Influences of Age, Gender, and Body Mass Index on the Thickness of the Abdominal Fatty Layers and its Relevance for Abdominal Liposuction and Abdominoplasty.

BACKGROUND: Liposuction and lipoabdominoplasty procedures frequently involve the treatment of the superficial and deep fatty layers of the abdomen. OBJECTIVES: The aim of the present investigation was to provide comprehensive data on the thickness of the abdominal fatty layers in relation to age, gender, and body mass index (BMI). METHODS: The study investigated 150 Caucasian individuals; there was an equal distribution of males and females (each n = 75) and a balanced distribution of age (n = 30 per decade: 20-29, 30-39, 40-49, 50-59, and 60-69 years) and BMI (n = 50 per group: BMI ≤24.9, 25.0-29.9, and ≥30 kg/m2). Ultrasound-based measurements of the superficial and deep abdominal fatty layers were performed. RESULTS: An increase in BMI was associated with an increase in total abdominal wall fat thickness. The measured increase was related more to the thickness of the deep fatty layer than to the thickness of the superficial fatty layer (Z = 1.80, P = 0.036). An increase in age was associated with a decrease in thickness of the superficial fatty layer (rp = -0.104, P = 0.071) but with an increase in thickness of the deep fatty layer (rp = 0.197, P = 0.001). CONCLUSIONS: Age and BMI can change the thickness of both the superficial and deep fatty layers of the anterior abdominal wall, thus influencing the plan and conduct of cosmetic surgical procedures. Knowledge of the layered anatomy of the anterior abdominal wall, as well as its associated blood supply, is important for surgeons performing procedures in this area.

Ultrasound Assessment of Subcutaneous Abdominal Fat Thickness After Treatments With a High-Intensity Focused Electromagnetic Field Device: A Multicenter Study.

BACKGROUND: High-intensity focused electromagnetic (HIFEM) technology is intended for muscle toning, firming, and strengthening. OBJECTIVE: The goal of this study is to quantify the effect of HIFEM treatments on subcutaneous fat. MATERIALS AND METHODS: A total of 33 patients participated in the study. Each subject underwent 4 treatments on the abdomen with the HIFEM device. Ultrasound images were obtained measuring the thickness of the subcutaneous fat from 4 standardized measurement points. Ultrasound images were taken before treatment and at 1-month and 3-month follow-up visits. Photographs were captured using both 2D and 3D cameras. Weight measurements were taken, as well as surveys assessing both patient comfort, satisfaction, and adverse events. RESULTS: A significant reduction in the subcutaneous fat thickness across the abdomen was observed, averaging 19.0%/4.47 ± 3.23 mm (p < .01) at 1 month after treatment and 23.3%/5.78 ± 4.07 mm 3 months after treatment. At 1 month, the most significant reduction in subcutaneous fat was measured subumbilically (26.6%/6.25 ± 4.70 mm; p < .01) and epiumbilically (21.6%/5.08 ± 3.69 mm; p < .01). No discomfort was reported, and 91% of study participants were satisfied with their result. CONCLUSION: Based on the ultrasonographic and photographic observations, the authors conclude that the application of an HIFEM field is an effective option for the noninvasive treatment of subcutaneous fat.

Change in visceral adiposity is an independent predictor of future arterial pulse pressure.

OBJECTIVES: Pulse pressure (PP), a marker of arterial stiffness, and body composition are both risk factors for cardiovascular disease. Little is known about whether changes in body composition may be linked to future PP. We sought to determine whether change in amount of abdominal and thigh fat over 5 years predicted PP at 10 years. METHODS: Visceral fat as well as abdominal and thigh subcutaneous fat areas were measured by computed tomography at baseline and 5 years later in 284 Japanese Americans (mean age 49.3 years; 50.4% men) without hypertension, heart disease, and glucose-lowering medication use at baseline. PP at 10 years was calculated as the difference between SBP and DBP measured with a mercury sphygmomanometer. The association between change in fat at 5 years and arterial PP at 10 years, adjusted for baseline PP, was examined using linear regression analysis. MAIN RESULTS: Change in abdominal visceral fat area at 5 years was positively associated with 10-year PP independent of sex, 5-year change in BMI, and baseline age, BMI, PP, abdominal visceral fat, smoking status, alcohol consumption, physical activity, homeostasis model assessment insulin resistance, and fasting plasma glucose. There were no significant associations between baseline amounts or change in abdominal or thigh subcutaneous fat areas and future PP. CONCLUSION: The accumulation of abdominal visceral fat over time independently predicted future PP in Japanese Americans.

