Outcome Study of the Surgical Management of Panniculitis

Negative Pressure Wound Therapy After Abdominal Body Contouring: A Comparative Matched Analysis of Outcomes and Cost

Background: Studies that have previously validated the use of incisional negative pressure wound therapy (iNPWT) after body contouring procedures (BCP) have provided limited data regarding associated health care utilization and cost. We matched 2 cohorts of patients after BCP with and without iNPWT and compared utilization of health care resources and post-operative clinical outcomes. Methods: Adult patients who underwent abdominoplasty and/or panniculectomy between 2015 and 2020 by a single surgeon were identified. Patients were propensity score matched by body mass index (BMI), gender, smoking history, diabetes mellitus, hypertension, and incision type. Primary outcomes included time to final drain removal, outpatient visits, homecare visits, emergency department visits, and cost. Secondary outcomes included surgical site occurrences (SSO), surgical site infections, reoperations, and revisions. Results: One hundred sixty-six patients were eligible, and 40 were matched (20 with iNPWT and 20 without iNPWT) with a median age of 47 years and BMI of 32 kg/m2. There were no differences in demographics or intraoperative details (all P > .05). No significant differences were found between the cohorts in terms of health care utilization measures or clinical outcomes (all P > .05). Direct cost was significantly greater in the iNPWT cohort (P = .0498). Inpatient length of stay and procedure time were independently associated with increased cost on multivariate analysis (all P < .0001). Conclusion: Consensus guidelines recommend the use of iNPWT in high-risk patients, including abdominal BCP. Our results show that iNPWT is associated with equivalent health care utilization and clinical outcomes, with increased cost. Additional randomized controlled trials are needed to further elucidate the cost utility of this technique in this patient population.

The Impact of Obesity on Plastic Surgery Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

Obesity is a potential risk factor for complications in plastic surgeries. However, the data presented by primary studies are contradictory.

OBJECTIVES

The aim of this study was to summarize and clarify the divergences in the literature to provide a better understanding of the impact of obesity in different plastic surgery procedures.

METHODS

We conducted a systematic review and meta-analysis of the impact of obesity on plastic surgery outcomes. Searches were conducted in MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu, and the Cochrane Database of Systematic Reviews. The primary outcomes assessed were surgical complications, medical complications, and reoperation rates. The secondary outcome assessed was patient satisfaction. Subgroup analysis was performed to investigate the impact of each BMI category on the outcomes.

RESULTS

Ninety-three articles were included in the qualitative synthesis, and 91 were used in the meta-analysis. Obese participants were 1.62 times more likely to present any of the primary outcomes (95% CI, 1.48-1.77; P < 0.00001). The highest increase in risk among plastic surgery types was observed in cosmetic procedures (risk ratio [RR], 1.80; 95% CI, 1.43-2.32; P < 0.00001). Compared with normal-weight participants, overweight participants presented a significantly increased RR for complications (RR, 1.16; 95% CI, 1.07-1.27; P = 0.0004). Most authors found no relation between BMI and overall patient satisfaction.

CONCLUSIONS

Obesity leads to more complications and greater incidence of reoperation compared with nonobese patients undergoing plastic surgeries. However, this effect is not evident in reconstructive surgeries in areas of the body other than the breast.

Defining the Role for Topically Administered Tranexamic Acid in Panniculectomy Surgery

Background

Abdominal panniculectomy after weight loss is a commonly performed procedure with high patient satisfaction yet continues to have a high post-operative complication profile. Several risk-reducing surgical approaches, such as preservation of Scarpa’s fascia, use of tissue adhesives, and progressive tension suture techniques have been described. However, the use of tranexamic acid (TXA) has not been previously reported in panniculectomy surgery.

Objectives

To improve the safety and predictability of this procedure, the authors investigate whether the use of topically administered TXA during panniculectomy surgery reduces seroma, hematoma, and drain duration.

