PRS- April 2008 Abdominotorso Contouring

SPECIAL TOPIC

Treating the Abdominotorso Region of the Massive Weight Loss Patient: An Algorithmic Approach

Steven G. Wallach, M.D. Summary: There has been tremendous growth in the number of patients seek- New York, N.Y. ing body contouring procedures after massive weight loss. Most patients desire improvement of the abdominotorso region first. After massive weight loss, there is enormous variability of body proportions, and therefore there have been many surgical options proposed based on the quality of the skin, subcutaneous fat component, and location of the lax tissue. Each area needs to be assessed to see whether there is a significant lower abdominal component, an upper midline abdominal component, or contributions from the buttocks and flanks. An algorithm for treatment is presented to simplify the decision-making process. Patient examples are also shown to demonstrate the usefulness of the algorithm. (Plast. Reconstr. Surg. 121: 1431, 2008.)

s a result of the increasing popularity of anatomical regions based on this rating system, bariatric surgery, plastic surgeons are treat- but details regarding the different treatment plans Aing greater numbers of massive weight loss were not elucidated. patients. These patients typically lose more than It is rare for a massive weight loss patient to 100 pounds and have significant skin laxity with undergo just a full abdominoplasty; treatment of varying amounts of subcutaneous tissue excess. the flanks and buttocks has become common. Commonly, the abdominotorso region is treated Therefore, many patients require a more involved first; it often gives patients the most grief. The procedure such as a circumferential abdomino- overhanging pannus may predispose this region to plasty or even one that uses a fleur-de-lis approach. rashes and can make it difficult for patients to wear It stands to reason that a new system is necessary properly fitted clothing. to classify and treat this subset of abdominotorso Several authors have proposed systems that have contour patients. In a fashion similar to the ap- become useful tools for classifying and treating pa- proach for arm contouring described by Appelt et tients desiring abdominal contour surgery.1–3 How- al.,5 the author has developed an algorithm for ever, these systems do not adequately classify the treatment and classification of the abdominotorso massive weight loss patients who are now seeking region specifically for the massive weight loss pa- treatment. tient. Included are descriptions of the procedures Recently, a classification of contour deformi- and patient examples illustrating the usefulness of ties after bariatric weight loss was described by the algorithm (Fig. 1). Song et al.4 The system involved evaluating 10 different anatomical regions commonly treated PREOPERATIVE EVALUATION after massive weight loss. A table was used to il- A discussion with the patient is performed re- lustrate preferred treatment plans for different garding their surgical goals, the various surgical treatment options, and the impact that their med- From the Department of Plastic and Reconstructive Surgery, ical conditions can have on the surgical outcome. Albert Einstein College of Medicine; Lenox Hill Hospital; Surgery is usually delayed until the weight loss has and Manhattan Eye, Ear, and Throat Hospital. Received for publication September 8, 2006; accepted De- cember 20, 2006. Presented in part at Advances in Aesthetic Plastic Surgery: Disclosure: The author has no commercial associ- The Cutting Edge VI Symposium, in New York, New York, ations or financial disclosures that would pose or November 12 through 16, 2006. create a conflict of interest with information pre- Copyright ©2008 by the American Society of Plastic Surgeons sented in this article. DOI: 10.1097/01.prs.0000302463.55208.bf