Estimation of DIEP flap weight for breast reconstruction by the pinch test.

BACKGROUND: Various methods have been introduced for estimating deep inferior epigastric artery perforator (DIEP) flap volume based on computed tomography or magnetic resonance angiographic images. However, when radiologic images cannot be obtained, estimations are subjective. The purpose of this study was to develop a prediction model for estimating DIEP flap weight using the pinch test. METHODS: The pinch test was performed at three paraumbilical sites using a skin-fold caliper in 107 consecutive patients who underwent DIEP flap breast reconstruction. Multiple linear regression analysis was used to develop a formula to estimate flap weight. Predictor variables included body mass index (BMI, kg/m2 ), flap height (H, cm), flap width (W, cm), and flap thickness (mm) measured by the pinch test at the following three paraumbilical sites: 5 cm right (R), left (L), and inferior (I) of the umbilicus. The model accuracy was tested using leave-one-out cross-validation. RESULTS: A prediction model was developed from the multiple regression analysis (R2 = 89.03%, P < .001); flap weight, g = -1308 + 24.57 × BMI + 6.80 × (R + L)/2 + 7.89 × I + 20.51 × H + 32.55 × W. The formula was implemented in a smartphone application, DIEP-W version 2.0, for real-time use. The mean absolute percentage error in the cross-validation was 12.15%. CONCLUSIONS: DIEP flap weight can be estimated by the pinch test with the developed prediction model in an easy, cost-effective, and relatively accurate manner. This method will improve surgical planning and allow surgeons to provide better counselling for patients when radiologic images are not available.

DIEP flap for breast reconstruction: Is abdominal fat thickness associated with post-operative complications?

INTRODUCTION: Some surgeons consider a high body mass index (BMI) or important abdominal fat excess as contraindications for breast reconstruction with free deep inferior epigastric perforator (DIEP) flap. This study aimed to identify factors associated with post-operative complications by using this type of flap, with an emphasis on BMI and abdominal subcutaneous fat thickness. METHODS: A retrospective chart review of 105 consecutive patients who underwent DIEP flap breast reconstruction at our institution was performed to assess post-operative complications. Among other risk factors, we specifically studied the influence of BMI and abdominal wall thickness on complication occurrence. Abdominal wall thickness was measured at 10 different points on the angio-computed tomography scan performed pre-operatively. RESULTS: Median age was 49.8 years (range, 27-69); average BMI was 25.57 kg/m2 (range, 18.07-41.91). Immediate breast reconstruction was performed for 35% of patients, and five patients (4.7%) underwent bilateral reconstruction. Twenty-six patients (24.8%) presented 29 post-operative complications; 12 concerned abdominal complications (delayed wound healing [n = 6] and seroma [n = 6]) and 17 were related to complications of the reconstructed breast (six minimal necrosis treated conservatively, eight minor necrosis requiring surgical debridement and three total flap loss). The complication rate was not correlated with increased BMI or abdominal wall thickness. The only factor that significantly predicts DIEP flap complications was pre-operative radiotherapy (odds ratio = 4.05; p = 0.03). CONCLUSIONS: No significant correlation was observed between BMI of 25-35 kg/m2 or abdominal wall thickness and post-operative complications of the donor site or DIEP flap. Therefore, these factors should not be considered as contraindication criteria.

Redefining abdominal anatomy: 10 key elements for restoring form in abdominoplasty.