Methods

Consecutive patients who underwent panniculectomy (January 2010 to January 2022) were retrospectively reviewed. Outcome measures included hematoma requiring surgical evacuation, seroma requiring percutaneous aspiration, and drain duration. Patients with thromboembolic diseases and those taking anticoagulation/antiplatelet medications were excluded. Patients who had received TXA were compared with a historical control group who had not received TXA.

Results

A total of 288 consecutive patients were included. Topical TXA was administered in 56 (19.4%) cases. The mean (standard deviation [SD]) follow-up was 43.9 (37.4) months (3.7 years). The median (range) resection weight was 2.6 kg (0.15-19.96 kg). Regarding seroma and hematoma formation, the use of TXA did not reduce the likelihood of developing seroma or hematoma (odds ratio [OR] = 1.7, 95% CI [0.56- 4.8], P = 0.38 and OR = 2.1, 95% CI [0.4-11.8], P = 0.42), respectively. The mean (SD) duration of drains was slightly lower in the TXA group (18.1 [12.1] days vs 19.8 [13.9] days); however, this difference was not statistically significant, albeit clinically significant.

Conclusions

As the use of TXA in plastic surgical procedures continues to expand, the utility of TXA in panniculectomy and abdominoplasty has not been elucidated. Although previous studies report hematoma and seroma risk reduction, the use of TXA was not associated with a statistically significant reduction in seroma, hematoma, or drain duration following panniculectomy surgery. Prospective, randomized controlled studies on the use of TXA in body contouring are needed.

Level of Evidence: 3

"Abdominal panniculectomy: Identifying complications and potential risk factors"

BACKGROUND

The abdominal panniculectomy is a common procedure that patients choose to undergo for the purpose of restoring hygiene, reducing infection, and improving personal esthetic. A panniculectomy is often indicated after bariatric surgery, which defines a high-risk patient population. This study sought to better establish the association of known risk factors that can complicate the postoperative care of the panniculectomy patient, and whether or not bariatric surgery plays a role in the development of these complications.

METHODS

Patients that underwent a panniculectomy between 2010 and 2018 were identified in PearlDiver, a national insurance-claims database, and identified by CPT code 15,380. Patient demographics and associated medical problems were elucidated, and various complications were then identified. Descriptive statistics as well as a multivariate analysis were used to evaluate the association of risk factors and complications.

RESULTS

A total of 8,282 panniculectomy patients were identified. Of these, 1,420 underwent bariatric weight loss surgery prior to their panniculectomy, whereas the remaining 6,869 underwent a panniculectomy alone. Obesity, tobacco use, and diabetes were significant in developing a surgical site infection, wound disruption, and the need to undergo reoperation. Charlson Comorbidity Index greater than one (CCI>1), male gender, age greater than 60, COPD, and HTN identified as potential risk factors in developing various complications. Although patients with prior weight loss surgery had a history significant for prior comorbidities, the overall postoperative complication rate was decreased compared to those who did not undergo preoperative bariatric surgery.

CONCLUSION

In the face of the obesity epidemic, the incidence of undergoing a panniculectomy has increased significantly, particularly following bariatric surgery. Identifying potential risk factors in this patient population could better help identify postoperative complications following a panniculectomy and perhaps allow for targeted intervention and medical optimization prior to surgery.

Abdominal Panniculectomy: An Analysis of Outcomes in 238 Consecutive Patients over 10 Years

Panniculectomy is a commonly performed body contouring procedure to address skin laxity and its related complications. This study aimed to assess clinical outcomes of abdominal panniculectomy and identify predictors of complications at a tertiary academic healthcare center.

Methods

A retrospective review of patients who underwent panniculectomy between January 2010 and January 2020 at our institution was performed. Exclusion criteria were a history of prior panniculectomy or abdominoplasty. Patient characteristics and clinical outcomes were collected. Univariate and multivariable analyses were performed to assess the risk factors of complications.

