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Category: Panniculectomy

Massive Weight Loss Body Contouring

tummy and liposuction after weight loss

I evaluated a 44-year-old female wanting to improve her stomach area after massive weight loss. During her consultation, she explained how she was hoping to remove the loose skin as well as contour specific areas of her midsection. After listening to her and setting the expectation, we agreed to schedule two separate procedures to enhance the area.

In September 2016, I performed a panniculectomy, which involves surgically removing the excess skin and adipose tissue. Then in March 2017, I performed liposuction to improve the contour of her stomach/abdominal area.

The post-op photo is four weeks out. As you can see, her skin and shape look great, and most importantly she is very happy with her new and improved look.

To schedule your consultation with Dr. Linder or learn more about body contouring, call our office at 310-275-4513 or fill out our online contact form today.

 

 

 

 

 

Massive Weight Loss, Body Contouring

A 39-year-old female who lost a massive amount of weight recently came to my to my Beverly Hills office. After losing over 110 pounds, she was looking to remove the loose skin and have a breast augmentation with a lift.
After listening to her goals, we scheduled surgery where I performed an abdominal panniculectomy (removal of dense layer of fatty tissue growth), liposuction of the hips, and submuscular formal lift of the breasts using 350 cc high-profile saline implants.
As a board-certified plastic surgeon, these procedures are very gratifying, and most patients can improve mobility as well as feel better about their appearance. To the left is the before and after photo at six weeks post op.

SEROMA FORMATION AFTER TUMMY TUCK

Jackson-Pratt Drain

Jackson-Pratt Drain

Patients after tummy tuck (abdominoplasty) procedure may present with multiple complications, one of which is a seroma.  Seroma is a complication that may occur in up to 1 to 2 percent of abdominoplasties, especially large paniculectomies.  In my opinion, in order to reduce this risk complication, it is important to drain the abdominal cavity.  In the majority of tummy tucks (abdominoplasties) I use 10 mm Jackson-Pratt drains; however, with large paniculectomies at least three drains will be place, one on each hip and one in the suprapubic region.  Removing the drain is easy and usually is performed at the office setting between postop day 7 and day 10, depending upon the amount of drainage fluid.  Normally, I wait until there is less than 24 cc of drainage fluid in a 24-hour period before removing the drain and usually not less than 7 days after the initial surgery. Seroma formation is associated with fluid that forms in an open abdominal space.  This can occur anywhere in the body where there is an open space that has been created surgically, including a breast pocket.  For example, when implants are removed, the pocket may create a seroma and therefore a drain should be placed as well.  Seromas are the serous fluid that the body creates within the cavity.  These can be painful on examination.  The serous fluid can find its way out either through the incision or it can be resorbed back through the body.  Small seromas are actually quite common and resorb within the body and are uneventful.  Large seroma, however, may be painful and expanding along the lower abdominal wall and require aspiration and/or secondary trips to the operating room with drainage tube placement.

In my practice, I have seen very few seromas in that we do using the drainage tubes for 7 to 10 days as well as we are very thorough on our hemostasis along the abdominal wall.  Opening of just enough tissue up to the subcostal margins in order to allow for the abdominal flap to be lowered and removed is important.  Excessive dissection above the subcostal margin or the ribcage can lead to increased seroma formation.  Lymphatics can also be disturbed in the inguinal area (the groin crease area) which could lead to lymphatic fluid formation and seromas.  Therefore, care should be taken on dissection along the inguinal area and along the groin region and suprapubic region toward the femoral area.  Seromas can be identified either clinically if large, a manual wave can be identified on clinical examination by palpation of the abdomen and if not certain, an ultrasound can be performed in order to determine specifically where the loculation of fluid collection is for aspiration either directly or through ultrasonic aspiration.

