databases who underwent outpatient functional or cosmetic abdominal contouring surgery (ie, abdominoplasty, liposuction, or panniculectomy) from April 2010 to August 2015. Patients were separated into 2 groups based upon PHS exposure, defined by hospitalization within 90 days before surgery. Differential health care utilization within 30 days after surgery was compared between cohorts.

RESULTS

Among the 18,947 patients included in the final cohort, 1045 patients (6%) had PHS at the time of abdominal contouring surgery. Patients with PHS experienced more emergency department visits (0.16 vs 0.08 visits; adjusted odds ratio, 1.60; P < 0.001) and more episodes of hospitalization (0.11 vs 0.04 episodes; adjusted odds ratio, 1.70; P < 0.001) within 30 days postoperatively. The mean unadjusted health care utilization after abdominal contouring surgery for patients with PHS was US $7888 (SD, 17,659) versus US $2943 (SD, 9096) in patients without PHS. After controlling for confounders, such as comorbidity burden, PHS was associated with US $3944 greater cost than patients without PHS (P < 0.001).

CONCLUSIONS

Among patients undergoing outpatient abdominal contouring surgery, having PHS increased the incidence of adverse medical events requiring medical attention in the 30-day postoperative period. These findings support the inclusion of PHS in preoperative evaluation and preparation for patients seeking abdominal contouring surgery.

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.

Physical attractiveness: analysis of buttocks patterns for planning body contouring treatment

BACKGROUND

As buttocks region is one of the most characteristic features of the ideal female body figure, the popularity of gluteal region contouring is on the rise. Perception of body form is influenced by its shape and size. Interventions to modify the form of this region are often difficult due to influence. The aim of this study is to investigate the attractiveness of various buttock shapes with the aid of a dedicated software.

METHODS

Standard personal photographs of the lower body were obtained from 200 healthy volunteers. Linear analyses were made and anatomical perception was calculated according to reference points.

RESULTS

Compared to males, all measurements concerning buttock dimensions were a significantly greater in females. Proportional assessments revealed that in females, the most attractive buttock waist-to-hip ratio was 0.75 from the posterior view. This ratio was 0.85 in males. From the lateral view, the most attractive buttocks have a waist-to-hip ratio of 0.70 in females. Positioning of the lateral prominence at the inferior gluteal fold was rated by 25% of the respondents as the most attractive in males from the posterior view. From the lateral view, the most prominent portion positioned at the midpoint (a 50:50 vertical ratio) was considered the most attractive for females.

CONCLUSIONS

These results suggest that utilizing digitalized reference values for a given body region may be an invaluable tool for determination of the correct fat volume, thus individualization of body contouring procedures. With the help of certain software, this research has shown that it is possible to measure the parameters of buttock, which may in turn be used to offer the best solution for any individual in quest for an improved buttocks form. New ideal waist-to-hip ratios of 0.7 update the previous standards.

Preoperative Respiratory Physiotherapy in Abdominoplasty Patients

BACKGROUND

After abdominoplasty, patients experience decreased ventilatory function and increased intra-abdominal pressure (IAP). Breathing exercises are used during the pre- and postoperative periods of several abdominal surgeries to prevent or minimize postoperative complications.

OBJECTIVES

The aim of this study was to assess the effect of preoperative respiratory physiotherapy on the outcome of abdominoplasty patients.

METHODS

Thirty-three patients were divided into 2 groups. The control group (n = 18) received no preoperative intervention. The intervention group (n = 15) performed breathing exercises during the preoperative period, including incentive spirometry, diaphragmatic breathing, shortened expiration, and sustained maximal inspiration. Respiratory physiotherapy started one week before surgery. Breathing exercises were performed daily. They were performed 3 times weekly in the presence of a physiotherapist and patients were instructed to carry on the exercises at home on days without physiotherapy sessions for three sets of 20 repetitions each. Patients were assessed by spirometry and IAP measurements.

RESULTS

No significant difference in spirometry was found between groups. However, patients in the intervention group had lower IAP at the start of surgery and at all time points (P = 0.010) compared with controls.

CONCLUSIONS

Preoperative respiratory physiotherapy had no impact on spirometry, but may have contributed to reduce IAP intraoperatively.