While traditional abdominoplasty methods can successfully achieve the objective of restoring a flat appearance, the results can be artificially board-like, lacking the subtle anatomical features of a three-dimensional abdomen, thus creating the potential for patient dissatisfaction. While often difficult to articulate, patient criticism is almost always distilled to the ubiquitous concern that the surgical abdomen lacks the natural features of an authentic, youthful abdomen. In an effort to provide a more anatomically accurate outcome and improve patient satisfaction, I have made a series of technical modifications to the abdominoplasty that I now perform. Ten key technical refinements, including a modified "Anatomy Defining" Progressive Tension Suture technique, were successively incorporated in 177 patients during the first 5 years of 2000-2014. All have been applied consistently in 961 abdominoplasty procedures during the subsequent 10 years, often accompanied by liposuction of adjacent lateral (non-abdominal) areas to ensure harmonious proportion. This series of refinements adds precision and detail by redefining the native anatomical nuances of the abdomen, an aesthetic objective that has been consistently achieved in BMI ranges between 20 and 35. Overall satisfaction with results was high (94%). The 10 elements described are safe, effective, and lasting.

Morphometric study (macroscopic and microscopic) of the lower abdominal wall.

BACKGROUND: Abdominoplasty using a more superficial plane of dissection has several advantages. Previous studies described a trilaminar structure (superficial and deep fat compartments separated by the Scarpa fascia) in the lower abdominal wall. This study aimed to gain a clearer understanding of compartment dominance and changes with increasing adiposity. METHODS: The study was performed on the surgical specimens of 41 female patients submitted to a full abdominoplasty. A morphometric study was performed on 82 sides to evaluate the thickness of the fat layers at predetermined locations (point A over the external oblique muscle and point B over the rectus abdominis muscle). A histologic study was performed in 31 samples to analyze the structure of the fat compartments and Scarpa fascia. RESULTS: A trilaminar structure was always present, and the Scarpa fascia did not become vestigial with increasing adiposity. Total thickness at point B was significantly higher than that at point A; this difference was mainly attributable to the superficial compartment. The deep fat compartment was always thinner than the superficial, corresponding to 25 percent of total thickness in point A and 23 percent in point B. It was less susceptible to an increase in thickness in cases of obesity. Histologic analysis demonstrated constant morphology, with an average Scarpa fascia thickness of 0.29 mm (point A) and 0.28 mm (point B). CONCLUSIONS: This study demonstrates a trilaminar structure with superficial compartment dominance and Scarpa fascia presence irrespective of adiposity in the lower abdominal wall. The deep fat compartment has a minor contribution to the lower abdominal wall thickness.

"The umbilical fat sign": an important and consistent landmark during single port/incision laparoscopic surgery and standard laparoscopy.

INTRODUCTION: During single port laparoscopic surgery (SPLS), access is obtained through the umbilicus and the scar is hidden within the scar of the umbilicus for providing good cosmesis. It is essential that the incision be well planned so as to get the maximum exposure through the umbilical incision. The umbilical fat sign is an important landmark to achieve this. PURPOSE: The aim of this study is to retrospectively review importance of the umbilical fat sign as a landmark for peritoneal access during SPLS in children. METHOD: A retrospective chart review of 57 children (33 males and 24 females) who underwent single port access surgery at Texas Children's Hospital from April 2009 to December 2010 was conducted. The median age of the patients was 10.8 years, ranging from 4 to 17 years. TECHNIQUE: The limits of the umbilicus were marked using a marking pen. A vertical incision is made through the center of the umbilical scar. It is of vital importance to maintain the incision in the exact center of the scar tissue. Skiving away from the center makes the entry in the peritoneal cavity harder and prolongs peritoneal access time. During all the single port cases, we have done so far we have noted that if we are in the center of the scar then we always see a blob of fat ("umbilical fat" sign) in the center. If we use a probe or grooved director through this fat direct access is obtained in the peritoneal cavity. Incision can then be extended on both sides and be kept to the limits of the umbilical ring. Peritoneal access can be obtained in 1 to 2 minutes using this approach. Umbilical reconstruction is the best performed with this approach. RESULTS: One child developed signs of wound infection and was treated successfully with antibiotics for 5 days. Scars healed well in all cases with no wound dehiscence. No umbilical scars were visible at follow-up (3 to 4 weeks postoperatively). CONCLUSION: Umbilical fat sign is an important landmark for surgeons during SPLS for direct and quick peritoneal access and better reconstruction of the umbilicus.