TOTAL BODY MAKEOVER

STATUS POST MASSIVE WEIGHT LOSS
linderThe patient presents with significant weight loss, well over 120 pounds, leaving her with severe breast asymmetry, grade 3 ptosis, massive abdominal pannus, skin laxity with residual lipodystrophy of the iliac crest roll hips.  The patient presented for breast enhancement, breast mastopexy and full tummy tuck procedure.  The frontal views show significant asymmetry with the right breast larger and saggier than the left.  She underwent augmentation mammoplasty procedure with 500 to 600 cc high profile Natrelle saline implants, a complete formal mastopexy using the inferior pedicle Wise-pattern The claimant with more skin taken from the right breast than the left in order to recreate symmetry.  Looking at her frontal postoperative view, the nipple areolar complex sits with excellent symmetry.  The upper pole fullness of her breast is excellent compared to her preoperative view with complete loss of fullness with a high profile saline implant placed subpectorally through the dual plane technique.  The scars have healed nicely.  Her oblique view shows good symmetry with nipple position straight out and well-healing to the scars at six weeks postop.

The abdominoplasty panniculectomy shows excellent tightening of the rectus abdominis muscle and the midline plication of the rectus sheath with complete correction of the lower abdominal skin laxity.  The lower abdominal hips show excellent contouring with loss of the significant dog-ear skin that is seen along the iliac crest rolls.

This patient is six weeks postop breast augmentation with high profile saline implants, subpectoral, formal breast lift and full tummy tuck with lipo body sculpting of the hips.  Her result is a standardized result with excellent contouring which is safe to perform all procedures, implant lift and tummy tuck on a healthy patient such as this that has been preoperatively cleared by her internist.  She will continue with vitamin E and Bio Corneum on the incisions with a Dr. Linder Bra and with an abdominal binder for another four to six weeks.

Mommy Makeover Beverly Hills Style

The patient below presents for Mommy Makeover Procedures.  The patient has multiple complaints of the body, including breast dysphoria and grade 2 ptosis with sagginess of the breast as well as abdominal wall laxity and vertical midline scar status post gastric bypass surgery procedure as well as a significantly large pannus requiring a panniculectomy, liposculpture of the hips, repositioning of the umbilicus and repair of an upper epigastric hernia with a general surgeon.

tummy-tuck-1b1Her front views preoperatively show grade 2 ptosis; however, patient declines a breast lift at this time and therefore conservative high profile saline implants will be placed subpectorally in order to reposition her nipples without performing a skin lift.  She also has a large abdominal pannus of lower abdomen with midline upper epigastric hernia found on abdominal CT scan.  The patient was referred to Dr. Robert Uyeda, our general surgeon, for concurrent reconstruction of abdominal wall with abdominoplasty and augmentation mammoplasty procedure.

The patient’s after photos show a very nice contouring of the lower abdominal area.  The midline vertical scar is now found below the umbilicus and the umbilicus has healed nicely.  The abdominal hernia was repaired with epigastric mesh, Marlex mesh graft reconstruction as well as liposculpturing of the iliac crest rolls and implant placement in the dual plane technique.  The patient is very happy with the results, showing a full C size breast with dual plane saline augmentation mammoplasty procedure using high profile saline implants, full tummy tuck with complete skin removal, tightening of the rectus sheath, hernia repair and sculpting of the iliac crest roll and muffin top procedure.

tummy-tuck-1a1Mommy Makeovers in Beverly Hills are performed in my operating room weekly.  These patients should be preoperatively evaluated by their internists, cleared for surgery for general anesthesia and if hernias are found, abdominal wall reconstruction should be performed concurrently with a general surgeon.

Massive Abdominal Pannus

MASSIVE ABDOMINAL PANNUS  WITH VENTRAL EPIGASTRIC AND UMBILICAL HERNIA REPAIR

The patient is a 45-year-old African-American female presenting from out of state with significant abdominal wall protrusion.  On examination, it was very evident that she had a significant hernia, both in the upper epigastric area as well as the umbilicus.  As a result, the patient was scheduled for abdominal CT scan and referred to our general surgeon for consultation for concurrent repair of abdominal hernia repairs with mesh wrap reconstruction and a panniculectomy.  The patient underwent the surgery recently with the abdominal wall reconstructed, requiring mesh graft.  A mesh graft is important and was placed in order to reduce recurrence of this very large rectus diastasis and significant epigastric hernia.  Hernias that are large, especially with abdominal wall diastasis that is severe, usually require reconstruction using a prosthetic mesh graft.  A Board Certified General Surgeon is a must when considering abdominal wall reconstruction concurrently with cosmetic or plastic surgery of an abdominal pannus removal.

