The long term results of abdominoplasty patients compare favorably in a number of reports in the literature. Hensel et al. reported an overall complication rate of 32% with only a 1.4% major complication rate. There were 43% surgery revision rates mostly due to aesthetic concerns. 14% of the patients had seroma requiring intervention while 7% had a wound infection. Less than 2% of the patients had a hematoma and as expected, there was a statistical significant difference in patients who smoked tobacco, had diabetes and/or hypertension [6]. Stewart and colleagues published a level IV evidence paper on 278 consecutive abdominoplasty patients where they stratified them according to “early” versus “late” time points and noted an 18% “early” complication rate for the seroma, hematoma, infection, skin or fat necrosis, and delayed wound healing. Approximately 25% of the patients developed “late” complications including dog ears, localized fatty excess, and unsatisfactory scars requiring a revision rate of 24% [7].

In the USA, obesity is a growing epidemic [8] that can be treated by several medical modalities. Bariatric surgery, aggressive diet, and exercise regimens have become more commonplace [9]. Thus, more patients are experiencing massive weight loss (MWL) defined as an intentional decrease of at least 100 pounds in a patient’s body weight in the setting of morbid obesity [10]. While this is life saving, there are a number of consequences of body transformation. The development of loose and overhanging skin in many different parts of the body is expected as patients lose weight; however, the abdomen tends to be a significant area of deformity and concern for many patients. Although abdominal contouring techniques are well established, treating the MWL patient is unique. The abdominal wall has more anatomic variability, and the patients often times have altered nutritional intake [11]. Therefore, the complication rates are higher in the post bariatric surgery patient [12, 13], forcing surgeons to have a different approach to the pre-operative evaluation, intraoperative execution, and post-operative care.

Successful wound healing is predicated on the patient having the necessary nutrition in a stressed state. Concerns for nutritional inadequacy are more likely in MWL patients after gastric surgeries than from diet and exercise. Specifically, gastric bypass patients are of particular concern because the operation limits both nutritional intake and absorption [11]. Therefore, knowing the specific type of bariatric surgery performed in addition to a detailed nutritional history is critical in the pre-operative evaluation. The nutritional history includes several components. The course of weight loss should be well defined: date of bariatric surgery, starting body mass index (BMI) before surgery, lowest BMI after surgery, current BMI, goal BMI, fluctuations over the past 1–3 months. The patient should ideally be stable in their weight for at least 4 months prior to undergoing abdominal contouring procedures. Generally, the weight loss plateau occurs 12–18 months after bariatric surgery [9, 14]. Patients who are still obese after MWL have further increased complication rates, and generally, the lower the BMI the better the aesthetic result. Patients may, therefore, consider additional weight loss. It is important to counsel patients that abdominal contouring does not result in significant weight reduction. A medication list detailing nutritional supplements should be obtained at the initial consultation and should include iron, vitamin B12, calcium, zinc, and a multivitamin. Ideally, a protein intake assessment should be performed, encouraging a peri-operative daily intake of 70–100 gm [11]. A laboratory workup should also be included to objectively define nutritional and metabolic values: hematocrit/hemoglobin, basic metabolic panel, albumin/prealbumin. The patient may need to be referred to a nutritionist to help optimize deficient aspects of the evaluation.

Physical examination of the abdomen in the MWL patient should include close assessment for hernias, prior incisions, and extent of skin laxity. Morbidly obese patients often times have umbilical hernias and patients with open bariatric procedures may have incisional hernias. These hernias may not necessarily be appreciated on exam; however, hernia repair can be safely performed at the same time as the contouring procedure [9, 15]. MWL patients often present with a history of multiple abdominal surgeries, and the location and extent of the prior incisions need to be closely assessed. The skin and soft tissue of the abdominal wall receives its blood supply from perforating vessels from the superior epigastric, inferior epigastric, circumflex iliac, intercostals, and lumbar arcade. The dissection required in many abdominal contouring procedures requires extensive dissection of the abdominal wall up to the costal margin and xiphoid process. As a result, the remainder of the blood supply to the abdominal soft tissue flap is coming laterally from the lumbar arcade and the intercostals [16, 17]. Therefore, prior incisions above the umbilicus of moderate length, such as an open cholecystectomy incision, are the most concerning for potential wound healing problems or skin flap necrosis. The inferior-central part of the abdominal flap is the furthest from the blood supply and the part under the most tension upon closure, making this portion of the incision most at risk for vascular compromise especially in the setting of a prior superior-lateral incision. Additionally, patients should be counseled that prior incisions above the umbilicus will translocate inferiorly and medially with the abdominal contouring procedure, while incisions below the umbilicus will likely be resected along with the pannus. MWL patients also present with excess skin and soft tissue in the cranial-caudal dimension, resulting in one or multiple overhanging pannus that can either be isolated to the abdomen or extend circumferentially. Additionally, excess abdominal tissue can also be present in the side-to-side dimension [18, 19]. Determining the extent of the laxity will determine the optimal abdominal contouring procedure required.

