Abdominoplasty with Combined Surgery.

Abdominoplasty is the fifth most common cosmetic plastic surgery procedure performed in the United States and combining it with other procedures has become more the norm than the outlier. Liposuction is the most common adjunctive procedure, followed by breast surgery, lower back lift, and thigh lift, in addition to hernia repair and gynecologic procedures. The goal of these combination procedures includes creating more global aesthetic improvement while protecting patients from complications, based on consideration of confounding medical variables and increased risks presented by surgery of prolonged duration and exposure.

An outcomes analysis of 2142 breast reduction procedures.

BACKGROUND: Breast reduction alleviates macromastia symptoms and facilitates symmetrical breast reconstruction after cancer treatment. We investigated a large series of consecutive breast reductions to study important factors that impact outcomes. METHODS: An institutional review board-approved, retrospective review of all breast reductions from 1999 to 2009 in a single institution was performed using the medical record for demographics, medical history, physical examination, intraoperative data, and postoperative complications. Multivariate statistical analysis was performed using Stata 1.0. P ≤ 0.05 defined significance. RESULTS: Seventeen surgeons performed 2152 consecutive breast reductions on 1148 patients using inferior pedicle/Wise pattern (56.4%), medial pedicle/Wise pattern (16.8%), superior pedicle/nipple graft/Wise pattern (15.1%), superior pedicle/vertical pattern (11.6%), and liposuction (0.1%) techniques. Complications included discernible scars (14.5%), nonsurgical wounds (13.5%), fat necrosis (8.2%), infection (7.3%), wounds requiring negative pressure wound therapy or reoperation (1.4%), and seroma (1.2%). Reoperation rates were 6.7% for scars, 1.4% for fat necrosis, and 1% for wounds.Body mass index greater than or equal to 35 kg/m increased risk of infections [odds ratio (OR), 2.3, P = 0.000], seromas (OR, 2.9, P = 0.03), fat necrosis (OR, 2.0, P = 0.002), and minor wounds (OR, 1.7, P = 0.001). Cardiac disease increased reoperation for scar (OR, 3.0, P = 0.04) and fat necrosis (OR, 5.3, P = 0.03). Tobacco use increased infection rate (OR, 2.1, P = 0.008). Secondary surgery increased seromas (OR, 12.0, P = 0.001). Previous hysterectomy/oophorectomy increased risk of wound reoperations (OR, 3.4, P = 0.02), and exogenous hormone supplementation trended toward decreasing infections (OR, 0.5, P = 0.08). χ analysis revealed 7.8% infection risk without exogenous hormone versus 3.8% risk with hormone supplementation (P = 0.02). CONCLUSIONS: Morbid obesity, tobacco, cardiac history, and secondary surgery negatively impacted breast reduction outcomes. Hormonal status impacted reoperations and infections.

Aesthetic refinements in body contouring in the massive weight loss patient: Part 2. Arms.

BACKGROUND: The literature has witnessed an evolution in brachioplasty technique since the procedure was introduced by Thorek in 1930. Aesthetic refinements in brachioplasty have been increasingly described in the literature, and this has paralleled the rise in the massive weight loss population. The aim of this review is to share the plastic surgery experience with this challenging body region and present different approaches to achieve the best results for a broad spectrum of patients. METHODS: A literature review studying brachioplasty was performed through PubMed. Throughout the literature there has been debate about scar placement, scar length, application of liposuction, drain placement, and optimization of outcomes, and differences of opinion have been compared. RESULTS: There is no definitive best method of brachioplasty, as evidenced by multiple classification systems which present algorithms for management depending on presentation. Not only does approach differ depending on degree of presentation, but there are also different approaches depending on author for similar manifestations. Approaches vary through incision length, incision placement, and use of liposuction. Outcomes studies similarly reveal lack of consensus. CONCLUSION: This literature review has elucidated multiple approaches to brachioplasty, and the pearls and pitfalls described may all be incorporated to produce excellent outcomes and patient satisfaction in an individualized approach.

The application of barbed sutures in body contouring surgery.

Even with the evolution of primary surgical techniques in body contouring, wound closure remains primarily traditional and has not advanced beyond the techniques followed in past decades. Streamlining wound closure would be the next advance for body contouring surgery. Absorbable barbed sutures offer a potential solution, and they are the subject of this review investigating the applications of absorbable barbed sutures in body contouring surgery. Barbed sutures hold tension as closure proceeds, theoretically decreasing the time required for wound closure, approximating dead space, and obliterating subcutaneous knots that may result in palpable, painful granulomas. Review of the literature reveals some evidence of time savings (in some cases significant and, in some, not); however, the literature also shows some wound complications from the use of barbed sutures, including infections and extrusions. Barbed sutures have not yet been conventionally embraced, and the technology will certainly continue to evolve in order to make the devices more desirable for plastic surgeons.