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Fig. 1. Algorithm for treatment and classification of the abdominotorso region after massive weight loss. plateaued; for a bariatric surgery patient, this is full abdominoplasty. The laxity and quality of the usually after at least a 100-pound weight loss or skin are evaluated in a vertical dimension in the longer than 1 year after the gastric procedure. supraumbilical region as well. Using the vertical up- Sometimes, surgery is performed sooner for a pa- per abdominal midline as a reference point, a ver- tient who requires a panniculectomy to assist in tical pinch is performed pinching tissue from each the management of other conditions. side of the midline to evaluate the upper abdominal The patient is first examined in supine posi- midline excess and laxity. If a vertical pinch improves tion and evaluated for hernias and the extent of the upper abdominal waistline and can eliminate rectus diastasis. A patient that has had an open supraumbilical fullness, the possibility of performing abdominal procedure has an increased risk of her- a vertical midline incision is discussed. The thresh- nia formation.6,7 A massive weight loss patient may old for using this additional incision is lowered if the have an excess subcutaneous fat component, patient has a preexisting paramedian or midline which can make palpation of a hernia difficult. vertical scar. Therefore, the hernia can remain occult until the The patient is then examined for mons pubis time of surgery. ptosis.8 This is marked in accordance with Baroudi’s The patient is then examined in the standing description, leaving a 5- to 7-cm length from the position. The abdominal region is evaluated for skin vulvar commissure to the top of the mons pubis.9 laxity and the extent of the subcutaneous fat com- The patient is evaluated in a right lateral, left ponent. Often, the patient will have striae, poor skin lateral, and posterior standing position using the elasticity, and recalcitrant rashes not amenable to horizontal pinch test to evaluate the impact the conservative treatment. A pinch test is performed in pinch has on lateral and anterior thigh laxity and a horizontal fashion to evaluate the amount of tissue buttock ptosis10 (Table 1). that can be excised. The horizontal pinch is per- The preoperative examination is essential be- formed on the lower transverse abdominal tissue cause there is tremendous variability of skin qual- that would be excised commonly during a routine ity, amount of the subcutaneous fat, and distribu-

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Table 1. Massive Weight Loss Abdominotorso Classification System Type Fat Vertical Abdomen Laxity (girth) Flank/Buttock Component Treatment I Variable Minimal Minimal Full abdominoplasty II Variable Moderate to severe Moderate to severe Fleur-de-lis abdominoplasty III Variable Minimal to moderate Moderate to severe Circumferential abdominoplasty IV Variable Severe Moderate to severe Fleur-de-lis circumferential abdominoplasty V Severe Moderate to severe Moderate to severe Panniculectomy tion of tissue laxity in these patients. Furthermore, is undermined and the redundant tissue is re- it is during this period when the risks, benefits, sected in the vertical midline to decrease the over- and alternatives of all procedure options can be all girth. The redundant transverse component discussed thoroughly with the patient. is then resected once the vertical component is reconciled.17–21 The key to the closure is minimal CLASSIFICATION SYSTEM tension. This patient is not flexed more than 20 to Type I: Full Abdominoplasty 30 degrees to remove the excess tissue. The post- This patient has moderate abdominal skin lax- surgical care is similar to that used for the type I ity with variable amounts of subcutaneous fat. The patient; however, I find that the drains stay in for vertical skin and subcutaneous component con- several days longer (Fig. 3). tributing to the abdominal girth is minimal. The laxity in the upper abdomen can be treated by superior elevation and excision in a transverse Type III: Circumferential Abdominoplasty fashion along the lower abdomen as performed This procedure is indicated for a patient with for non–massive weight loss patients. The flanks moderate to severe skin laxity of the abdominal and buttocks are not significantly lax and are not skin with a significant flank/buttock component. treated. Repair of the rectus diastasis is performed. The patient may have minimal to moderate excess This patient has fairly good skin elasticity that in the supraumbilical component that can be contributes to the resiliency of the tissues, pre- treated by undermining alone and excising along cluding the need for a more involved procedure. the lower transverse abdomen.10,22–26 In addition, the I have found this more commonly in the younger patient requires resection of the flank/buttock com- massive weight loss patient or in those patients ponent to treat the laxity. After anesthetic induction, who have had less than a 100-pound weight loss. the patient is placed prone and the buttocks and However, in general, this massive weight loss pa- flanks are treated first. The excess tissue is resected tient is not common. Traditional abdominoplasty and closed without tension or significant undermin- procedures have been described elsewhere.11–16 Two closed suction drains are placed in the mons ing. The patient is then placed supine and the ab- pubis region through separate stab incisions. They dominal component is treated. The patient is flexed are removed once the total fluid is less than 30 5 to 10 degrees for final excision and closure of the cc/24-hour period, usually within 1 week. The lower transverse abdomen. The postsurgical care is patient is encouraged to ambulate the first night similar to that described earlier, with the exception of surgery and is to wear an abdominal binder for that four closed suction drains are placed. Two drain 3 to 6 weeks (Fig. 2). the buttock and flank region and two drain the ab- dominal region. These drains will often be kept in Type II: Fleur-de-Lis Abdominoplasty for 2 to 3 weeks (Fig. 4). A massive weight loss patient ideally fitting this profile is more theoretical than an actual patient. If individuals have enough vertical laxity to war- Type IV: Fleur-de-Lis Circumferential rant a fleur-de-lis, they will likely have similar laxity Abdominoplasty of the flanks and buttocks, requiring a circumfer- This patient has significant upper abdominal ential procedure. Unlike the type I patient, there laxity, and redundancy in the lower abdomen re- is significant vertical laxity contributing to the quiring both vertical and transverse excision. The overall girth that cannot be treated alone by un- flank and buttock regions contribute to the overall dermining and excision along the lower abdo- laxity and require treatment. There is noticeable men. Furthermore, diastasis repair alone will not laxity in the upper midline that contributes to the significantly narrow this patient. The superior flap overall girth of the patient that cannot be treated by