Patient selection and managing expectations is critical in successful abdominal contouring, especially in the MWL patient. Many patients expect minimal downtime, low complications, minimal scarring, flawless results without needing revisions, and no out-of-pocket costs [9, 10, 20]. Patients must understand that abdominal contouring in this setting is a larger operation than the bariatric surgery in the sense that the incisions are longer, the dissection is more extensive, and the duration of the operation may be longer. Therefore, the downtime and the recovery can be more painful, more prolonged, and more likely to have wound healing complications. Abdominal contouring in the MWL patient is more functional than aesthetic with the surgical goal of restoring the dynamics of the abdominal wall with hernia repair, fascial plication, and soft tissue tailoring; therefore, the aesthetic results may not necessarily be the same as a purely cosmetic operation. Patients have to accept that there is a trade-off between contour and scars: improving contour is limited by the size of excision, and thus, the size of the resulting scar. Furthermore, the evolution of the scar and its final appearance is, in part, a function of genetics, ethnicity, anatomic location, and intrinsic/extrinsic biologic factors [21]. Unlike cosmetic abdominal contouring where the goal is to minimize scarring, in the MWL patient, contour is valued higher. Therefore, scarring is inevitable, and several excisions may be necessary to achieve the desired contour.

Operative staging is necessary in many MWL patients especially if several anatomic locations require contouring. The risks of infections, poor wound healing, and thromboembolic events inherent with prolonged operative times means that the surgeon and the patient need to prioritize surgical locations and goals. Often times, the abdomen is the patient’s highest priority; and, abdominoplasty can be combined with mastopexy, lower body lift, or brachioplasty in the first stage [22, 23]. However, patient safety is the primary concern and procedures should be divided into as many stages as necessary.

Patients may present for excision of a large abdominal pannus before bariatric surgery or significant weight loss or for a repair of large hernia. A large, overhanging abdominal pannus can greatly impede adequate hygiene and ambulation, resulting in intertrigo, recurrent cellulitis, and ulcerations. Furthermore, removing the pannus can aid in surgical access for bariatric, gynecologic, and colorectal procedures. Panniculectomy can sometimes be combined with these procedures; however, combining these procedures can result in high complication rates [24–26], and strong consideration for staging is recommended.

The patient is marked in the standing position to determine the superior and lateral extent of the pannus, which will be obscured in the supine position. The primary goal in panniculectomy is removal of the overhanging pannus with minimal to no undermining of skin flaps and minimal to no tension at the incision line. The size and weight of the pannus can be unwieldy, making dissection without undermining and minimizing blood loss difficult. Furthermore, sterilely preparing the abdominal surgical site with an overhanging pannus is difficult to perform and increases the risk of wound complications in a patient who is already at high risk for wound dehiscence and infection. Therefore, utilizing a pannus suspension system (Hoya crane) during the operation to help lift the pannus off the abdomen can be beneficial. After initial preparation and draping of the surgical site and the suspension system, large penetrating clamps are placed along the pannus and a sterile rope is pasted through the clamps and secured to the suspension system. The pannus can then be lifted for additional sterile preparation and the remainder of the operation.