Pearls and perils of caring for the postbariatric body contouring patient.

Postbariatric body contouring surgery has grown in prevalence, mirroring the ascent of weight loss surgery. With the rise in prevalence of this subset of plastic surgery procedures, we are gaining wisdom about technique, safety, and outcomes associated with this patient population. The pearls of patient management include discussion about characteristics specific to massive weight loss patients, patient preparation for surgery, intraoperative safety measures, markings, surgical options in a landscape of scars, management of the total body lift, volumetric augmentation, and postoperative care. The aim of this review is to share these pearls and pitfalls to assist in patient management and in optimization of outcomes.

Body contouring.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. List patient selection factors for body lift surgery. 2. Describe operative approaches for brachioplasty, upper body lift, abdominoplasty, lower body lift, and thigh lift. 3. Identify complications and pitfalls related to body lifting and describe how to avoid them. SUMMARY: The author discusses the preoperative assessment, surgical treatment plan, postoperative management, outcomes, and possible complications for a comprehensive spectrum of body-contouring surgical procedures. Preoperative planning includes medical history and physical examination, along with an open discussion with the patient. Surgical procedures for brachioplasty, upper back lift, abdominoplasty, lower back lift, gluteal augmentation and thigh lift are discussed. Postoperative management pearls are shared, as well as pitfalls to be avoided.

Increasing age impairs outcomes in breast reduction surgery.

BACKGROUND: Although multiple breast reduction outcomes studies have been performed, none has specifically identified the impact of advanced age. The authors aimed to study the impact of age on breast reduction outcome. METHODS: Medical records for all patients billed for Current Procedural Terminology code 19318 over the past 10 years (1999 to 2009) at a large academic institution were analyzed under an institutional review board-approved protocol. A total of 1192 consecutive patients underwent 2156 reduction mammaplasties performed by 17 plastic surgeons over a 10-year period. Breast reduction techniques included inferior pedicle/Wise pattern in 1250 patients (58.9 percent), medial pedicle/Wise pattern in 360 (16.9 percent), superior pedicle/nipple graft in 305 (14.4 percent), superior pedicle/vertical pattern in 206 (9.7 percent), and liposuction in three (0.14 percent). The average patient age was 36 years. Age groups were divided into younger than 40 years, 40 to 50 years, and older than 50 years. Multiple logistic regression analysis was performed to identify significant relationships. RESULTS: Women older than 50 years more likely experienced infection (odds ratio, 2.7; p = 0.003), with trends toward wound healing problems (odds ratio, 1.6; p = 0.09) and reoperative wound débridement (odds ratio, 5.1; p = 0.07). There was a trend toward infection in women aged 40 to 50 years (odds ratio, 1.7; p = 0.08). Advanced age did not exacerbate fat necrosis or seroma development. CONCLUSIONS: Age older than 50 years impairs breast reduction outcomes, particularly infection, and may negatively impact wound healing. Hormonal deficiency may partially account for this finding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Preventing liposuction complications.

Liposuction is one of the most common surgical procedures performed by plastic surgeons. According to the latest American Society of Plastic Surgeons statistics, over 245,000 liposuction procedures were performed in 2008, making it the third most common plastic surgical procedure behind breast augmentation and rhinoplasty.

Barbed suture impact on wound closure in body contouring surgery.

BACKGROUND: As artistry has been refined in body contouring surgery, streamlining wound closure is the next advance on the horizon. Absorbable barbed suture is one potential solution. The authors present their experience with this suture in wound closure for different body regions. METHODS: A review of operative and clinic notes of 496 patients who had body contouring procedures from March of 1998 to September of 2008 was performed. Variables studied included age, gender, body mass index, medical history, and operative data. Use of barbed suture was noted, and complications were tabulated. Multilevel analysis was performed using generalized estimate equation method. RESULTS: The records of 910 operations in 496 patients were analyzed. Procedures were performed on multiple body regions: abdomen (n=493), chest (n=124), back (n=104), thigh (n=104), and arm (n=88). Barbed suture was used in 114 cases. There were 115 wound-healing problems, with barbed suture present in 17 cases. On unadjusted analysis, the wound complication rate with barbed suture was 17.5 percent, compared with 12.0 percent when barbed suture was not used (p=0.093). On multilevel multivariable analysis, age (odds ratio, 1.04) and body mass index at contour (odds ratio, 1.05) were significant in impairing wound healing (p<0.01), and barbed suture was not associated with the wound complication rate. In subset analysis, barbed suture was associated with significantly higher wound complication rate in the arm (odds ratio, 8.4; p=0.046). CONCLUSIONS: Barbed suture presents problems with wound healing, particularly in the arm. The authors look forward to seeing the evolution in technologies designed to improve the speed and outcome of wound closure for lengthy body contouring procedures.