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Fig. 2. A 36-year-old woman, 5 feet 2 inches tall, after a 78-pound weight loss, with good skin tone and laxity confined mainly to the lower abdomen. Preoperative (left) and 3-week postoperative appearance (right) following a full abdominoplasty. just undermining of the superior flap and resection redundant lower abdominal transverse component along the inferior abdominal incision. Technical is excised. There is no tension on the closure. The variations for treatment have been described keys to this procedure are in the initial marking of elsewhere.17–21 As with the type III patient, the pa- the patient, which is used as a guideline during the tient is placed prone and the buttock and flank tissue surgical procedure, and minimizing the abdominal is excised without undermining and with minimal closure tension (Figs. 5 and 6). tension. The patient is then placed supine and the abdominal component is treated. Once the superior Type V: Panniculectomy flap is elevated, the excess in the vertical midline is This is reserved for a patient who has signif- treated. The patient is flexed 5 to 10 degrees and the icant amounts of subcutaneous fat with moder-

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Fig. 3. A 48-year-old woman, 5 feet 2 inches tall, after a 101-pound weight loss. She had had a recurrent umbilical hernia and multiple scars on her abdomen. The patient had significant laxity of her lower abdomen, her vertical midline abdomen, and her flanks and buttocks. The patient chose not to have the flanks and buttocks treated at the time of surgery. Appearance preoperatively (left) and 7 months after fleur-de-lis abdominoplasty and 1 month after um- bilicoplasty (right). ate to severe skin laxity. This patient is best cant surgical risks including delayed wound treated after his or her goal weight is achieved, healing.27–29 Delaying surgery until weight loss is when the patient can be assigned to a type I to complete is preferable, because the risks of sur- IV abdominotorso group. Unfortunately, be- gery are significantly diminished.28 Excision of cause of hygiene issues or the need to perform the pannus is performed without undermining other surgical procedures (i.e., general surgical, to avoid creating poorly perfused tissue and to gynecologic, or urologic procedures), the pan- decrease the risk of seroma formation. In some nus is obstructing access and requires excision. instances, the umbilicus may have to be sacrificed26,28,29 This patient is still overweight and has signifi- (Fig. 7).

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Fig. 4. A 34-year-old man, 6 feet 1 inch tall, after a 145-pound weight loss, with moderate skin laxity and significant lower abdominal transverse laxity and significant buttock and flank lax- ity. He had an upper midline vertical scar. He did not have significant vertical abdominal skin laxity. He was a good candidate for a circumferential abdominoplasty. Preoperative (left) and 3-month postoperative (right) appearance following a full abdominoplasty.