Quantitation of the results of abdominal liposuction.

BACKGROUND: There are few objective techniques to accurately measure the outcome of liposuction. Consequently, there is also a paucity of data quantifying the results of this procedure. OBJECTIVES: The authors compare changes in abdominal volume and circumference with several objective measurement techniques in a relatively homogeneous group of individuals undergoing liposuction in a single, defined abdominal region. METHODS: This clinical study enrolled 23 patients with a body mass index (BMI) <25 kg/m(2) who had a localized anterior abdominal contour defect. Patients underwent standard suction-assisted tumescent liposuction. Changes in abdominal volume and circumference in the operative area (60 mm above to 80 mm below the umbilicus) preoperatively and 10 weeks postoperatively were assessed using a 3-dimensional (3D) digital photographic system and a standardized constant-tension manual tape measure procedure. RESULTS: The majority of the patients in this study were Caucasian women with a mean age of 42 years, a mean weight of 65.8 kg, and a mean BMI of 23.8 kg/m(2). In the study population, mean abdominal volume and umbilical circumference were reduced by 231.0 mL (~30% of subcutaneous fat) and 1.7 cm, respectively, at 10 weeks postoperatively as determined by 3D digital imaging. Fat volume in the surgical aspirate (mean = -183.3 mL) was a poor predictor of individual outcome, as assessed 10 weeks postoperatively by both the 3D digital imaging and multilevel constant-tension tape measure assessment tools. CONCLUSIONS: Both 3D digital photographic imaging and a standardized manual tape measurement procedure proved to be reliable tools for objectively assessing changes in abdominal circumference and volume produced by standard liposuction of a single, defined abdominal region.

Cellularity and adipogenic profile of the abdominal subcutaneous adipose tissue from obese adolescents: association with insulin resistance and hepatic steatosis.

OBJECTIVE: We explored whether the distribution of adipose cell size, the estimated total number of adipose cells, and the expression of adipogenic genes in subcutaneous adipose tissue are linked to the phenotype of high visceral and low subcutaneous fat depots in obese adolescents. RESEARCH DESIGN AND METHODS: A total of 38 adolescents with similar degrees of obesity agreed to have a subcutaneous periumbilical adipose tissue biopsy, in addition to metabolic (oral glucose tolerance test and hyperinsulinemic euglycemic clamp) and imaging studies (MRI, DEXA, (1)H-NMR). Subcutaneous periumbilical adipose cell-size distribution and the estimated total number of subcutaneous adipose cells were obtained from tissue biopsy samples fixed in osmium tetroxide and analyzed by Beckman Coulter Multisizer. The adipogenic capacity was measured by Affymetrix GeneChip and quantitative RT-PCR. RESULTS: Subjects were divided into two groups: high versus low ratio of visceral to visceral + subcutaneous fat (VAT/[VAT+SAT]). The cell-size distribution curves were significantly different between the high and low VAT/(VAT+SAT) groups, even after adjusting for age, sex, and ethnicity (MANOVA P = 0.035). Surprisingly, the fraction of large adipocytes was significantly lower (P < 0.01) in the group with high VAT/(VAT+SAT), along with the estimated total number of large adipose cells (P < 0.05), while the mean diameter was increased (P < 0.01). From the microarray analyses emerged a lower expression of lipogenesis/adipogenesis markers (sterol regulatory element binding protein-1, acetyl-CoA carboxylase, fatty acid synthase) in the group with high VAT/(VAT+SAT), which was confirmed by RT-PCR. CONCLUSIONS: A reduced lipo-/adipogenic capacity, fraction, and estimated number of large subcutaneous adipocytes may contribute to the abnormal distribution of abdominal fat and hepatic steatosis, as well as to insulin resistance in obese adolescents.