LEVEL OF EVIDENCE 2

Intraoperative factors associated with postoperative complications in body contouring surgery

BACKGROUND

Several preoperative factors have been shown to influence outcome of body contouring surgeries. The effect of intraoperative features, including fluid volume administered, hemodynamic and respiratory parameters, and body temperature on postoperative complication, has not been reported to date.

MATERIALS AND METHODS

All subsequent patients undergoing body contouring surgery in the Tel Aviv Medical Center between 2007 and 2012 were enrolled. Demographic and intraoperative data were collected and analyzed for possible associations with postoperative complications, including formation of seroma, hematoma/bleeding, other surgical site complications (infection, adhesiolysis, or need for debridement), formation of a hypertrophic scar, any documented, infection or a composite outcome of any of the previously mentioned.

RESULTS

Data of 218 patients were assessed. Mean (standard deviation) age of patients was 41(14) y. Intraoperative administration of higher volumes of fluids was significantly associated with formation of seroma (P = 0.01), hematoma/bleeding (P = 0.03), hypertrophic scar (P = 0.01), surgical site complications (P = 0.01), and a composite outcome (P < 0.001). Development of hematoma/bleeding was associated with longer periods of low (<35.6°C) intraoperative core temperature (72% versus 50% of surgery duration in patients who did not develop this complication, P < 0.05). Surgical site complications were associated with longer periods of intraoperative oxygen desaturation (saturation ≤92%, 4.2% versus 0.9% of surgery duration in patients who did not develop surgical site complications, P < 0.01).

CONCLUSIONS

Intraoperative moderate hypothermia, hypoxemia, and liberal fluid administration are associated with worse surgical outcome in patients undergoing body contouring surgery. Increased awareness of the potential adverse effects of these factors in body contouring surgery will enhance interventions aimed at avoiding and promptly treating such events.

Rates and Predictors of Readmission Following Body Contouring Procedures: An Analysis of 5100 Patients From The National Surgical Quality Improvement Program Database

BACKGROUND

Hospital readmissions can be a major contributor to increased healthcare costs and are a salient current topic in healthcare. There is a paucity of large, prospective studies that evaluate rates and risk factors of readmission within the aesthetic subset of plastic surgery.

OBJECTIVES

The authors propose to determine the rates of unplanned readmission following body contouring procedures and to analyze the predictors associated with it.

METHODS

The 2011 and 2012 National Surgical Quality Improvement Program Database was queried for body contouring procedures using the appropriate Current Procedural Terminology codes. The rate of unplanned readmission, preoperative risk factors, comorbidities, and medical and surgical postoperative complications data were analyzed using multivariate regression models to determine predictors of readmission after these procedures.

RESULTS

We identified 5100 patients who underwent body contouring procedures, of which 142 (2.8%) experienced an unplanned readmission. Forty-eight per cent of readmitted patients experienced at least one surgical complication, and 23.9% experienced at least one medical complication. Multivariate regression analyses identified several independent predictors of unplanned readmission: increasing age (odds ratio [OR] 1.018 per year, P = 0.039), bleeding disorders (OR 3.674, P = 0.039), increased operative time (each additional hour conferring a 20% increased risk), surgical complications (OR 19.179, P < 0.001), and medical complications (OR 10.240, P < 0.001).

CONCLUSIONS

The unplanned readmission rate for body contouring procedures is low overall (2.8%). We identified age, bleeding disorders, operative duration, and postoperative complication as independent risk factors for unplanned readmission. These data can help guide preoperative risk stratification and future interventions in high-risk patient populations.

LEVEL OF EVIDENCE

2.

Autologous breast reconstruction in the postbariatric patient population

BACKGROUND

Over 175,000 Americans underwent bariatric surgery in 2013 alone, resulting in rapid growth of the massive weight loss population. As obesity is a known risk factor for breast cancer, plastic surgeons are increasingly challenged to reconstruct the breasts of massive weight loss patients after oncologic resection. The goal of this study is to assess the outcomes of autologous breast reconstruction in postbariatric surgery patients at a single institution.

METHODS

Patients who underwent autologous breast reconstruction between 2008 and 2014 were identified. Those with a history of bariatric surgery were compared to those without a history of bariatric surgery. Analysis included age, ethnicity, BMI, comorbidities, flap type, operative complications, and reoperation rates. Propensity matched analysis was also conducted to control for preoperative differences between the two cohorts.