CASE REPORTS Case 2 A 48-year-old woman, 5 feet 2 inches tall and initially weigh- Case 1 ing 275 pounds, lost 101 pounds after her gastric bypass and A 36-year-old woman, 5 feet 2 inches tall and initially weighed 174 pounds. The patient had significant skin laxity of weighing 228 pounds, lost 78 pounds after undergoing a her abdomen, flanks, and buttocks, including severe supraum- laparoscopic gastric bypass and weighed 150 pounds. On bilical laxity. She had a reducible umbilical hernia. She also had physical examination, she had moderate skin laxity confined an upper vertical midline scar, a prior appendectomy scar, and to her lower abdomen, with minimal upper midline vertical previous laparoscopic bypass incisions. Although she was a good skin laxity. She was classified as a type I patient that under- candidate for a type IV procedure, she opted to be down-staged went a full abdominoplasty. Her 3-week postoperative pho- to a type II, fleur-de-lis abdominoplasty for financial reasons. At tographs are shown (Fig. 2). the time of her combined type II procedure and umbilical

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Fig. 5. A 47-year-old woman, 5 feet 6 inches tall, after a 107-pound weight loss. She had significant transverse and vertical abdominal skin laxity. She also had significant flank and buttock laxity. She had prior cesarean section surgery resulting in a lower midline vertical incision and a Pfannenstiel incision. Appearance preoperatively (left) and 6 months after a fleur-de-lis circumferential abdominoplasty (right). hernia repair, the general surgeon elected to amputate her he had moderate skin laxity confined to the lower abdomen and umbilical stalk. The patient underwent an umbilicoplasty 6½ a moderate amount of subcutaneous fat. He also had significant months after the type II operation. Photographs of the 7½- buttock and flank laxity. The patient had an upper midline vertical month result from the type II procedure and 1 month after her scar that he did not want revised. He was classified as a type III umbilicoplasty are shown (Fig. 3). patient. His 3-month postoperative result is shown (Fig. 4). Case 3 Case 4 A 34-year-old man, 6 feet 1 inch tall and initially weighing 360 A 47-year-old woman, 5 feet 6 inches tall and initially weigh- pounds, lost 145 pounds after an open gastric bypass procedure ing 285 pounds, subsequently weighed 178 pounds after a lapa- and subsequently weighed 215 pounds. On physical examination, roscopic gastric bypass. On physical examination, she had sig-

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Fig. 6. Additional views of the patient shown in Figure 5.

Fig. 7. A 43-year-old woman, 5 feet 6 inches tall, after a 78-pound weight loss, with a large painful umbilical hernia. The patient had significant skin laxity and rashes below her large abdominal pannus. She had a significant amount of fat in her subcutaneous component circumferentially and had a previous upper vertical midline incision. She was still actively losing weight. Because she needed to have her umbilical hernia treated but was still se- verelyoverweight,shewasagoodcandidateforapanniculectomy.Preoperativeview(left) and 16 months after panniculectomy with umbilical sacrifice (right).

nificant transverse and vertical laxity of the abdomen and cision. She was an excellent candidate for a type IV procedure. significant flank and buttock laxity. She had undergone three Her 6½-month postoperative photographs are shown (Figs. 5 prior cesarean sections: one by means of a lower midline vertical and 6). She was pleased with her postoperative result but de- abdominal incision and the others through a Pfannenstiel in- veloped meralgia paresthetica in her left upper thigh.