Avaliação da reprodutibilidade ultrassonográfica como método para medida da gordura abdominal e visceral / Reproducibility of ultrasonography as a method to measure abdominal and visceral fat

OBJETIVO: O objetivo deste estudo é avaliar a variabilidade interobservador do método ultrassonográfico para medida da gordura subcutânea, visceral e perirrenal por meio de técnica padronizada. MATERIAIS E MÉTODOS: Foram avaliados 50 pacientes entre novembro de 2006 e janeiro de 2007. A medida da espessura subcutânea foi realizada com transdutor linear de 7,5 MHz posicionado transversalmente a 1 cm acima da cicatriz umbilical. Para a gordura visceral foi utilizado transdutor de 3,5 MHz posicionado 1 cm acima da cicatriz umbilical, considerando-se a medida entre a face interna do músculo reto abdominal e a parede posterior da aorta na linha média do abdome. A gordura perirrenal foi medida no terço médio do rim direito, com transdutor posicionado na linha axilar média. RESULTADOS: A reprodutibilidade interobservador foi analisada por meio do teste t de Student, com significância de 95 por cento. Não houve diferença significativa entre as médias das medidas das gorduras subcutânea, visceral e perirrenal, com p = 0,7141, 0,7286 e 0,6368, respectivamente. As médias encontradas, com seus respectivos desvios-padrão, foram: 2,64 ± 1,37 para a espessura subcutânea, 6,84 ± 2,38 para a espessura visceral e 4,89 ± 2,6 para a espessura perirrenal. CONCLUSÃO: A ultrassonografia apresentou boa reprodutibilidade interobservador para avaliação da gordura abdominal por meio das medidas das espessuras subcutânea, visceral e perirrenal.

OBJECTIVE: The purpose of this study was to evaluate the interobserver variability of ultrasound in the measurement of subcutaneous, visceral and perirenal fat through standard technique. MATERIALS AND METHODS: From November 2006 to January 2007, 50 patients were evaluated. The subcutaneous fat thickness was measured with a 7.5 MHz linear transducer transversely positioned 1 cm above the umbilical scar. For the visceral fat, a 3.5 MHz transducer was also positioned 1 cm above the umbilical scar, considering the distance between the internal surface of the abdominal rectus muscle and the posterior aortic wall in the abdominal midline. The perirenal fat was measured in the middle third of the right kidney, with the transducer positioned at the axillary midline. RESULTS: The t-Student test was utilized to analyze the interobserver reproducibility with significance level of 95 percent. No statistically significant difference was observed among mean values for subcutaneous, visceral and perirenal fat (p = 0.7141, 0.7286 and 0.6368, respectively). Mean and standard deviation corresponded to 2.64 ± 1.37 for subcutaneous thickness, 6.84 ± 2.38 for visceral fat, and 4.89 ± 2.6 for perirenal fat. CONCLUSION: Ultrasound presented a good interobserver reproducibility in the evaluation of abdominal fat based on measurement of subcutaneous, visceral and perirenal fat as parameters.

The contribution of breast and abdominal pannus weight to body mass index: implications for rationing of reduction mammaplasty and abdominoplasty.

The body mass index (BMI) is an arbitrary criterion used by third party fundholders in some countries for rationing the public funding of reduction mammaplasty and abdominoplasty surgery. Many patients have commented that the weight of their excess breast tissue or abdominal pannus contributes to an overestimation of their body mass index. This study seeks to establish the truth of this by ascertaining whether the difference between pre- and postoperative body mass indices of patients undergoing reduction mammaplasty or abdominoplasty is significant. Case notes of 30 sequential reduction mammaplasty patients and 16 abdominoplasty patients were analyzed to ascertain their preoperative weight, height, calculated BMI, and the mass of the breast reduction or abdominal resection specimen as measured in theater. This information was used to retrospectively calculate the difference the weight of the specimen would have made to their BMI. Overall, the difference between pre- and postoperative BMI is not statistically significant (reduction mammaplasty P = 0.22; abdominoplasty P = 0.62, 2-tailed t test). However, the largest contribution breast reduction and abdominoplasty resection specimens made to the BMI in our series was 1 and 2.4, respectively. We suggest that it may be appropriate to consider a minority of patients for surgery if their BMI is within 1.0 (for breast reduction) or 2 (for abdominoplasty) of any set target BMI, and highlight the specific patient subpopulations to which this is most applicable. An estimate of resection weight preoperatively may allow a "corrected" BMI to be used for determining eligibility for surgery.