RESULTS

Fourteen women underwent breast reconstruction following bariatric surgery, compared to 1,012 controls. Outcomes analysis revealed significant differences in breast revisions (1.35 vs. 0.61, P = .0055), implant placements (0.42 vs. 0.08, P = .0003), and total OR visits (2.78 vs. 1.67, P = .0007). There was no significant difference noted in delayed healing of the breast (57.4% vs. 33.7%, P = .087) or donor site (14.3% vs. 15.8%, P = 1.00).

CONCLUSIONS

As the rise in bariatric surgery mirrors that of obesity, an increasing amount of massive weight loss patients undergo treatment for breast cancer. We demonstrate profound differences in this patient population, particularly in regards to revision rates, which affects operative planning, patient counseling, and satisfaction.

Quality of life and scar evolution after negative pressure or conventional therapy for wound dehiscence following post-bariatric abdominoplasty

No studies have examined scars and quality of life after different treatments of wound dehiscence in patients undergoing post-bariatric abdominoplasty. Scars and quality of life of patients with postoperative wound dehiscence managed with negative pressure wound therapy (group A) and conventional wound therapy (group B) were reviewed 6 months after wound healing. Of 38 patients undergoing treatment for wound dehiscence after 203 abdominoplasty, 35 (group A = 14 versus group B = 21) entered the study. Wound healing in group A was significantly faster than group B (P = 0·001). Patients (P = 0·0001) and observers (P = 0·0001) reported better overall opinions on a scar assessment scale for group A. Better overall quality of life and general health satisfaction were observed in group A (P < 0·05). A significant correlation was observed between the World Health Organization Quality of Life scores and Patient and Observer Scar Assessment Scale scores (r=-0·68, P < 0·0001) in all 35 patients. Negative pressure wound therapy is feasible and effective in patients with wound dehiscence following post-bariatric abdominoplasty. An adequate post-treatment outcome is achieved compared with conventional wound therapy in light of a strong association found between worse patient scar self-assessment and poor overall quality of life, regardless of the received treatment.

Online Patient Resources for Liposuction: A Comparative Analysis of Readability

BACKGROUND

As patients strive to become informed about health care, inadequate functional health literacy is a significant barrier. Nearly half of American adults have poor or marginal health literacy skills and the National Institutes of Health and American Medical Association have recommended that patient information should be written at a sixth grade level. The aim of this study is to identify the most commonly used online patient information about liposuction and to evaluate its readability relative to average American literacy.

METHODS

An internet search of "liposuction" was performed and the 10 most popular websites identified. User and location data were disabled and sponsored results excluded. All relevant, patient-directed articles were downloaded and formatted into plain text. Articles were then analyzed using 10 established readability tests. A comparison group was constructed to identify the most popular online consumer information about tattooing. Mean readability scores and specific article characteristics were compared.

RESULTS

A total of 80 articles were collected from websites about liposuction. Readability analysis revealed an overall 13.6 grade reading level (range, 10-16 grade); all articles exceeded the target sixth grade level. Consumer websites about tattooing were significantly easier to read, with a mean 7.8 grade level. These sites contained significantly fewer characters per word and words per sentence, as well as a smaller proportion of complex, long, and unfamiliar words.

CONCLUSIONS

Online patient resources about liposuction are potentially too difficult for a large number of Americans to understand. Liposuction websites are significantly harder to read than consumer websites about tattooing. Aesthetic surgeons are advised to discuss with patients resources they use and guide patients to appropriate information for their skill level.

Circumferential Contouring of the Lower Trunk: Indications, Operative Techniques, and Outcomes-A Systematic Review

BACKGROUND

Increasing obesity prevalence and development of bariatric surgery have led to the development of skin re-draping techniques. Several contouring techniques have been described for treating the circumferential excess of the lower trunk.

MATERIALS AND METHODS

We performed a systematic review to summarize surgical indications, operative techniques, peri-operative management (nutritional supplementation, antibiotic prophylaxis, thrombo-prophylaxis), outcomes, complications, patient satisfaction, and impact on quality of life of circumferential contouring of the lower trunk procedures. A systematic review, based on the PRISMA criteria, was conducted using the Pubmed and Cochrane databases.

