Abdominoplasty with Total Abdominal Liposuction for Patients with MassiveWeight Loss

Antonio Espinosa-de-los-Monteros, M.D., Jorge I. de la Torre, M.D., Laurence Z. Rosenberg, M.D.,Leonik A. Ahumada, M.D., Alexander Sto, M.D., Eric H. Williams, M.D., and Luis O. Vasconez, M.D.

Division of Plastic Surgery, University of Alabama at Birmingham and The Center for Advanced Surgical Aesthetics, 51020th Street, South, Birmingham, AL 35294, USA

Abstract.

Background: Massive weight loss after bariatric surgery isassociated with signicant skin excess, laxity, and ptosisover the abdomen. Good results have been achieved withabdominoplasty and circumferential lipectomy. However,

blood transfusions are sometimes needed, and patients mayrequire long hospital stays. Furthermore, morbidity ratesare high. Total abdominal liposuction performed with ab-

dominoplasty allows for the preservation of lymphaticvessels below Scarpas fascia and eliminates the need forupper ap undermining. This study aimed to evaluate this

technique in patients with anterior abdominal redundancyattributable to massive weight loss after bariatric surgery.Methods: The charts of 60 patients treated betweenDecember 2001 and October 2004 were retrospectively re-

viewed. All the patients had undergone previous bariatricsurgery as well as subsequent total abdominal liposuctionand abdominoplasty.

Results: The average amount of wetting solution used was3.1 l, and the average total aspirate was 2.5 l. The meanpannus weight was 3,649 g, and the average dimension was

48 25 6 cm. No patient required a blood transfusion.The median in-hospital stay was 1 day, with 42% of thepatients treated as outpatients. The median follow-up per-

iod was 3 months. Morbidity was 22%. Factors associatedwith the development of complications were weight of thepannus, transverse dimension of the pannus, and bodymass index. All the patients were satised with the results.

Conclusions: Total abdominal liposuction followed by ab-dominoplasty is adequate treatment for anterior abdominalredundancy for patients with massive weight loss.

Key words: Abdominal redundancyAbdominoplasty

Bariatric surgeryMassive weight lossTotal abdominalliposuction

Bariatric surgery has evolved as a very eectivetherapy for morbid obesity. Patients who undergobariatric surgery lose an average of 40% to 84% oftheir excess weight over 12 to 18 months [17]. Bari-atric surgery improves abnormal lipid levels, controlshypertension, and reduces the risk of diabetes by asmuch as 75%. Overall, mortality from obesity-relatedproblems can be decreased as much as 24% [7,21,23].Unfortunately, these patients experience signicantskin excess, laxity, and ptosis in multiple areas, whichmay lead to postural, functional, hygenic, dermato-logic, and aesthetic impairment.Typically, these patients initially pursue body

contouring out of concern for excess abdominal lax-ity, but other aected areas are the trunk, hips,thighs, arms, and breasts. The abdominal deformitycan be corrected with many techniques includingabdominal dermolipectomy, full abdominoplastywith or without liposuction, belt lipectomy, high-lateral-tension abdominoplasty, and vertical abdom-inoplasty [1,3,5,14,15]. Traditionally, good resultshave been achieved. However blood transfusions areneeded in 5% to 80% of these patients. The hospitallength of stay averages 2 to 9 days among reportedseries, and morbidity rates range between 15% and60% in specialized centers [4,6,19].Abdominoplasty techniques were introduced in the

1960s, but have undergone a continuous process ofevolution to provide better and safer results. Onemajor advance has been the introduction of total

Correspondence to Jorge I. de la Torre, M.D., FOT 1102,1530 3rd Avenue South Birmingham, AL 35294-3411,USA; email: jdlt@uab.edu

Aesth. Plast. Surg. 30:4246, 2006DOI: 10.1007/s00266-005-0126-9

abdominal liposuction before pannus resection [18].The technique of selective upper ap underminingwith preservation of blood vessels and nerves elimi-nates the need for total surgical undermining [8,13].Also, suctioning rather than resection of the deepabdominal fat, preserves lymphatics while allowingfor resection of the pannus at a more supercial level[10,11]. Finally, a smoother transition between upperand lower aps is achieved [12].The purpose of this study was to evaluate the ef-

fects of total abdominal liposuction and subsequentabdominoplasty for patients with anterior redun-dancy attributable to massive weight loss afterbariatric surgery.