Biomechanical properties of skin in massive weight loss patients.

BACKGROUND: The aim of this study is to assess skin strength in MWL patients relative to control cosmetic abdominoplasty patients biophysically, biochemically, and histologically. Growing success of weight loss programs has brought about an increase in the MWL population. Skin quality is thought to be impaired by MWL, but there are no compelling studies that have fully addressed the structural mechanisms involved. METHODS: Skin from the medial and lateral abdomen was harvested fresh from patients undergoing cosmetic abdominoplasty (n = 6) or abdominal panniculectomy for MWL (n = 35), and burst strength was tested in the horizontal and vertical directions. Collagen content was measured, and histological studies were performed to assess epidermal and dermal thickness, vascularity as well as the morphology and density of the collagen fibers. RESULTS: In all groups, skin stretched horizontally was stronger than skin stretched vertically (p < 0.001). The skin of MWL patients was stronger medially compared to the skin of cosmetic patients. (p = 0.047) Newly formed collagen was diminished in MWL than that in the control group, but the results were not statistically significant. Epidermal thickness was significantly higher medially in MWL (p = 0.049). Elastin fibers were decreased in the MWL group, while dermal vascularity was higher in the MWL group. CONCLUSIONS: The skin of MWL patients demonstrated stronger mechanical parameters than that of cosmetic patients in the medial part of the abdomen; however, the decrease in elastic fibers associated with a decrease in newly formed collagen seemingly provides a contradiction. Skin changes with MWL merits further study to understand it more completely.

Do preexisting abdominal scars threaten wound healing in abdominoplasty?

PURPOSE: Abdominal scars may impair healing after abdominoplasty. We aimed to determine whether right subcostal or upper midline scars led to increased wound healing problems. METHODS AND MATERIALS: Review of all patients who had abdominoplasty from March 1998 to February 2008 was performed. Variables studied included age, gender, body mass index (BMI), medical history, and postoperative complications. Statistical analysis was performed in Stata SE, version 10. RESULTS: Of 420 abdominoplasty procedures, 62.2% had open gastric bypass surgery (GBS) and 19% had laparoscopic GBS. Seven percent (n = 29) of the series had a right subcostal scar. Overall risk of any complication was 32.9%, with 18.3% risk of wound healing problem (18.3%) and seroma (14.9%). chi(2)analysis revealed a significant relationship between any abdominal scar and any complication (P = .001), and wound healing problem specifically (P = .009). The subcostal scar was significantly associated with wound healing problems (P = .003). The upper midline scar was not associated with wound healing or seroma complication. While multivariate analysis erased any significant relationship between abdominal scars and complications, elevated BMI presented a significant threat to wound healing. With every unit increase in BMI, a 5% increase in the risk of any complication and a 6% increased risk in wound healing was calculated (P = .001). There was no difference in complications between the open and laparoscopic GBS groups, indicating that the upper midline incision did not pose a threat to wound healing. CONCLUSIONS: Elevated BMI poses a greater threat to healing than does abdominal scar. Caution is recommended in undermining when the right subcostal scar exists.

Does thighplasty for upper thigh laxity after massive weight loss require a vertical incision?

BACKGROUND: After massive weight loss (MWL), many patients present with concerns about skin excess and laxity. The thigh is one of the more complex regions to address in MWL patients because of the differing degree, location, and quality of skin excess and fatty tissue, as well as surgical risk factors. OBJECTIVE: The authors describe a technique called the anterior proximal extended (APEX) thighlift to effectively treat upper thigh skin excess with a hidden scar while also enhancing adjacent body regions. METHODS: A review was performed of 97 MWL patients who underwent thighlift surgery between March 1998 and October 2007. Eighty-six women and 11 men, with average weight loss of 146 lb and average body mass index (BMI) at contouring of 29.8, were included in the study. The risk factors that were assessed included age, gender, medical conditions, tobacco use, BMI, weight of skin excised, and surgery performed. The outcomes that were assessed included wound healing and lymphedema. Extended vertical thighlift was performed in 11 patients and anterior superior thighlift in 86 patients. RESULTS: Complications of thighlift included wound healing problems (n = 18; 18.6%); lymphedema (n = 8; 8.3%); cellulitis (n = 7; 7.2%); seroma (n = 3; 3.1%); and bleeding (n = 1; 1%). On multivariate statistical analysis, age and BMI were found to impair healing in the entire thighlift group. For patients with a BMI greater than or equal to 35, the odds ratio (OR) for a wound healing complication was 13.7 (P = .03). Hypothyroidism was strongly associated with lymphedema, with an OR of 23 (P = .06). Extended thighlift trended toward lymphedema (OR = 16.7; P = .08). CONCLUSIONS: Thighlift can be a satisfying procedure for both the patient and surgeon because it provides aesthetic improvement in terms of skin excess and laxity. The APEX thighlift is a new technique that expands upon those previously described in the literature to effectively treat upper thigh laxity with a hidden scar after MWL.