RESULTS

The review included 42 articles and 1748 operated patients. Two studies only were graded as level of evidence II; the others were graded as levels III to V. The most frequently reported indication was massive weight loss. All the described techniques derived either from belt lipectomy or lower bodylift. Belt lipectomy resulted in a posterior scar situated at the waistline and allowed a better correction of hip back rolls, whereas lower bodylift was more effective on buttock and lateral thigh ptosis. The most reported complication was wound dehiscence. Patient satisfaction and quality of life scores were high in all studies.

CONCLUSIONS

This review included a majority of low-level evidence studies that limit extrapolability of the results. Future randomized prospective studies may generate stronger evidence, with a standardization of surgical indications and operative techniques.

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 .

Safety and Efficacy of Novel Oral Anticoagulants vs Low Molecular Weight Heparin for Thromboprophylaxis in Large-Volume Liposuction and Body Contouring Procedures

BACKGROUND

Preventing venous thromboembolism (VTE) remains an important topic in the plastic surgery community. However, there is little consensus regarding appropriate VTE prophylaxis for patients undergoing common body contouring procedures.

OBJECTIVES

This study compared the use of two novel oral anticoagulants (Rivaroxaban and Apixiban) vs low molecular weight heparin (LMWH) for postoperative chemical prophylaxis in body contouring plastic surgery procedures.

METHODS

A single center retrospective chart review of 1572 patients who underwent body contouring plastic surgery procedures from January 2012 to February 2015 was performed. Major complications associated with chemical prophylaxis were reviewed including hematomas requiring surgical evacuation, acute blood loss anemia requiring transfusions, and thrombotic or hemorrhagic events.

RESULTS

Drug-related adverse events occurred in 1.27% (n = 20) of patients. The complications encountered by the 454 patients on LMWH consisted of 0.88% (n = 4) with hematomas requiring surgical evacuation, 0.44% (n = 2) with decreased hemoglobin requiring transfusions, and 0.22% (n = 1) with a deep vein thrombosis (DVT). The complications encountered by 703 patients on with Rivaroxaban consisted of 1.3% (n = 9) with hematomas requiring surgical evacuation, 0.43% (n = 3) with decreased hemoglobin requiring transfusions, and 0.1% (n = 1) with a DVT and pulmonary embolism. The complications encountered by 415 patients on with Apixaban consisted of 0.48% (n = 2) with a DVT.

CONCLUSIONS

Novel oral anticoagulants (Rivaroxaban and Apixiban) are comparable to LMWH for chemical prophylaxis after body contouring procedures with similar rates of drug-related complications. Further investigation is warranted with more clinical cases in order to recommend the use of this medication for routine postoperative chemical prophylaxis after body contouring procedures.

LEVEL OF EVIDENCE

3 Therapeutic.

Complications Associated With Medial Thigh Lift: A Comprehensive Literature Review

Medial contouring of the thigh is frequently requested to improve appearance and function of medial thigh deformities, following massive weight loss or aging process. This surgical procedure can be associated with a significant rate of complications. Our aim was to consider the complications and outcomes according to the performed technique, through a wide and comprehensive review of the literature. A search on PubMed/Medline was performed using “medial thighplasty”, “medial thigh lifting” and “technique” as key words. As inclusion criteria, we selected the clinical studies describing techniques of medial thighplasty. We excluded the papers in which complications related to medial thighplasty were not specified. We also excluded literature-review articles. We found 16 studies from 1988 to 2015. Overall, 447 patients were treated. Different techniques were applied. Complications were observed in 191/447 patients (42.72%). The most frequent complications were wound dehiscence(18.34%) and seroma (8.05%). No major complications, such as thromboembolism and sepsis, were observed. Minor complications occurred in a high percent of patients, regardless of the performed surgical procedure. Patients should be informed about the possible occurrence of wound dehiscence and seroma, as common complications associated with this surgical procedure.

Cryolipolysis for fat reduction and body contouring: safety and efficacy of current treatment paradigms

BACKGROUND

Cryolipolysis is a nonsurgical technique for localized fat reduction. With the increased risk of complications from more invasive methods such as liposuction, cryolipolysis presents a promising method for nonsurgical body contouring. This study presents a systematic review of the available clinical data, with an emphasis on the efficacy, methods, safety, and complications of cryolipolysis.