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Case 5 have significant supraumbilical fullness or laxity A 43 year-old woman, 5 feet 6 inches tall and initially weigh- that, on performing a vertical pinch, warrants a ing 303 pounds, weighed 225 pounds after an open gastric fleur-de-lis procedure yet still has the laxity in the bypass and was not at her ideal weight. She was referred by her flanks and buttocks that warrants a circumferen- bariatric surgeon to remove the pannus in conjunction with treatment of her painful umbilical hernia. On physical exam- tial procedure. ination, the patient had a large reducible umbilical hernia and Abdominotorso contour surgery in the mas- an upper midline vertical scar. She had significant skin laxity sive weight loss patient involves a complex deci- and rashes below her abdominal pannus. She was a candidate sion-making process to ensure the best result with for type V procedure at this time and desired further treatment 20,21,26,30,31 of other anatomical regions once her weight loss was complete. the least amount of complications. With The patient underwent a type V procedure (panniculectomy) this, there are certain tradeoffs that a massive combined with an umbilical hernia repair and sacrifice of her weight loss patient must consider when choosing umbilicus. Sixteen-month postoperative results are shown (Fig. 7). an abdominotorso contouring procedure. These include the following: reconciliation of scarring versus additional contour improvement, the amount DISCUSSION of time that the patient can take off from work or The algorithm described is based on ideal pa- daily activities, and the potential financial obliga- tient conditions so that general guidelines can be tions that may impact the choice of surgical proce- used as a starting point for patient classification dure. More extensive procedures will probably re- and treatment. Most massive weight loss patients quire a longer convalescence period, additional who desire abdominal contour surgery fall into incisions, and often a greater financial burden, all of the five general treatment categories that I have which impact the patient’s decision. Certainly, many described previously. Types I through IV are those variables including those described above can im- patients who have reached their goal weight. The pact the procedure choice, and in some cases down- type V patient (i.e., one that requires a pannicu- staging to a lesser procedure may be appropriate. lectomy) is the one that has not reached her ideal Prior surgical procedures can impact the body weight but requires excision of the abdom- choice of treatment. There has been some debate inal pannus to facilitate other surgical procedures regarding abdominoplasty after open cholecystec- (i.e., gynecologic, urologic, or general surgical tomy because of the potential of having a limited procedures). blood supply to tissue that would end up between The classification system described is simple the new lower abdominal scar and the cholecys- and straightforward (Fig. 1). Although many of 32,33 the patient categories appear to have very similar tectomy scar. Chevron incisions in the upper midline may lead to consideration of using a re- characteristics, there are unique differences. A 34–36 type I patient has minimal supraumbilical vertical verse abdominoplasty. Commonly, a McBur- pinch laxity and does not have flank or buttock ney incision, a lower midline or paramedian ver- laxity. Both the type II patient and the type IV tical incision, and a Pfannenstiel incision can patient have severe vertical abdominal laxity dem- usually be removed when performing one of the onstrated by a significant vertical pinch; this dif- five procedures described. Having a vertical upper ferentiates them from the other types. What midline abdominal scar may tether and restrict should differentiate the type II from the type IV movement of the upper abdominal flap. A simple patient is that the type IV patient also has signif- scar revision for a patient without significant mid- icant flank and buttock laxity, warranting a cir- line vertical laxity or using a fleur-de-lis approach cumferential procedure. In my experience, a type for the patient that does have significant vertical II patient is a theoretical entity. I do not think the laxity can alleviate this problem. patient really exists in the sense that she could only Often, the massive weight loss patient requests have significant vertical upper midline laxity with- treatment of several different anatomical regions. out also having flank and buttock laxity. The type Combining surgical procedures in addition to the II patient that I encounter is originally classified as abdominotorso contour procedure can impact a type IV patient but, because the patient may not the treatment choice as well. Sometimes, these be able to afford the circumferential procedure or may be performed together during the same op- may not want the increased surgical risk of a erative session. However, performing combined lengthier and more complex surgical procedure procedures will increase the length of surgery and and/or the potential increased downtime from complexity, and may increase the risk of compli- the procedure, opts to be down-staged to have a cations, requirement for blood transfusions, and type II procedure. The type III patient does not need for extended hospital stays,37,38 although