Financial analysis of factors impacting reimbursement for abdominoplasty.

BACKGROUND: With growth in numbers of abdominoplasty procedures performed, we studied our experience with reimbursement and factors that impacted reimbursement and indirectly access to care. METHODS: From July 2004 to June 2007, 245 patients had abdominoplasty. Demographic and financial variables were noted. Twenty different insurance plans were categorized as a single "commercial insurance" group in our analysis, and the other two study groups were "self-pay" and "Medicare" patients. RESULTS: Of the 245 patients studied, 87 paid for surgery ("self pay"), while 134 had commercial insurance, and 24 had Medicare. One hundred sixty patients (65%) had gastric bypass surgery (gbs). Medicare paid 28% less than insurance, and insurance paid 48% less than patients who prepaid. Of the 24 Medicare patients, 16 (67%) resulted in zero payment. On multiple logistic regression analysis, BMI, gbs history, and coincident hernia repair significantly impacted payment. BMI negatively impacted reimbursement, with every unit increase in BMI leading to a 0.77 percentage point reduction in reimbursement. Coincident hernia repair was associated with 17.5 percentage points reduction in reimbursement (p = 0.002). History of gbs improved reimbursement by a factor of 11 (p = 0.01). Neither age, gender, race, nor weight of tissue removed impacted reimbursement. CONCLUSIONS: Higher BMI and coincident hernia repair impaired reimbursement for abdominoplasty, while massive weight loss after gbs improved compensation. While having patients pay for their surgery guarantees the best reimbursement, strategies such as assuring authorization prior to surgery, which Medicare will not do, will secure better reimbursement.

Management of back rolls.

The excisional management of back rolls has become more common as the population with massive weight loss grows. The direct excision of upper back skin excess is frequently an extension of anterior chest surgery and may be performed as a single circumferential procedure or in several stages. In a woman with massive weight loss, rather than disposing of this back tissue, it may be deepithelialized and rotated anteriorly onto the chest for autologous augmentation, yielding the double benefit of reducing the back and also providing well-vascularized tissue perfused by intercostal artery perforators to fill the deflated breast.

Seroma development following body contouring surgery for massive weight loss: patient risk factors and treatment strategies.

BACKGROUND: The most common complications following body contouring surgery for massive weight loss include delayed wound healing and seroma. The authors investigated risk factors for seroma in this patient population and describe treatment strategies. METHODS: A retrospective review of 222 patients who underwent body contouring surgery for massive weight loss from March of 1997 to December of 2005 was performed. Risk factors assessed included age, sex, medical conditions, tobacco use, body mass index, weight of skin excised, and surgery performed. RESULTS: Within this group, there were 187 women and 35 men, with a mean age of 42 years. Weight loss was achieved by open (n = 167) or laparoscopic (n = 35) gastric bypass surgery, or diet (n = 20). Average body mass index at contouring was 33, ranging from 20 to 69. Surgical areas addressed alone or in combination included the abdomen (n = 205), thigh (n = 71), arm (n = 69), back (n = 59), and chest (n = 57). Average weight of skin excised at surgery was 9.6 lb, ranging up to 49 lb. Seroma occurred in 31 patients, placing the risk at 14 percent in this series. Seroma risk in abdominal panniculectomy was 12 percent; in circumferential belt lipectomy, the risk was 18 percent; and in thigh lift, the risk was 4 percent. On multivariate statistical analysis, the major risk factor for seroma formation was weight of skin excised, with seroma risk increasing 9 percent for each additional pound of skin excised. CONCLUSIONS: The most important risk factor for seroma is weight of skin excised at the time of surgery. Treatment strategies include aspiration, drain placement, sclerosis, and surgery.