Results

The mean age in the included 238 patients was 51.7 ± 12.7 years, and the mean body mass index (BMI) at the time of panniculectomy was 33 ± 7.5 kg/m². Median resection weight was 2.7 kg (range: 0.15-14.6) and median length of hospital stay was 2 days (range: 0-24). Mean follow-up time was 50 ± 37 months. The rate of major complications was 22.3%. Revision surgery was performed in 3.4% of the cases. Multivariable analyses demonstrated that increase in BMI (P = 0.007) and active smoking (P = 0.026) were significantly associated with increased odds of major complication, and increase in BMI (P = 0.0004), history of venous thromboembolism (P = 0.034) and having a concomitant ventral hernia repair (P = 0.0044) were significantly associated with having a length of hospital stay of 3 days or more.

Conclusions

Panniculectomy is generally safe to perform, with major postoperative complication rate of 22.3% in our series. Increase in BMI and active smoking were significantly associated with having a major complication. Higher BMI, concomitant hernia repair, and a history of venous thromboembolism were associated with length of hospital stay of 3 days or more.

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.

Panniculectomy Outcomes by Body Mass Index: an Analysis of 12,732 Cases

Purpose

With an increasing rate of obesity in the USA, bariatric surgery has become widespread, resulting in a greater number of patients seeking panniculectomy. The authors aim to determine the complication profile of panniculectomies by body mass index (BMI).

Methods

The 2012–2018 National Surgical Quality Improvement Program database was queried for all panniculectomy cases. Patients were assigned to a category by their calculated BMI. Rates of complications were compared across BMI ranges. Demographics, comorbidities, and perioperative factors were compared between those with and without complications. Multivariable analyses were performed to analyze the associations between BMI ranges and post-surgical complications.

Results

Twelve thousand seven hundred thirty-two cases were analyzed, of which 1759 (13.8%) had at least one postoperative complication. As BMI increased, patients were more likely to experience postoperative complications (p<0.001). Patients experiencing complications were more likely to be male, older, of a higher BMI group, have a higher American Society of Anesthesiologists Personal Status classification, be an inpatient, have various comorbidities, or be undergoing a concurrent procedure. On multivariable analysis, patients who were overweight (OR=1.24, p=0.039), with class 1 (OR=1.72, p<0.001), class 2 (OR=2.10, p<0.001), or class 3 (OR=3.01, p<0.001) obesity were more likely to have a postoperative complication. Wound complications were particularly prevalent in patients who were overweight (OR=1.77, p=0.001) or with class 1 (OR=2.59, p<0.001), class 2 (OR=4.05, p<0.001), or class 3 (p=5.84, p<0.001) obesity compared to non-overweight patients.

Conclusion

A higher BMI is associated with more postoperative complications, particularly wound healing complications, following panniculectomy in a dose-dependent manner.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05468-w.

Postoperative Complications of Panniculectomy and Abdominoplasty: A Retrospective Review

BACKGROUND

Recent studies of panniculectomy outcomes have reported variable complication rates ranging from 8.65% to 56%. Meanwhile, reported abdominoplasty complication rates are considerably lower (~4%). This discrepancy may be attributable to inaccurate inclusion of abdominoplasty patients in panniculectomy cohorts. We performed the current study to better characterize panniculectomy complication rates at a large tertiary care center.

METHODS

We performed a retrospective review of patients who underwent abdominoplasty or panniculectomy at the Johns Hopkins Hospitals between 2010 and 2017. Patients were identified by Common Procedural Terminology codes (15847/17999, 15830) confirmed via the operative note. We examined postoperative complication rates including surgical site infection, seroma formation, wound dehiscence, readmission/reoperation, and postoperative length of stay (LOS). We used parametric and nonparametric methods to determine differences between abdominoplasty and panniculectomy outcomes, as well as logistic regression analysis to evaluate factors associated with patient outcomes following panniculectomy.