The hernia is shown which is quite large from the abdominal wall.  Preperitoneal fat has been exenterated and the hernia fascial defects have been dissected out.  The general surgeon then reconstructs the abdominal wall and the massive abdominal pannus skin is then removed.  These surgeries most likely should be performed in a hospital setting in order to allow for intravenous fluid hydration pain management postoperatively.  Whenever considering large abdominal protruding abdomens, it is extremely important to preoperatively obtain diagnostic CT scans in order to determine the integrity of the abdominal wall for fascial defect hernias.

Total Mommy Makeover Status Post Massive Weight Loss

The patient below is status post massive weight loss, over 140 pounds, was actually featured on the Dr. Oz Show with Dr. Linder after Dr. Linder’s total transformation of the patient’s breasts and abdomen. The patient had severe grade 3 ptosis, skin laxity and a massive abdominal pannus after losing 140 pounds. She, however, was left with a massive amount of loose skin from the breasts as well as the abdominal area. She has undergone a formal mastopexy using the inferior pedicle Wise-pattern technique (a massive breast lift) and a panniculectomy, removing the pannus. She also had liposuctioning of the iliac crest rolls or the muffin-top. She is two years postop now and presents with a postoperative photo. Notice that she has excellent fullness and scarring is quite reasonable. Her pannus is gone and she no longer has those rolls of skin and fat along the lower beltline. She is content with the results, even two years later, with the use of underwire brassieres, sports bras and a Dr. Linder Bra at night. She now still has good breast fullness without skin recurrent laxity.

The total mommy makeovers can be performed on women who have had massive weight loss either due to gastric bypass surgery or simply due to diet and exercise. Regardless, removing skin from the breasts and stomach with patients who have a significant amount of breast tissue can end up with nice volume breasts without the use of an implant and paniculectomies can be formed allowing for a night tightening effect concurrently.

 

Total Male Makeover

STATUS POST MASSIVE WEIGHT LOSS

The patient to the left presents with massive weight loss, weighing over 340 pounds, having had a laparoscopic banding procedure (gastric bypass surgery), lost over 140 pounds, now weighs 200 pounds even. He has massive amounts of skin from the chest area extending to the lateral breast and extending down to the pannus. He will undergo a partial subcutaneous mastectomy with tumescent lipectomy, lipo-sculpting of the lateral chest area as well as a full panniculectomy or large abdominoplasty with umbilical hernia repair with our general surgeon as well as lipo-sculpting of the hip region.

The second photograph shows the patient undergoing a partial mastectomy. Tissue is being removed in the retroareolar plane, extending to the fascia over the pectoralis major muscle. Once this tissue is removed, complete lipo-sculpting of the rest of the chest from the infraclavicular, parasternal, inframammary into the lateral anterior axillary line was performed. Subsequently, at this time a mastopexy or lift will not be performed. We will determine how much skin tightening occurs and then on a separate stage several months from now a breast lift may be required in order to tighten up representative skin. Looking at the pannus, there is a massive overhang. He does have an umbilical hernia on examination and the general surgeon will be repairing this. In the operating room he was found to have rectus diastasis. The muscles were plicated. The hernia was repaired.

The postoperative photo here on the operating table shows the chest is softened immensely. There is great smoothing out of the chest wall as well as reduction of the lipodystrophy of the lateral breast chest area. Notice the incision is hip-to-hip and there are three drainage tubes in. The abdominal wall is now flat. The patient has done extraordinarily well.

The photograph shows the actual 25 pounds of tissue that was removed from the abdominal wall as well as the liposuctioned fat from the lateral chest and hips.