Dissection is started at the lateral aspect of the pannus and performed straight down to the fascia, avoiding undermining of the inferior and the superior skin flaps. Avoiding skin flap undermining is important to minimize potential space and maximize skin flap vascularity to help prevent post-operative collections and wound dehiscence. Often times, large perforating vessels are encountered during the dissection and require clip application or suture ligation. LigaSure Impact (Covidien Surgical Solutions Group, Boulder, CO) can also be used as an adjunct in the dissection to facilitate speed of the resection without having to identify and dissect the individual intermediate to large sized subcutaneous vessels. The pannus is removed from the abdominal wall at the level of the fascia from lateral to medial and the suspension system can be further elevated to facilitate identifying the proper plane. Often times, the umbilicus is part of the overhanging pannus and will need to be amputated along with the specimen. If the pannus resection does not include the umbilicus, care must be taken to avoid undermining the umbilical stalk and the patient should be warned that the umbilical position will be lower on the abdominal wall upon closure and may possibly appeared tethered. Since occult umbilical hernias may be present, caution should be paid during dissection in the periumbilical region.

The management of the closure in a panniculectomy is varied. The lymphatic vessels in a large pannus are often dysfunctional, contributing to expanding cycle of lymphedematous skin and subcutaneous tissue [27]. The risk of post-operative wound infections, collections, and dehiscence in this setting is significantly high. Additionally, proper sterile preparation of the pannus is difficult. Therefore, some surgeons will opt for an open wound closure method [28]. Large permanent sutures are placed in a wide mattress fashion with skin retention bolsters at 10–15 cm intervals. The knots are placed on the superior skin flap to aid in removal in the office and provide improved comfort for the patient. A saline moist kerlix gauze is used to pack the interval wounds and changed 1–2 times a day until the wound has healed from deep to superficial. The sutures are removed when complete healing is achieved which may take 2–4 weeks. On the other spectrum, some report low complications with a standard layer closure [25]. As a compromise, others have utilized negative pressure wound therapy applied to the open incisions laterally while performing a loose or layered closure centrally. The advantage of negative pressure therapy is a reduction of dressing changes for the patient as well as faster wound closure compared to traditional open wound management. Brown et al. demonstrated that layer closure of massive panniculectomies resulted in a 44% readmission rate and a 33% reoperation rate for wound complications compared to a 0% readmission and reoperation rate in patients treated with open wound management with negative pressure therapy [29].

The post-massive weight loss abdominoplasty can be performed in either one of the two patterns of resection. The traditional pattern, as described earlier in the chapter, consists of an elliptical excision of infraumbilical skin laxity and adiposity that spans from hip to hip. This pattern mainly addresses skin laxity in a cranial-caudal direction with mild to moderate improvement of the horizontal laxity through a high lateral tension technique [30] and by the Poisson ratio when the abdominal flap is put on vertical tension. However, MWL patients may present with excessive horizontal skin laxity and adiposity in addition to the overhanging pannus, which cannot be adequately addressed with a traditional resection pattern. A fleur-de-lis pattern may be more appropriate in this setting and is characterized by a midline vertical elliptical resection in addition to the infraumbilical resection. The final resection pattern resembles the stylized French lily symbol to which the pattern is named. The ability of the fleur-de-lis abdominoplasty to provide a superior abdominal contour in the MWL patient has been well described [30–35]. In short, abdominal contour deformity in the setting of massive weight loss can be highly variable and may require additional contouring techniques to achieve the best cosmetic result.

In 2005, Song et al. [18] developed the Pittsburgh Rating Scale: a four-tiered, region-specific classification system for skin laxity and ptosis following bariatric surgery. The abdomen scale consists of grades 0, 1, 2, 3: 0 indicates normal appearance, 1 for moderate adiposity without overhang, 2 for overhanging pannus, and 3 for all multiple roll deformities. The multiple roll deformity was further broken down into sub-grades because the lateral extent and number of rolls had clinical significance on whether a traditional abdominoplasty could be performed. Patients with an upper roll restricted to the panty-girdle line anteriorly were 3a grade, extending to midaxillary line were 3b grade, extending to the back were 3c grade, and triple roll deformities were 3d grade. In a retrospective review of 1006 massive weight loss patients presenting for abdominal contouring procedures, Zammerilla et al. [19] determined that patients with higher deformity grades, crossing into grade 3, were more likely to undergo fleur-de-lis abdominoplasties. Furthermore, patients with larger changes in BMI after massive weight loss were more likely to have higher grade deformities as well as patients who had massive weight loss secondary to bariatric surgery versus diet and exercise . The maximum BMI before weight loss did not significantly differ between the traditional and the fleur-de-lis groups. Therefore, patients that have a large change in BMI after weight loss with high grade deformities are most likely to benefit from adding a vertical component to an abdominoplasty.

