Abdominoplasty in Morbidly Obese Patients, Benefits and Risks Is It Valuable?

Egypt, J. Plast. Reconstr. Surg., Vol. 39, No. 1, January: 109-113, 2015

Abdominoplasty in Morbidly Obese Patients, Benefits and Risks Is it Valuable?

SHERIF MOHAMED ELKASHTY, M.D.* and MOHAMED ABDELMOHSEN GHANEM, M.D.** The Department of Plastic & Reconstructive Surgery, Menoufia University Hospitals* and Ain Shams University Hospitals**

ABSTRACT dant panniculus. The extents of the panniculus has been described as small, moderate, or sever [4]. Background: Obesity is a growing problem worldwide, with morbidly obese patients frequently presenting with Although bariatric surgery has been shown to redundant panniculus causing physical, social, and emotional problems. Functional abdominoplasty may be offered for be the most effective method in providing substan- those patients who refused bariatric surgery to alleviate these tial long-term weight loss obese patients, yet some problems. Controlling co-morbid diseases and risk factors obese patients decline the surgery and prefer to was done to decrease risks of abdominoplasty. spend more time on exercise and dieting trying to Purpose: The objective of this article is to evaluate the lose weight. Unfortunately, they mostly fail, result- effectiveness, benefits, and risks of abdominoplasty in morbidly ing in a miserable life style, having a pendulous obese patients on a functional basis. abdomen with back pain, bad odor caused by fungal Patients and Methods: 19 patients included in this study, infection in the skin folds, low self esteem, and 7 males and 12 females from February 2012 to March 2014. sexual relation problems [5]. They were underwent abdominoplasty after strict controlling of co-morbid diseases and risk factors and the results Although abdominoplasty is an aesthetic pro- were evaluated in light of the incidence of complications and cedure used to make the abdomen tighter and of a questionnaire measuring subjective opinions about postop- more aesthetic shape, yet it can be done as an erative improvements. immediate and definitive functional management Results: 19 patients (7 males and 12 females) were in- for the above mentioned category of patients to cluded. Their age ranged from 33 to 56 years. Their (BMI) remove their aprons (panniculus) to improve their ranged from 35 to 51 kgm2. Their panniculus ranged from quality of life, psychological status, sexual relations grade 2 to 4. All the patients were satisfied by their improve- and self hygiene [6]. ments in life style, psychological status, and sexual activities. There were 2 patients with seroma, 2 patients with wound The aim of this article is to evaluate the effec- infection, 3 patients with major flap necrosis and 5 patients with delayed wound healing. tiveness, benefits, and risks of the functional abdominoplasty in managing morbidly obese patients Conclusion: Morbid obesity should not preclude abdominoplasty. On the contrary, the patients benefit in many ways to get red off their panniculus and its related bad from the operation. Strict controlling of co-morbid diseases squeale. and risk factors is a preoperative requisite to decrease the incidence of complications. PATIENTS AND METHODS

INTRODUCTION This study was done at the Departments of Plastic Surgery, of both Ain Sham and Menoufia Obesity is a growing problem worldwide, with University Hospitals in the period from February a mean prevalence of approximately 20-30% in 2012 to March 2014 with a follow-up period of adults in Europe and USA, while morbid obesity about 12 months. rates range from 4.7 to 6% in the adult population. Obesity is defined as a body mass index (BMI) The study included 19 morbidly obese patients, above 30, and morbid obesity as a BMI above 7 males and twelve females. Their age ranged from 33 to 56 years. Their body mass index (BMI) 40kgm2 [1-3]. ranged from 35 to 51kgm2. The patients were The Morbidly obese patients present with a assessed for risk factors and co-morbid diseases myriad of problems, a frequent one being a redun- including diabetes mellitus, hypertension, smoking,