RESULTS

Of the 306 patients included, 103 underwent abdominoplasty while 203 underwent panniculectomy. Initial complication rates following abdominoplasty and panniculectomy were 1.94% and 12.8%, respectively (P = 0.002). Thirty-day complication rates were 9.7% for abdominoplasty and 21.2% for panniculectomy (P = 0.012). The median LOS was 1 day (interquartile range, 0-1 day) for abdominoplasty and 2 days (interquartile range, 1-4 days) for panniculectomy (P = 0.002). No statistically significant differences in complication rates at 6 months and 1 year were observed.

CONCLUSIONS

Panniculectomy offers many functional benefits including improved hygiene and enhanced mobility. However, this study demonstrates that panniculectomy patients may have significantly higher complication rates initially and 30 days postoperatively and longer LOS than individuals undergoing abdominoplasty.

What Is the Impact of Residual Obesity on the Risk for Postoperative Body-Contouring Surgery Complications in Postbariatric Patients?

BACKGROUND

There are an increasing number of patients presenting for plastic surgery after massive weight loss, and many of these patients have residual obesity that may compromise outcomes. The impact of residual obesity on the development of postoperative complications in postbariatric patients undergoing plastic surgery procedures is unclear.

METHODS

We report the outcomes of 207 patients who underwent plastic surgery following RYGB from January 2011 to December 2018.

RESULTS

Two hundred and seven patients (196 females, 11 males) with a mean age of 42 years underwent 335 separate operations. The average BMI at the time of plastic surgery was 27.43 kg/m². The average weight loss was 47.08 kg. The prevalence of comorbidities was 26.6% and the most important presurgery comorbidities were arterial hypertension (10.1%) and diabetes mellitus (4.8%). Of the 207 patients who underwent surgery, 78.3% (168/207) underwent abdominoplasty and 45.0% underwent mammoplasty. The overall rate of complications was 27.5%. The prevalence of postoperative complications was not significantly different between patients with a BMI ≥ 30 kg/m² and patients with a BMI < 30 kg/m² (33.3% vs 25.9%, respectively; p = 0.344).

CONCLUSION

In this group of patients, with specified anthropometric and clinical profiles, the residual obesity did not influence the incidence of postoperative complications in postbariatric patients after plastic surgery.

Panniculectomy: Practical Pearls and Pitfalls

Panniculectomy is an increasingly common operation, given the current obesity epidemic and the increasing prevalence of bariatric surgery. At first glance, it could be considered a technically simple operation; however, this procedure can be fraught with complications, given the patient population and high demands placed on compromised abdominal tissue. Sufficient attention must be given to the nuances of patient optimization and surgical planning to maximize safe and ideal outcomes. We highlight our practical tips when performing standard or massive panniculectomy for preoperative optimization, intraoperative techniques, and postoperative management to reduce complication and maximize outcomes of this procedure from a surgeon's and a patient's perspective.

What Is the Impact of Comorbidities on the Risk for Postoperative Body-Contouring Surgery Complications in Postbariatric Patients?

BACKGROUND

There is an increasing number of patients presenting after massive weight loss for plastic surgery, and many of these patients have residual diseases that may compromise outcomes. This study aims to evaluate the impact of comorbidities on the development of postoperative complications in postbariatric patients undergoing plastic surgery procedures at the Federal District North Wing Regional Hospital, Brasília, Brazil.

METHODS

Descriptive, analytical, and prospective study was performed on patients who underwent plastic surgery following RYGB from January 2011 to December 2016. Measures included BMI (body mass index) before RYGB and before plastic surgery, medical complications and comorbidities.