Patients present after massive weight loss laparoscopic banding procedures for tummy tucks, paniculectomies and gynecomastic surgeries or possible breast lifts. This is an excellent example.

Panniculectomy Procedure in Beverly Hills

PANNICULECTOMY CASE STUDY

This case study shows a representative patient who presents with massive abdominal pannus, status post significant weight loss, status post gastric bypass surgery. The patient has lost well over 120 pounds and now has significant amounts of skin with a massive abdominal pannus. A panniculectomy can be performed in order to reduce the massive skin apron or pannus. It also is helpful as a functional surgery to reduce the mid and lower back pain in a similar fashion as to a breast reduction that reduces back pain from the upper back and the cervical region. This patient also presented with intertriginous rashes for over six months with dermatitis, contact dermatitis and tinea fungal infections. She was cleared by her internist, rheumatologist, orthopedic surgery as well as dermatologist for contact dermatitis and fungal infections.

She underwent a panniculectomy under general anesthesia using an endotracheal tube, given Ancef intravenously with no history of penicillin allergies. The panniculectomy was completely resected. The abdominal wall was tightened in the midline conservatively using O-Ethibond sutures. The massive skin was then redraped, excised and sutured down the edges of the wound with three large 10 mm JP drains placed for at least 7 to 10 days. Liposculpturing of the iliac crest rolls was accomplished to reduce the lateral fullness of the hip area.

Patients do particularly well with paniculectomies when they have a massive abdominal pannus or apron after a significant weight loss, either through lap band, gastric bypass surgery or simple exercise and dietary routines.

Suspension Technique for Panniculectomy in a Morbidly Obese Patient

Written by: Stuart A. Linder, M.D., G.M. Buncke, M.D., Timothy Cooper, M.D., J.A. Mele, M.D., G. M. Kind, M.D., H. J. Buncke, M.D. 

 

ABSTRACT

A simplified technique for removal of a large pannus is described. The case presented involves a 63-year old morbidly obese man (more than 500 pounds) with multiple medical problems. Complications encountered when operating on the morbidly obese because of the sheer size of the patient and the body part to be operated on are briefly discussed.

Two operating tables were necessary to accommodate the patient’s large bulk. Preparation of the skin as well as the operative procedure were greatly facilitated by using a hydraulic lift to elevate the pannus. No injuries were sustained by the surgeons of the operating room staff. Total operative time was 2.5 hours, and there were no intraoperative or postoperative complications. This technique may be used to perform other procedures in the morbidly obese that require elevation of a body part.

INTRODUCTION

Contemporary Surgery Magazine Cover

A 63-year old morbidly obese male (estimated weight: 515 pounds) was admitted for surgical correction of an enormous pannus. Indications for panniculectomy included mechanical compression of the lower extremity lower venous system, lower abdominal hygiene, and decreased mobility. The patient initially was admitted to the cardiology service with multiple medical problems associated with his morbid obesity including congestive heart failure, artial fibrillation, and marked chronic venous stasis of the lower extremities. On examination, the abdominal pannus and lower legs appeared markedly lymphadematous.

Preoperative medical workup included pulmonary function tests, echocardiogram, and upper and lower gastrointestinal endoscopy for investigation of microcytic anemia. With aggressive preoperative diuresis, a weight loss of 45 pounds was achieved.

OPERATIVE PROCEDURE

Figure 1: Preoperative view prior to panniculectomy

Intraoperative monitoring was performed using an arterial line and a Swan-Ganz catheter. Two operating tables were necessary to accommodate the patient’s bulk (Figure 1). Preparation of the skin and the operative procedure were greatly facilitated by using a hydraulic lift to elevate the pannus. With assistance from the biomedical engineering department, two intramedullary rods (1/4-inch stainless steel) were bent into lifting hooks. The “Ruger hoist” included an extension book with variable standing positions (450, 750, and 1000 pounds) determined by its length (Figure 2). In order to gain maximum extension of the boom for positioning at the side of the surgical table, a total weight of 450 pounds could be elevated safely. The hooks were connected by rope to a gamble that was mounted on the hydraulic lift. (Figure 3)

The total operative time was 2.5 hours, and there were no intraoperative complications. Equally important, no injuries occurred to either the operating room staff or the surgeons in association with the physical difficulty of maneuvering a morbidly obese patient intraoperatively. The entire operative specimen weighed 100 pounds. The estimated blood loss was approximately 450cc. The patient received one unit of packed red blood cells and two liters of crystalloid intraoperatively. No further transfusions were required.