Material and Methods

We retrospectively reviewed the charts of all the pa-tients who presented to our service with anteriorabdominal wall redundancy resulting from massiveweight loss after bariatric surgery. The patientstreated by means of total abdominal liposuction andsubsequent abdominoplasty during the period be-tween December 2001 and October 2004 wereincluded in this study.The surgical technique begins with prepping and

draping of the patient, usually under general anes-thesia. Preoperative antibiotics are administered to allpatients. Lidocaine 1% with epinephrine 1:200,000 isadministered along the dermis in the region that willbe excised as part of the panniculectomy. Supercialskin incisions are made to avoid losing the markingsduring liposuction. Wetting solution then is inl-trated throughout both the supercial and deep fatlayers of the whole anterior abdomen, and liposuc-tion then is performed. With this technique, we areable to remove the deep fat beneath the Scarpasfascia, to undermine the upper ap selectively bytunneling with the liposuction cannula, to preservethe upper ap blood supply by eliminating the needfor further surgical undermining, and to liposuctionthroughout the whole anterior abdomen, facilitatinga smooth transition between the upper and loweraps once the pannus is removed.After liposuction, we excise the redundant skin and

supercial fat layer above the level of the Scarpasfascia, preserving the lymph vessels below it. A ligh-ted retractor is used to create a narrow tunnel in themidline from the umbilicus to the epigastrium. Adouble-layered rectus muscle plication is performedfrom the epigastrium to the pubis using interrupted 0Prolene suture reinforced with continuous running 0nylon. Finally, the umbilicus is repositioned; 19-Blake drains are exteriorized; and the upper andlower aps are approximated with the hips exed. Acompression binder is placed, and patients are al-lowed to ambulate immediately with the hips exed.The drains are removed when the output is less than30 ml of serous uid per day.

The variables studied included gender, age, height,weight, body mass index (BMI) (both at the time ofbariatric surgery and at the time of abdominoplasty),time elapsed between procedures, comorbidities,pannus dimension, amount of wetting solution inl-tered and total aspirate, pannus weight, other pro-cedures performed, transfusions, hospital length ofstay, pre- and postoperative hemoglobin and hemat-ocrit, complications, their treatment, and total fol-low-up evaluation. Also we examined patientsatisfaction labeled as regretful, disappointed, satis-ed, or very satised. Dierences in complicationswere studied by unpaired Students t-test, and statis-tical signicance was set to a p value less than 0.05.Factors aecting pannus weight were analyzed withthe correlation coecient, and signicance was set atan r2 value greater than 0.25.

Results

The study enrolled 60 patients with an average age of43 years (range, 2561 years). The average BMI atthe time of the bariatric procedure was 54 kg/m2

(range, 4272 kg/m2). Gastric bypass had been per-formed for 97% of the patients, whereas vertical-banded gastroplasty had been performed for 3%. Theaverage time from the bariatric surgery to the ab-dominoplasty was 26 months (range, 11216months). The BMI at the time of abdominoplastywas 31 kg/m2 (range, 2147 kg/m2), with 8% of thepatients rated as morbidly obese (BMI > 35 kg/m2).The mean weight loss after bariatric surgery was 40%(range, 2854%). The average amount of wettingsolution used was 3.1 l (15l), and the average totalaspirate was 2.5 l (range, 0.56.4 l). The inltration-to-aspiration ratio was 1.3:1. The mean pannusweight was 3,649 g (range, 6908575 g), and theaverage dimensions were 48 25 6 cm (range, 15 15 2 to 99 55 20 cm).At the time of the abdominoplasty, 25% of the

patients underwent hernia repair, and 33% underwentother procedures including mastopexy for 11 pa-tients, reduction mammaplasty for 5 patients, brac-hioplasty for 3 patients, and thighplasty for 1 patient.No patient required a blood transfusion. The medianin-hospital stay was 1 day (range, 05 days), with 25patients (42%) treated as outpatients. The meanhemoglobin levels were 12.8 g/dl preoperatively and10.5 g/dl postoperatively, and the average decreasewas 15%. A total of 14 complications occurred in 13patients (22%), including 13 local complications (6partial dehiscences, 3 skin edge necrosis, 2 seromas, 1abscess, and 1 wound infection) and 1 case of acuterenal failure requiring intravenous uid resuscitation.None of the local complications required furtherhospital admission or treatment in the operatingroom. The median follow-up period was 3 months(range, 115 months). The factors associated withthe development of complications were weight of the

A. Espinosa-de-los-Monteros 43

pannus (5,433 vs 2848 g; p < 0.0001), transversedimension of the pannus (61 vs 42 cm; p< 0.01), andBMI (35 vs 28 kg/m2; p< 0.05). The factors aectingpannus weight were BMI (r2 = 0.89) and transversedimension of the pannus (r2 = 0.38). Neither thedierence in the amount of wetting solution injectednor the dierence in the total fat aspirated had aneect on the dierences in the pannus weight (r2 =0.05 and 0.04, respectively). The patients treated asoutpatients did not have any dened comorbidity andwere not obese (BMI < 30 kg/m2). According to aseparate analysis, their pannus transverse dimensionwas shorter than 60 cm, and their pannus weighedless than 4,000 g. The associated postoperative mor-bidity rate was 12% (partial wound dehiscences).Whereas 88% of the patients were very satised withtheir results, 12% graded their results as satisfactory.No patients were disappointed or regretful.