1439 Plastic and Reconstructive Surgery • April 2008 some studies do not support the potential in- 5. Appelt, E. A., Janis, J. E., and Rohrich, R. J. An algorithmic creased complication risk.39–41 The patient may be approach to upper arm contouring. Plast. Reconstr. Surg. 118: down-staged to a less invasive abdominotorso pro- 237, 2006. 6. Podnos, Y. D., Jiminez, J. C., Wilson, S. E., et al. Complica- cedure while also treating the additional anatom- tions after laparoscopic gastric bypass: A review of 3464 cases. ical region, so that these risks can be minimized. Arch. Surg. 138: 957, 2003. For instance, a mastopexy or breast reduction pro- 7. Hesselnik, V. J., Luijendijk, R. W., de Witt, J. H. W., et al. An cedure using a Wise pattern performed in com- evaluation of risk factors in incisional hernia recurrence. bination with an abdominal contour procedure Surg. Gynecol. Obstet. 176: 228, 1993. may impact the blood supply to the abdominal 8. Matarasso, A., and Wallach, S. G. Abdominal contour sur- gery: Treating all of the aesthetic units including the mons flap, especially with a fleur-de-lis approach, and so pubis. Aesthetic Surg. J. 21: 111, 2001. down-staging may be appropriate. 9. Baroudi, R., and Ferreira, A. A. Contouring the hip and the Sometimes, the massive weight loss patient abdomen. Clin. Plast. Surg. 23: 551, 1996. requires hernia repair, and this can be per- 10. Lockwood, T. E. Transverse flank-thigh-buttock lift with su- formed in conjunction with their abdomino- perficial fascial suspension. Plast. Reconstr. Surg. 87: 1019, torso contour procedure. An umbilical or inci- 1991. 11. Baroudi, R., and Moraes, M. A ‘bicycle-handlebar’ type of sional hernia usually does not affect the choice incision for primary and secondary abdominoplasty. Aesthetic of surgical procedure but may impact the com- Plast. Surg. 19: 307, 1995. plexity and length of the procedure, potentially 12. Grazer, F. M. Abdominoplasty. Plast. Reconstr. Surg. 51: 617, increasing the risks as well.37–41 Hernia repair in 1973. conjunction with an abdominotorso contour 13. Lockwood, T. Lower body lift with superficial fascial suspen- procedure may impact the viability of the um- sion. Plast. Reconstr. Surg. 92: 1112, 1993. 14. Pitanguy, I. Abdominal lipectomy. Clin. Plast. Surg. 2: 401, bilicus (see case 2), and when a ventral hernia 1975. is repaired, it may impede the quality of the 15. Planas, J. The “vest over pants” abdominoplasty. Plast. Re- diastasis repair. constr. Surg. 61: 694, 1978. The algorithmic approach is set up for the 16. Regnault, P. Abdominoplasty by the W technique. Plast. Re- ideal situation, barring contributory medical con- constr. Surg. 55: 265, 1975. ditions, scarring, hernia repair, or combined pro- 17. Castanares, S., and Goethel, J. A. Abdominal lipectomy: A modification in technique. Plast. Reconstr. Surg. 40: 378, 1967. cedures. The algorithm is presented to provide an 18. Costa, L. F., Landecker, A., and Manta, A. M. Optimizing easy, reliable method with which to classify pa- body contour in massive weight loss patients: The modified tients so that an adequate treatment plan can be vertical abdominoplasty. Plast. Reconstr. Surg. 114: 1917, 2004. offered. 19. Dellon, A. L. Fleur-de-lis abdominoplasty. Aesthetic Plast. Surg. 9: 27, 1985. Steven G. Wallach, M.D. 20. Duff, C. G., Aslam, S., and Griffiths, R. W. Fleur-de-lys ab- 1049 Fifth Avenue, Suite 2D dominoplasty: A consecutive case series. Br. J. Plast. Surg. 56: New York, N.Y. 10028 557, 2003. [email protected] 21. Wallach, S. G. Abdominal contour surgery for the massive weight loss patient: The fleur-de-lis approach. Aesthetic Surg. J. 25: 454, 2005. ACKNOWLEDGMENTS 22. Aly, A. S., Cram, A. E., Chao, M, et al. Belt lipectomy for The author thanks Eric A. Appelt, M.D., Jeffrey E. circumferential truncal excess: The University of Iowa ex- Janis, M.D., and Rod J. Rohrich, M.D., for inspiring perience. Plast. Reconstr. Surg. 111: 398, 2003. him to submit this article after reading their article en- 23. Gonzalez-Ulloa, M. Belt lipectomy. Br. J. Plast. Surg. 13: 179, 1960. titled “An Algorithmic Approach to Upper Arm Contour” 24. Hunstad, J. P. Body contouring in the obese patient. Clin. (Plast. Reconstr. Surg. 118: 237, 2006). Plast. Surg. 23: 647, 1996. 25. Muhlbauer, W. Radical abdominoplasty, including body shaping: Representative cases. Aesthetic Plast. Surg. 13: 105, REFERENCES 1989. 1. Avelar, J. Fat suction versus abdominoplasty. Aesthetic Plast. 26. Strauch, B., Herman, C., Rohde, C., and Baum, T. Mid-body Surg. 9: 265, 1985. contouring in the post-bariatric surgery patient. Plast. Reconstr. 2. Bozola, A. R., and Psillakis, J. M. Abdominoplasty: A new Surg. 117: 2200, 2006. concept and classification for treatment. Plast. Reconstr. Surg. 27. Matory, W. E., Jr., O’Sullivan, J., Fudem, G., and Dunn, R. 82: 983, 1988. Abdominal surgery in patients with severe morbid obesity. 3. Matarasso, A. Abdominolipoplasty: A system of classification Plast. Reconstr. Surg. 94: 976, 1994. and treatment for combined abdominoplasty and suction 28. Vastine, V. L., Morgan, R. F., Gampper, T. J., et al. Wound assisted lipectomy. Aesthetic Plast. Surg. 15: 111, 1991. complications of abdominoplasty in obese patients. Ann. 4. Song, A. Y., Jean, R. D., Hurwitz, D. J., et al. A classification Plast. Surg. 42: 34, 1999. of contour deformities after bariatric weight loss: The Pitts- 29. Petty, P., Manson, P., Black, R., et al. Panniculus morbidus. burgh Rating Scale. Plast. Reconstr. Surg. 116: 1535, 2005. Ann. Plast. Surg. 28: 442, 1992.