RESULTS

One hundred thirty-nine patients (130 female, 9 male) with a mean age of 41 years underwent 233 separate operations. The average BMI at the time of plastic surgery was 27.44 kg/m². The average weight loss was 47.02 kg, and the mean pre-weight-loss BMI (max BMI) was 45.17 kg/m². The most important pre-plastic comorbidities were arterial hypertension (11.5%), degenerative arthropathy (5.4%), diabetes mellitus (5.0%), and metabolic syndrome (4.3%). Of the 139 patients operated upon, 76.97% underwent abdominoplasty followed by mammoplasty (42.46%). The overall rate of complications was 26.65%. Initially, on univariate regression analyses, comorbidities influenced the development of postoperative complications. However, after multiple logistic regression, the most important comorbidities failed to predict an increased risk of complications.

CONCLUSION

In this group of patients, with these anthropometric and clinical profiles, the most important comorbidities (diabetes, arterial hypertension, and metabolic syndrome) failed to influence the incidence of postoperative complications in postbariatric patients after plastic surgery.

Abdominal Contouring Outcomes in Class III Obesity: Analysis of the ACS-NSQIP Database

BACKGROUND

Obesity may increase the risk of complications following abdominal contouring. The aim of this study is to evaluate panniculectomy outcomes in patients with class III obesity (BMI > 40 kg/m²).

METHODS

The American College of Surgeon's National Surgical Quality Improvement Program ACS-NSQIP (2010-2014) was used to identify patients who underwent panniculectomy. Class III obesity patients were identified. Demographics, comorbidities and postoperative outcomes were evaluated. Risk-adjusted multivariate logistic regression analyses were performed to assess impact of class III obesity on panniculectomy outcomes.

RESULTS

A total of 4497 panniculectomies were identified. Of these, 545 (12.1%) were performed in patients with class III obesity. This group was older (mean age 50.3 vs. 45.9, p < 0.01) with a higher proportion of men (23.4 vs. 12.4%, p < 0.01). Class III obesity group also had higher rates of comorbidities (p < 0.01). Postoperatively, class III obesity patients experienced much higher rates of wound complications (17.8 vs. 6.8%), sepsis (3.3 vs. 0.8%), venous thromboembolism (1.5 vs. 0.7%) and medical complications (6.4 vs. 1.8%), p < 0.05. Additionally, this group had higher rates of unplanned reoperation (9.2 vs. 3.7%) and 30-day readmissions (3.5 vs. 1.0%), p < 0.01. On risk-adjusted multivariate regression analyses, class III obesity was independently associated with increased risk of wound complications (OR 2.22, p < 0.01), sepsis (OR 3.53, p < 0.01), medical adverse events (OR 1.98, p < 0.05), unplanned reoperation (OR 1.62, p < 0.05) and 30-day readmission (OR 2.30, p < 0.05).

CONCLUSION

Class III obesity patients are at significantly increased risk of adverse outcomes following abdominal contouring. Plastic surgeons should consider these risks for counseling and preoperative risk optimization.

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 .

Concomitant Panniculectomy Affects Wound Morbidity but Not Hernia Recurrence Rates in Abdominal Wall Reconstruction: A Propensity Score Analysis

BACKGROUND

Studies of abdominal wall reconstruction with concurrent panniculectomy have reported contradictory results. The authors hypothesized that patients undergoing abdominal wall reconstruction with concurrent panniculectomy experience more wound healing complications but similar rates of hernia recurrence compared with abdominal wall reconstruction alone.

METHODS

Of 548 consecutive patients, 305 patients (55.7 percent) underwent abdominal wall reconstruction alone and 243 (44.3 percent) underwent abdominal wall reconstruction with concurrent panniculectomy. Mean follow-up was 30 months. The authors compared these two groups' postoperative complications and outcomes before and after propensity score analysis.