Discussion

Obesity is dened as a BMI of 30 kg/m2 or more.Approximately 20% of obese people are morbidly ob-ese, dened as aBMIof at least 40 kg/m2 or aBMI of atleast 35 kg/m2 in the presence of high-risk comorbidconditions such as hypertension, coronary artery dis-ease, cerebral ischemia, peripheral venous insu-ciency, thrombophlebitis, obstructive sleep apnea,obesityhypoventilation syndrome, diabetes mellitus,hyperlipidemia, and back disc herniation or osteoar-thritis of weightbearing areas, among others [2,16].Although lifestyle changes, use of herbal therapies,

and some pharmacologic agents may improve weightloss, the results often are disappointing and tempo-rary. For these reasons, bariatric surgery has becomethe method of choice for the management of morbidobesity [9].After surgery, patients lose 80% of their excess

weight, on the average, by 1 year [17]. As this massiveweight loss occurs, patients experience changes intheir morphology. The skin that drapes their excessvolume becomes lax and redundant, particularly atthe abdomen. As a result, mechanical and posturaldeciencies along with dermatosis on the skin foldsinterfere with their ability to perform routine tasks,worsen their self-esteem, and facilitate the develop-ment of secondary conditions. Also, the trunk,thighs, arms, and breasts may be aected, creating achallenging dilemma that usually requires severalsurgical procedures for proper correction.In the most severe cases, the abdominal deformity

occurs circumferentially, and is better managed witha circumferential procedure such as belt lipectomy orhigh-lateral-tension abdominoplasty. Nevertheless,some patients are better served by an anterior-onlyprocedure, either because they have a dermatoliposisthat is more prominent on the abdomen itself and noton the anks and on the back, or because their desireis to undergo an anterior-only procedure (Figs. 1, 2,

and 3). Either anterior dermolipectomy or full ab-dominoplasty may be considered for this subset ofpatients. Directed liposuction also has been used forcontour-specic areas such as the anks and thepubis. With these techniques, the reported morbidityrates have ranged from 15% to 60%, with 5% to 80%

Fig. 1. A 39-year-old patient with 79 kg of weight loss whounderwent total abdominal liposuction and full abdomi-noplasty through a low transverse incision. Above left:preoperative anterior view. Above right: postoperativeanterior view. Below left: preoperative lateral view. Belowright: postoperative lateral view.

Fig. 2. A 40-year-old patient with 50 kg of weight loss whounderwent total abdominal liposuction and full abdomin-oplasty through a eur-de-lis incision. Above left: preop-erative anterior view. Above right: postoperative anteriorview. Below left: preoperative lateral view. Below right:postoperative lateral view.

44 Abdominoplasty with Total Abdominal Liposuction

of patients requiring a blood transfusion, and thereported length of hospitalization has ranged from 2to 9 days [4,6,19].In 1987, Ohana et al. [18] described some advan-

tages of using liposuction as an adjunct to abdom-inoplasty, including easier upper ap advancement.In 1992, Le Louarn [11] proposed liposuctioning theabdominal pannus to remove the deep abdominal fat,and then performing the abdominoplasty resection ata more supercial level to preserve the blood vesselsand lymphatics, thus decreasing the risk for seromaformation. In the same year, Illouz [8] reinforced hisprevious ndings, noting that an eective, discon-tinuous undermining is achieved by liposuction of theupper ap. This method avoids the need for surgicalundermining, thus preserving the vessels and nervesto the ap and to the area that denes the woundedge. It also decreases the amount of blood lossduring and after the surgery [8]. Lockwood [13] alsorecognized the utility of liposuction underminingduring abdominoplasty, and its ability to preserveperforators to the surface of the abdominal wall.One year later, in 1996, Le Louarn [10] updated his

experience with his technique, reporting no seromaformation and shorter hospitalizations by removal offat with liposuction and preservation of the abdomi-nal layers that include lymphatic vessels. Le Louarnand Pascal [12] detailed several steps for an attempt toavoid local complications during abdominoplasty bythe use of liposuction. In 1999, Shestak [22] intro-duced the term marriage abdominoplasty because itinvolves the use of abdominoplasty and extendedliposuction, and reported a morbidity rate of 7%, with

60% of cases managed on an outpatient basis.Saldanha et al. [20] further demonstrated the safety ofthis technique with a published morbidity of 3%.In the current series, we applied these concepts to

patients with anterior abdominal skin excess resultingfrom massive weight loss who were candidates for ananterior-only procedure. In our series, the morbidityrate of 22% resulted from local wound complicationsrequiring standard ambulatory care and one case oftransient renal insuciency. None of the patientsrequired intraoperative or postoperative transfusions,and the median hospital stay was 1 day. The patientswith less severe abdominal dermatoliposis and with-out comorbidities (including current obesity) weretreated successfully in the outpatient setting.The factor most commonly associated with post-

operative complications was the weight of the pan-nus, a factor that cannot be accurately known beforesurgery. Pannus dimension and BMI (factors that canbe determined before surgery) also were associatedwith postoperative complications, and correlatedpositively with pannus weight. Dierences in theamount of wetting solution administered or in theamount of fat aspirated did not aect the weight ofthe pannus among patients. All the patients weresatised with the results and willing to undergo fur-ther contouring procedures. Further technical devel-opments are needed to guarantee safer results for thissubset of patients, and for those with a more severeform of the disease.

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A. Espinosa-de-los-Monteros 45

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46 Abdominoplasty with Total Abdominal Liposuction