PANNICULECTOMY, THE FINAL STEP AFTER MASSIVE WEIGHT LOSS, WHAT TO EXPECT
Interestingly, everywhere you look today, society is gauged, measured and delineated according to weight loss, weight management and maintaining a thin, streamline physique.
Patients today are undergoing more body lift surgeries after massive weight loss than ever. According to the American Society of Plastic Surgeons, “ More than 106,000 body contouring procedures were performed in 2004, that is up 77% over the last five years.” In fact, nearly 56,000 procedures were associated with massive weight loss alone have been performed in the last year. There were 43 times more lower body lifts in 2004 versus 200 (ASPS, March 16, 2005).
The need for panniculectomy surgery, as well as other plastic surgical and reconstructive surgeries associated with massive weight loss procedures have exploded, associated with the increased number of bariatric surgery procedures over the last five years. In Fact, the number of tummy tucks (abdominoplasty and panniculectomy) was approximately 16,810 in 1992 up 102,497 in 2004, according to statistics from the American Society of Plastic Surgeons. This shows an increase of 510% over the last 12 years. With the massive weight loss, we as plastic surgeons will continue to see more and more patients requiring panniculectomy-type surgeries to remove the massive hanging pannus (overhanging skin and fat of the abdominal area.)
Panniculectomy should be differentiated from an abdominoplasty. A panniculectomy is usually associated with incisions of the abdominal pannus. This should be compared with reconstructive abdominoplasty with the muscles of the abdominal wall (rectus sheath plicated). Paniculectomies have been shown to be performed with other operations, including gastric bypass surgery (Foley procedure), hysterectomies and herniorrhaphies, if necessary. Patients who require a panniculectomy, excision of the abdominal pannus or apron, easily show functional signs of the massive abdominal excess skin and fat, which can include hygienic rashes along the suprapubic area, which may extend from the inguinal area and the groin creases, up to the hips. The massive amount of weight may also cause functional back pain from the lower and mid-back region, which will be greatly improved by removing this enormous abdominal pannus.
Abdominoplasties normally differ from a panniculectomy in that not only is skin and fat removed, but application of the midline rectus abdominal wall muscles is normally performed. Patients undergoing abdominoplasty usually do not have the same symptoms and functional problems associated with this massive pannus. Literature describes abdominoplasty and panniculectomy as two different procedures. Once again, the panniculectomy is usually only associated with the direct excision of the skin and fat, while abdominoplasty allows for reconstruction of the abdominal wall. A grading system has been developed, associated with scale of 1 to 5 with the higher grades associated with patients with heavier weight. They have also found the correlation that the higher grades have with more problems postoperatively. The higher the grades may also be associated with increased dehiscence of the wound (opening of the wound) with increased rash along the incision site with infection and breakdown of skin. Similar incisions are performed with abdominoplasty and panniculectomy along the lower pubic area extending to the hips; however, often in a panniculectomy a midline incision will be made below the breast bone, extending all the way to the muscle and up to the belly button n order to maintain good blood supply to the thick flap of tissue in order to maintain blood supply of the lower flap to prevent loss of skin which could occur with inadequate blood supply.
Abdominal paniculectomies should be differentiated from a belt lipectomy. A belt lipectomy usually is associated with direct excision of skin and fat circumferentially around the abdomen as well as the back region above the belt line. This is often performed in patients who have had massive weight loss from gastric bypass or bariatric surgery.
Typically, a dermolipectomy or an abdominal/panniculectomy is removal of loss skin and fat from the lower abdominal area. Tightening of a muscle can often also be performed which would bring the rectus sheath anterior muscle layer to the midline and help tighten up the middle abdominal region. Hernias should be evaluated, especially if it’s palpable on clinical examination and should be worked up with an ultrasound and if necessary a CT scan if it’s large. It should be referred to a general surgeon and may require the use of Marlex mesh graft reconstruction of the abdominal wall. Patients who have undergone gastric bypass surgery, especially with upper midline procedural scars in the past, have shown a significant instance of incisional hernias to the upper midline scar and should be evaluated preoperatively with general surgeon.
Complications associated with either an abdominoplasty or panniculectomy include bleeding such as a hermatoma which may be associated with opening of a vessel which may require returning to the operating room to control the bleeding. Drainage tubes are normally placed for 7 to 10 days until the amount of fluid through the drains is minimal. Infections may be associated with graft placement with concurrent hernia repair as well skin infections which may be associated with cellulitus or erythema. These must be immediately attended to, usually requiring IV antibiotics in a hospital setting.
Severe scarring can certainly occur along the incisions site and the patient must realize that the scars are always a trade off removal of massive amount of tissue and there can never be a guarantee of the final outcome of any scars. The scars can include keloids, hypertrophic scarring, widespread scarring, hyper or hypopigmentation or a variety of the above. Skin breakdown through rare can occur if dissection is to great which causes inadequate blood supply to the flap being pulled down.
Other complications can include fluid collections called seroma in which the fluid is formed within the extra abdominal space that was created. This may require a secondary drain placement once again and antibiotics.
Finally, deep venous thrombosis of the legs, which could lead to pulmonary embolus clots in the lungs, can be deadly and patients should have some mobility immediately after surgery, as well as special pneumatic boots within the operating room during the operation to reduce this incidence.
Revisions of these large paniculectomies are not uncommon, especially when patients desire debulking of the upper abdominal area or the hip regions or flanks. We prefer to wait six months prior liposuction of the upper abdominal or flank areas after abdominoplasty or panniculectomy surgery to reduce the incidents of skin loss or flap death.
Concomitant surgeries are often performed with large paniculectomies for massive weight loss, which may include breast augmentation to regain fullness with or without mastopexies or breast lift to remove the excess skin of the lower breast regions. Brachioplasties (removal of skin from the arm.) and thigh plasties, both medical and lateral, may help to smooth out the thigh area with removal of massive amount of lax skin from the inner and outer thighs. These surgeries are all associated with significant scarring. Once again, the scarring is unpredictable and the patient must understand the trade off of the scars for the removal of this massive amount of skin and fat.
Massive paniculectomies are excellent surgeries for the patients who either had massive weight loss by diet and exercise or by bariatric surgery. Similar to breast reduction, patients have greatly improved quality of life with massive amount of heaviness of skin and fat that often weighs upon their backs through the day is gone and rashes are also no longer present and hygienic infections are reduced greatly. These can include fungal-type infections. Patients normally feel much improved both in and out of clothing after the surgery.