RESULTS

Abdominal wall reconstruction with concurrent panniculectomy patients had a significantly higher overall complication rate (38.3 percent versus 29.2 percent; p = 0.025) and a trend toward a higher surgical-site occurrence rate (27.6 percent versus 20.7 percent; p = 0.06) compared with abdominal wall reconstruction alone. There were significantly higher incidences of skin dehiscence (19.3 percent versus 12.5 percent; p = 0.032), fat necrosis (10.7 percent versus 3.6 percent; p = 0.002), and infection abscess (9.5 percent versus 4.3 percent; p = 0.023) but no significant difference in hernia recurrence (6.9 percent versus 11.5 percent; p = 0.27) at long-term follow-up. Propensity score analysis yielded 188 pairs of matched patients with no significant differences in overall complication and hernia recurrence rates. Significantly higher rates of fat necrosis (9.6 percent versus 4.3 percent; p = 0.041) and abscess (10.1 percent versus 3.2 percent; p = 0.007) were observed in the abdominal wall reconstruction with concurrent panniculectomy group.

CONCLUSIONS

Abdominal wall reconstruction with concurrent panniculectomy is associated with higher wound morbidity but similar surgical-site occurrence and hernia recurrence rates at long-term follow-up. The authors believe that panniculectomy can be safely performed when indicated.

Impact of Metabolic Syndrome on the Morbidity and Mortality of Patients Undergoing Panniculectomy

BACKGROUND

Metabolic syndrome (MetS) is defined as the concomitant disease process of obesity and at least two of the following variables: diabetes, hypertension, hypertriglyceridemia, or reduced high-density lipoprotein. These entities are well established as risk factors for complications following surgery. Obese patients are particularly prone to the development of MetS. The authors therefore aimed at elucidating the impact of MetS on the perioperative panniculectomy outcomes.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was analyzed for all primary procedures of panniculectomy from 2010 through 2015. The cases were stratified based on the presence or absence of MetS and evaluated for demographic data, intraoperative details, and their morbidity and mortality within 30 days after surgery.

RESULTS

A total of 7030 cases were included in this study. Patients with MetS (6.2%) were of significantly worse health, required more emergency admissions (p = 0.022), longer hospitalization (p < 0.001), and more frequently inpatient procedures (p < 0.001) compared to the control group without MetS (3.8%). Plastic surgery was the predominant specialty operating on 79.5% of all cases. Surgical (23.3 vs. 8.7%) complications, readmission (8.7 vs. 3.0%), and reoperations (6.9 vs. 3.1%) rates were all significantly higher in patients with MetS that those without (p < 0.001). One fatality occurred in each cohort (0.23 vs. 0.02%, p = 0.010).

CONCLUSION

Comorbidities are not uncommon in patients undergoing panniculectomy, especially in those diagnosed with MetS. Health-care providers need to be aware of the increased morbidity and mortality in this high-risk subgroup and need to consider preoperative optimization and management before proceeding with surgery.

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 .

Surgical Site Occurrences of Simultaneous Panniculectomy and Incisional Hernia Repair

Horizontal panniculectomy (PAN) offers the advantage of wide exposure for hernia repair with elimination of excess skin and adiposity, at the expense of massive subcutaneous flap creation and its attendant risks. We report our experience with ventral hernia repair (VHR) with PAN compared with patients with hernia repair alone. A prospective database was reviewed retrospectively for all patients undergoing open VHR + PAN. A matched cohort of patients without PAN was used for comparison, resulting in 43 study and 43 control patients. Incidence of surgical site occurrences (SSO), surgical site infection (SSI), and recurrence were analyzed. A total of 43 patients underwent PAN + VHR with mesh. Mean body mass index was 34.3 kg/m2, with 35 per cent having undergone prior bariatric surgery. Repair techniques included retromuscular (74.4%), preperitoneal (11.6%), intraperitoneal (6.9%), onlay (4.6%), and suture (2.3%). Mesh used was polypropylene (76.7%), polyester (18.6%), bioabsorbable (2.3%), and polytetrafluoroethylene (ePTFE) (2.3%). Component separation was performed in 44.2 per cent of patients. There was a significant difference in total SSO between PAN + VHR and VHR alone (46.5% vs 27.9%; P < 0.001), though the difference for individual SSOs was not significant. There was no difference in SSI between groups (16.3% vs 20.9%; P = 0.776). Mean follow-up was 11.4 months, with recurrence rate of 11.6 per cent in the PAN group and 9.3 per cent in the control group ( P = 0.725). Panniculectomy at the time of VHR does not increase the incidence of SSI, though higher rates of skin necrosis and cellulitis were seen. There is no difference in recurrence. This approach is a valid option for patients with excessive abdominal panniculus requiring VHR.