There were no postoperative complications. The patient was extubated with removal of a central line on the second postoperative day. Embolic prophylaxis with subcutaneous heparin was administered for five days until ambulation. Unna boots were placed on the lower extremities every three days to aid in the reduction of edema and as a treatment for chronic venous ulcerations. After one week, the patient was transferred to a skilled nursing facility from which he was discharged on postoperative day 13.

DISCUSSION

The pathophysiology of Panniculus morbidus was described by Petta et all in 19921. A large pannus creates a vicious cycle of lymphatic and venous congestion leading to further ischemia and lymphedema, ultimately resulting in celluitis, abcess formation, and infarction. During surgical dissection it was ecident that this patient has a markedly lymphadematous pannus.

Surgery in the obese patient has been associated with an increased incidence of complications and mortality including deep vein thrombosis, pulmonary embolism, pneumonia, sepsis, and would dehiscence with fat/skin necrosis. Obesity is commonly defined as being more than 20% over the ideal body weight; morbid obesity is defined as being more than twice the ideal body weight. In a review of the literature published in 1985, Hirsch et al2 found a variable, but nonetheless high (20-78%), incidence of complications following surgery in the morbidly obese patient. Abdel-Moneim noted a 2.6% mortality rate from surgery in obese patients.3 According to Foley and Lee,4 the incidence of would infections in morbidly obese patients is as high as 40%, and would dehiscence is ten times more likely to occur in this patient population. Reducing operative time may decrease the incedence of would sepsis, would dehiscence, and hernia formation.

Various techniques have been described to aid in suspension of the pannus. Richard5 described placement of a rigid bar through the pannus to provide suspension and enhance manipulation. Meyerowitz et al6 described the transverse placement of Rush nails for suspension. The skewered Rush nail method has been modified by bending the intramedullary rods into hooks. Sterilized “shark hooks” also could be used easily. Matory (7) et al described a pannus elevation technique using rope suspension with towel clips and Steinmann pins.

The method of suspension used in this case allows complete surgical resection of the pannus without requiring multiple assistants. The hydraulic lift boom was extended to its greatest length to maintain the sterile field. The nurse controlled the manual pump that is used to elevate the pannus on the hoist. Our biomedical engineers recommended using a thicker rod, at least 3/8-inch in diameter, to prevent the bending that was evident with the 1/4 inch rod.

CONCLUSION

The technique describes for panniculectomy will expedite the operation, reduce blood loss, and optimize the volume and venous return. Visualization of the vessels is easier and hemostasis is more readily accomplished with reduced blood loss. Prevention of injury to the operating room staff and surgeons also is an important consideration.

REFERENCES

  1. Petty P, Mandon PN, Black R, et al: Panniculus morbidus. Ann Plast Surg 28:442-454, 1992.
  2. Hirsch J, et al: Health implications of obesity: NIH Consensus Development Conference statement. Ann Intern Med 103:1073, 1985.
  3. Abdel-Moneim RI: The hazards of surgery in the obese. Int Surg 70:101, 1985.
  4. Foley K, Lee R: Surgical complications of obese patients with endometrial carcinoma. Gynecol Oncol 39:171, 1990.
  5. Richard EF: A mechanical aid for abdominal panniculectomy. Br J Plast Surg 18:336, 1965.
  6. Meyerowitz BR, Gruber RP, Laub DR, et al: Massive abdominal panniculectomy. JAMA 225:408, 1973.
  7. Matory WE, O’Sullivan J, Fudem G, Dunn R: Abdominal surgery in patients with severe morbid obesity. Plasty Reconstr Surg 94:976:987, 1994.

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