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30. Matory, W. E., Jr., O’Sullivan, J., Fudem, G., and Dunn, R. 36. Hurwitz, D. J., and Agha-Mohammadi, S. Postbariatric sur- Abdominal surgery in patients with severe morbid obesity. gery breast reshaping: The spiral flap. Ann. Plast. Surg. 56: Plast. Reconstr. Surg. 94: 976, 1994. 481, 2006. 31. Vastine, V. L., Morgan, R. F., Gampper, T. J., et al. Wound 37. Hunter, G. R., Carpo, R. O., Broadbent, T. R., and Woolf, R. complications of abdominoplasty in obese patients. Ann. M. Pulmonary complications following abdominal lipec- Plast. Surg. 42: 34, 1999. tomy. Plast. Reconstr. Surg. 71: 809, 1983. 32. Cardoso de Castro, C., Aboudib, J. H., Jr., Salema, R., Gradel, 38. Voss, S. C., Sharp, H. C., and Scott, J. R. Abdominoplasty J., and Braga, L. How to deal with abdominoplasty in an combined with gynecologic surgical procedures. Obstet. Gynecol. abdomen with a scar. Aesthetic Plast. Surg. 17: 67, 1993. 67: 181, 1986. 33. El-Khatib, H. A., and Bener, A. Abdominal dermolipectomy 39. Gemperli, R., Neves, R. I., Tuma, P., Jr., Bonamichi, G. T., Ferreira, in an abdomen with pre-existing scars: A different concept. M. C., and Manders, E. K. Abdominoplasty combined with other Plast. Reconstr. Surg. 114: 992, 2004. intraabdominal procedures. Ann. Plast. Surg. 29: 18, 1992. 34. Akbas, H., Guneren, E., Eroglu, L., Demir, A., and Uysal, 40. Hester, T. R., Jr., Baird, W., Bostwick, J., III, Nahai, F., and A. The combined use of classic and reverse abdomino- Cukic, J. Abdominoplasty combined with other major sur- plasty on the same patient. Plast. Reconstr. Surg. 109: 2595, gical procedures: Safe or sorry? Plast. Reconstr. Surg. 83: 2002. 997, 1989. 35. Baroudi, R., Keppke, E. M., and Carvalho, C. G. Mammary 41. Shull, B. L., and Verheyden, C. N. Combined plastic and reduction combined with reverse abdominoplasty. Ann. gynecological surgical procedures. Ann. Plast. Surg. 20: Plast. Surg. 2: 368, 1979. 552, 1988.

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