109 110 Vol. 39, No. 1 / Abdominoplasty in Morbidly Obese Patients contraceptive pills use and previous thrombo- above the pubic and inguinal creases (including embolic disease. any cesarean scar) extending laterally beyond the anterior superior iliac spine to include the pannic- The extent of their panniculus had been graded ulus, and carried down through the subcutaneous according to the grading system devised by Daniel tissue until the external oblique fascia was reached. et al. [4] as follows, Grade 1: Panniculus covering The superficial inferior epigastric vessels were pubic hair line but not entire mons pubis; Grade ligated. The dissection was carried above the ex- 2: Panniculus extended to cover entire mons pubis; ternal oblique fascia within the confines of the Grade 3: Panniculus extended to cover the upper inferior incision in a cehpalad direction until the thigh; Grade 4: Panniculus extended to mid thigh; umbilicus is reached. The periumbilical perforators and Grade 5: Panniculus extended to the knee and were ligated by vicryle 2/0. The umbilicus was beyond. dissected free by a scissors and prepared for repo- A questionnaire was formulated on a subjective sitioning during closure of the superior tissue flap. basis to evaluate the results and benefits about 6 Dissection above the umbilicus is narrowed only months postoperatively. It had scores from 0 to 10 to the extent needed for placation of divaricated with three grades as follows; (unsatisfied: scoring recti to preserve the blood and nerve supply from from 0 to 3), (satisfied: scoring from 4 to 7), and the subcostal region to the flap. If there was divar- (well satisfied: scoring from 8 to 10). The ques- ication of recti, placation of the rectus sheath was tionnaire included the following items, scarring, done using double layer of prolene zero from the abdominal shape, backache, weight loss, skin in- xephoid to the pubic region. tertrigo, daily activity and life style, psychological satisfaction, sexual satisfaction, sleep comfort, diet At this point, the entire flap was pulled down and exercise compliance. by the assistant surgeon, bringing the superior marked line close to the inferior incision. The Preoperative preparation of patients: superior incision was now made following the The aim was to control the co-morbid conditions estimated line or a few centimeters below, such and risk factors to decrease the incidence of com- that the edge of the superior flap could be approx- plications: imated to the inferior skin margin without tension. Having excised the redundant pannus, closure of ¥ Diabetic patients were hospitalized one day before the wound was started. Perfect hemostasis was surgery, and subjected to strict diabetes control done. Two suction drains were inserted on either by regular insulin scale supervised by our endo- side of the anterior fascia, under the superior flap crinology colleagues. and brought out through a stab wound on either ¥ Hypertensive patients had their blood pressure side of mons pubis. The umbilicus was refashioned controlled by proper medications. to a smaller size if necessary and brought out ¥ Patients with intertrigo and fungal infections through the superior flap about the level of the were treated by dermatologists before surgery. iliac crest, without angulation or tension. The superior and inferior skin flaps were closed in a 3 ¥ Smoking was ceased about 8 weeks before sur- layer tension free manner. The scarpa,s fascia was gery. closed by interrupted no 1 vicryle sutures, the ¥ The patients were examined for the presence of subcutaneous layer was closed with interrupted no umbilical hernias and divarication of recti. 2/0 vicryle sutures, and the skin was closed with prolene no 2/0 running subcuticluar suture. Dry Preoperative markings: gauze and adhesive tape was then applied. The patients were marked the day of surgery in a standing position. The inferior incision extend- Postoperative care: ed inferiorly above the inguinal ligament and pubic ¥ Anticoagulation was initiated on the first postop- crease, and laterally to encompass the panniculus. erative day (clexan 40mg per day). The superior mark was arbitrarily at the level of the umbilicus. ¥ Leg exercise, early ambulation, adequate hydra- tion and chest physiotherapy were encouraged. Surgical technique: ¥ Blood glucose was strictly controlled by crystal- The patients were operated on under general line insulin scale in diabetic patients. anesthesia, prepped and draped in the usual fashion. The panniculus was retracted by one assistant ¥ Drains were remove when the output fallen below surgeon, then the inferior incision was done just 50ml over 24 hours. Egypt, J. Plast. Reconstr. Surg., January 2015 111

RESULTS The majority of complications occurred in patients having co-morbid disease, rather than the This study included 19 morbidly obese patients, isolated high BMI. 7 males and 12 females. Their panniculus ranged from grade 2 to grade 4. Their age ranged from 33 Table (1): Subjective improvements 6-month postoperatively. to 56 years. Their body mass index (BMI) ranged from 35 to 51kgm2. Item Average scoring Grading Scarring 4 Satisfied The study sample included 4 smokers, all were Abdominal shape 6 Satisfied males, (who stopped smoking 4 weeks before Backache 8 Well satisfied surgery), five diabetic patients (3 females and 2 Skin intertrigo 8 Well satisfied males), and six hypertensive patients (4 males and Weight loss 5 Satisfied Daily activity and life style 7 Satisfied 2 females), and five female patients with history Psychological satisfaction 7 Satisfied of caesarian section. Sexual satisfaction 7 Satisfied Sleep comfort 8 Well satisfied As regards patient improvements, the results Exercise compliance 6 Satisfied were shown in the 6-month postoperative questionnaire in Table (1). Table (2): Complications and their association with co-morbid diseases. All the patients were satisfied by their improve- Number of ment in life style, psychological status, abdominal Co-morbid disease Complication patients association shape, general appearance and sexual activities Total (19) (Figs. 1-6). Seroma 100% (D.M.- smoking) 2 patients As regards the complications, they were shown (10.5%) in Table (2). Hematoma None None Wound infection 100% (D.M.) 2 patients There were 2 patients having seroma treated (10.5%) by repeated aseptic aspiration and pressure gar- Major skin necrosis 100% (D.M.- smoking 3 patients ments. Three patients had major flap necrosis, (15.7%) underwent surgical debridement and repeated dressing and healed by secondary intention in 5 to 9 Delayed wound 60% (D.M.) 5 patients weeks. The two patients with abdominal wound healing (26.3%) infection treated with culture specific antibiotics DVT and pulmonary None None and repeated dressing. embolism

Fig. (1): Preoperative frontal view of male patient Fig. (2): Postoperative frontal view of patient in (BMI 48kg.m2) with grade 4 panniculus. Fig. (1) after panniculectomy. 112 Vol. 39, No. 1 / Abdominoplasty in Morbidly Obese Patients

Fig. (3): Preoperative frontal view of male patient Fig. (4): Postoperative frontal view of patient in (BMI 41kg.m2) with grade 3 panniculus. Fig. (3) after panniculectomy

Fig. (5): Preoperative frontal view of female patient Fig. (6): Postoperative frontal view of patient in (BMI 38kg.m2) with grade 3 panniculus. Fig. (5) after panniculectomy.