METHODS

To identify clinical studies that assessed outcomes of cryolipolysis, a systematic review of the MEDLINE and Cochrane databases was performed with the search algorithm cryolipolysis OR cool sculpting OR fat freezing OR lipocryolysis.

RESULTS

The primary literature search returned 319 articles. After inclusion criteria were applied and additional articles were idenfied via manual review of article references, 19 studies were selected for review. Average reduction in caliper measurement ranged from 14.67 percent to 28.5 percent. Average reduction by ultrasound ranged from 10.3 percent to 25.5 percent. No significant impact on lipid levels or liver function tests after cryolipolysis treatments was noted in any study. Only mild, short-term side effects, such as erythema, swelling, and pain, were noted. Paradoxical adipose hyperplasia was described in one patient.

CONCLUSIONS

Cryolipolysis is a promising procedure for nonsurgical fat reduction and body contouring and presents a compelling alternative to liposuction and other, more invasive methods. This procedure appears to be safe in the short term, with a limited side effect profile, and results in significant fat reduction when used for localized adiposities. It remains unclear whether posttreatment manual massage and multiple treatments in the same anatomic area enhance the efficacy of cryolipolysis.

Plastic surgery after bariatric surgery

BACKGROUND

Massive weight loss after bariatric surgery often results in excess skin, which can lead to stigma due to appearance and pronounced physical and psychological impairments. This review considers the evidence base for post-bariatric plastic surgery and the treatment options that are available.

METHOD

The article is based on a literature search in PubMed with the keywords «bariatric surgery» AND «plastic surgery», in addition to the authors' experience with a large number of patients.

RESULTS

Body contouring surgery after massive weight loss is offered primarily for the treatment of troublesome skin conditions. The surgery can help to improve quality of life and functional status. However, there is little scientific evidence regarding indications for surgery, choice of surgical techniques and risk of complications, and the surgeon's own opinions and clinical experience often play a major role. Many plastic surgeons limit body contouring surgery to those with BMI < 28 kg/m². However, most patients who have undergone bariatric surgery have BMI ≥ 30 kg/m², and requests for body contouring surgery for these individuals are often denied, except when there are compelling medical grounds.

INTERPRETATION

Plastic surgery can lead to improved functioning and increased quality of life. The evidence base with respect to indications, treatment methods and outcomes should be strengthened through well-planned prospective studies and a patient registry. There is a particular need for documentation of treatment outcomes in the large group of patients with BMI ≥ 30 kg/m².

Liposuction-assisted medial brachioplasty after massive weight loss: an efficient procedure with a high functional benefit

BACKGROUND

Brachioplasty frequently offers functional benefits but results in poor aesthetic scars and a relatively high complication rate. The authors describe the complications and risk factors inherent in liposuction-assisted medial brachioplasty and assess patient satisfaction with the functional and aesthetic benefits.

METHODS

A 5-year retrospective study was performed that included all patients who underwent liposuction-assisted medial brachioplasty. Complications were reviewed and analyzed by aesthetic and nonaesthetic categories, and patient satisfaction was rated.

RESULTS

Sixty-six patients were included (mean age, 44.4 years). The average body mass index was 30.2 kg/m; mean weight reduction was 50.72 kg. Thirty-seven patients (56.1 percent) developed at least one complication, including six (9.1 percent) with a nonaesthetic complication versus 31 (47.0 percent) with an aesthetic complication. Complications were significantly associated with a longer operative time (p = 0.015), 233 minutes in the complication group versus 164 minutes in the no-complication group. Fifty-three patients answered the questionnaire. Forty-six (86.8 percent) stated that they would undergo this intervention again. Overall satisfaction was reported as excellent for 12 patients (22.6 percent) and pleasing for 24 (45.3 percent). All patients rated the functional outcome superior or equal to the aesthetic outcome. Quality of life was estimated to be better after than before the intervention for 41 patients (77.4 percent).

CONCLUSIONS

Liposuction-assisted medial brachioplasty is a safe and efficient technique. It offers a functional benefit with a low nonaesthetic complication rate. Despite the inherent scars, the majority of patients would undergo this intervention again because of an important satisfaction rate and improvement in quality of life.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.