"Supersize" panniculectomy: indications, technique, and results

BACKGROUND

Obesity remains a significant health problem associated with considerable morbidity and mortality. Panniculectomy in the obese patient population aims at treating complications related to excess abdominal skin in an attempt to improve quality of life, increase mobility, and potentially prepare the patient for subsequent bariatric surgery or enrollment in a weight-loss program. We describe the indications and outcomes of "supersize" panniculectomy in the extreme obesity patient population.

PATIENTS AND METHODS

A Duke University institutional review board-approved retrospective chart review of patients who underwent a "supersize" panniculectomy by a single surgeon during a 6-year period was conducted. Data on patient demographics, operative indication, preoperative imaging, concomitant operations, and postoperative complications were collected.

RESULTS

Twenty-six patients underwent a "supersize" panniculectomy for indications including immobility secondary to excess abdominal skin, panniculitis, ventral hernia, and presence of a gynecologic tumor. The mean pannus resection weight was 15.6 kg and the mean follow-up was 15.7 months. Twelve patients underwent preoperative abdominal computed tomographic imaging. Eleven patients underwent concomitant surgical procedures at the time of their panniculectomy. The overall wound complication rate for the "supersize" panniculectomy was 42.3% (11/26 patients). However, the rate of major complications, defined as those complications requiring a return to the operating room, was only 11.5% (3/26 patients).

CONCLUSIONS

"Supersize" panniculectomy is defined as a panniculectomy in the obese patient population with a resected pannus specimen weight greater than or equal to 10 kg, and a pannus formation that extends to the mid-thigh level or below. Despite the obstacles and reported high complication rates, the incidence of major complications in this series justifies the operative intervention in patients with an otherwise therapy-resistant "supersize" pannus. A preoperative computed tomographic imaging may rule out an underlying hernia in most cases and is recommended by the authors.

Impact of the Establishment of a Specialty Hernia Referral Center

Background. Creating a surgical specialty referral center requires a strong interest, expertise, and a market demand in that particular field, as well as some form of promotion. In 2004, we established a tertiary hernia referral center. Our goal in this study was to examine its impact on institutional volume and economics. Materials and methods. The database of all hernia repairs (2004-2011) was reviewed comparing hernia repair type and volume and center financial performance. The ventral hernia repair (VHR) patient subset was further analyzed with particular attention paid to previous repairs, comorbidities, referral patterns, and the concomitant involvement of plastic surgery. Results. From 2004 to 2011, 4927 hernia repairs were performed: 39.3% inguinal, 35.5% ventral or incisional, 16.2% umbilical, 5.8% diaphragmatic, 1.6% femoral, and 1.5% other. Annual billing increased yearly from 7% to 85% and averaged 37% per year. Comparing 2004 with 2011, procedural volume increased 234%, and billing increased 713%. During that period, there was a 2.5-fold increase in open VHRs, and plastic surgeon involvement increased almost 8-fold, ( P = .004). In 2005, 51 VHR patients had a previous repair, 27.0% with mesh, versus 114 previous VHR in 2011, 58.3% with mesh ( P < .0001). For VHR, in-state referrals from 2004 to 2011 increased 340% while out-of-state referrals jumped 580%. In 2011, 21% of all patients had more than 4 comorbidities, significantly increased from 2004 ( P = .02). Conclusion. The establishment of a tertiary, regional referral center for hernia repair has led to a substantial increase in surgical volume, complexity, referral geography, and financial benefit to the institution.