DISCUSSION the elimination of fungal infection, ability to wear fitted garments and improvement of psychiatric Body contouring surgery especially abdomino- status [9]. plasty, has become an increasingly popular procedure not only for aesthetic purposes, but also for Although the complication rates for abdomino- its preventive and therapeutic effect on back pain plasty are significantly higher in smokers [10], or [7]. in co-morbid conditions like diabetes or hypertension [11,12], the effect of the body mass index is Abdominoplasty can also improve the quality always argued [13,14]. of life, in terms of daily physical activity and sexual life, and improves the relationship with the Comparing our results with those of Daniel et other partner [8]. Abdominoplasty also benefits in al. [4] who did 428 panniculectomies concurrently Egypt, J. Plast. Reconstr. Surg., January 2015 113 with bariatric surgery on morbidly obese patients, touring in the post-bariatric surgery patient. Plast. Recon- they had a wound necrosis and dehiscence of about stur. Surg., 117: 2200, 2006. (9.8%), seroma about (4.2%), wound infection 4- Daniel I. Jr., Malgar Zata S., Hoil L., et al.: Panniculectomy about (2.3%), and hematoma (1.9%), respectively. adjuvant to obesity surgery. Obesity Surgery, 10: 530, 2000. Murshid et al., had done abdominoplasty on 5- Saxe A., Shwartz S., Gallardo L., et al.: Simultaneous 100 morbidly obese patients. They had a major panniculectomy and ventral hernia repair following weight necrosis about (3%), seroma about (6%), wound reduction after gastric bypass surgery: Is it safe? Obesity infection about (3%) and hematoma about (1%), Surgery, 18: 192, 2008. respectively. 6- Murshid M., Khalid K.N., Shakir A, et al.: Abdominoplasty in obese and morbidly obese patients. J. Plast. Reconstur. Aesthet. Surg., 63: 820, 2010. Our results were, wound necrosis about (15.7%), seroma about (10.5%), wound infection 7- Rocher F., Drevet J.G. and Auberge T.: Breast reduction about (10.5%), and no hematomas. The complica- and abdominoplasty: Preventive and therapeutic effect on back pain in women. Ann. Chir. Plast. Esthet., 35: 228, tions encountered in this study were more common 1990. in patients presenting with co-morbid diseases like 8- Bolton M., Pruzinsky T., Cash T., et al.: Measuring out- diabetes mellitus or hypertension or were smokers. comes in plastic surgery: Body image and quality of life Strict controlling and elimination of these co- in abdominoplasty patients. Plast. Reconstur. Surg., 112: morbid/risk factors decreases the risks of abdom- 619, 2003. inoplasty. 9- El-Khatib H. and Bener A.: Abdominal dermolipectomy in an abdomen with pre-existing scars: A different concept. In conclusion, morbid obesity should not pre- Plast. Reconstur. Surg., 114: 992, 2004. clude an abdominoplasy. On the contrary, the 10- Krueger J.K. and Rorich R.J.: Clearing the smoker: The patients benefit in many ways from the operation scientific rationale for tobacco abstention with plastic even if it is performed as a functional procedure surgery. Plast. Reconstur. Surg., 108: 1063, 2001. and not a cosmetic one, provided the risk factors 11- Hensel J.M., Lehmon J.A.J., Tantir M.P., et al.: An outcome and co-morbid conditions are controlled. analysis and satisfaction survey of 199 consecutive ab- dominoplasties. Ann. Plast. Surg., 46: 357, 2001. REFERENCES 12- Von Uchelen J.H., Werker M.P. and Kon M.: Complications of abdominoplasty in 86 patients. Plast. Reconstur. Surg., 1- Van Huizum M.A., Roche N.A. and Hafer S.O.P.: Circular 107: 1869, 2001. belt lipectomy. A retrospective follow-up study on perio- perative complications and cosmetic outcome. Ann. Plast. 13- Roglaiani M., Labardi L., Maggiuli F., et al.: Obese and Surg., 54: 459, 2005. non obese patients complications of abdominoplsty. Ann. Plast. Surg., 57: 336, 2006. 2- Matarasso A., Aly A., Hurwitz D.J., et al.: Body contouring after massive weight loss. Aesth. Surg. J., 25: 452, 2004. 14- Vasttine V.L., Morgan R.F. and Williams G.S.: Wound complications of abdominoplsty in obese patients. Ann. 3- Strauch B., Herman C., Rohde C., et al.: Mid-body con- Plast. Surg., 42: 34, 1999.