The initial surgical approach to abdominoplasty in the MWL patient is similar to the traditional operation described earlier. The inferior incision is marked first in the midline at a point 6–7 cm above the vulvar commissure with the tissues on full stretch. The lateral extent of the hip roll is marked and the midline and lateral points are connected, forming the inferior incision. In the MWL patient, the inferior incision may be inferior to the inguinal ligament; however, upon closure, the final position of the incision is pulled superiorly. If a fleur-de-lis is indicated, a pinch test in the midline is used to approximate the extent of the vertical resection. Dissection through the inferior incision is started first. Lymphatics below the inguinal ligament should be preserved. Therefore, if the marking is below the inguinal ligament laterally, dissection is superficial until superior to the inguinal ligament at which point dissection is deepened to the abdominal wall fascia. The infraumbilical flap is dissected in a plane at the level of the fascia and the umbilicus is detached from the abdominal flap. The superior extent of the resection is determined with the patient in the flexed position and then transverse resection is performed. The transverse incision is then temporarily closed with staples or towel clips in order to address the vertical component of the resection. The vertical markings from the transverse incision to the xiphoid are confirmed with the pinch test, being more conservative with the resection inferiorly. The vertical dissection is then performed down to the abdominal wall fascia. No undermining of the vertical resection is crucial in order to preserve the perforating vessels to the skin flap. The “T” junction can then be adjusted to maximize the vertical and transverse resections to create the best contour. The transverse incision is closed first, starting at the mons pubis. Often times in the MWL patient, there is more thickness of the soft tissue at the mons pubis compared to the abdominal skin flap. Direct fat excision or suction assisted lipectomy can be performed. If the mons is inferiorly displaced, it can be suspended to the anterior abdominal wall. Drains extending laterally and centrally are placed and the incisions are closed in layers. The umbilicus is inset directly into the vertical incision at the level of the anterior superior iliac spine.

Post-operatively, the patient is placed in an abdominal binder and maintained in a flexed position when transferring from the operating table to the stretcher . The patient records the drain output, and the drains are removed when the daily output is less than 30 cc. A compression garment can be applied once the drains are removed. Strenuous activity and exercise is avoided for 4 weeks.

The lateral and posterior extensions of high grade abdominal contour deformities are not necessarily corrected with an abdominoplasty even if a vertical resection component is included. This set of patients require lateral hip and back dermatolipectomies in addition to the abdominoplasty. Although these procedures can be separated in multiple stages, a circumferential lower truncal contouring procedure can be performed in a single stage. Belt lipectomy and lower body lift are the most commonly described [22, 36, 37]. In a recent study, approximately 50% of surgical patients presenting for body contouring after massive weight loss received a concomitant contouring procedure in addition to abdominoplasty. Most commonly, the additional procedure was a lower body lift [19]. Although there are numerous terms used for circumferential lower truncal procedures, each with slight variation on technique, the principles are generally the same. Anteriorly, the objective is to remove the overhanging pannus and pull down excess skin and adiposity. While posteriorly, the objective is to remove any continuance of the abdominal pannus and pull up the hanging skin and adiposity of the hip and buttock. When a circumferential resection is performed in a single stage, a more aggressive skin resection can be utilized laterally without creating a point of redundancy, often referred to as a dog-ear deformity [38]. There may also be a need for concomitant reinforcement with acellular dermal matrix for fascial integrity (Fig. 24.2).

The belt lipectomy incision is often higher than in lower body lift and better targets waist contouring than posterior-lateral lifting. The lower body lift incision over the buttocks allows for focused gluteal shaping and augmentation, and lifting of the lateral thighs [39]. Circumferential lower truncal procedures must be performed with one or more intraoperative position changes, which require several people to perform in a well-coordinated manner. A two position (prone to supine) sequence is commonly used in the lower body lift; however, a three position (supine to left lateral to right lateral) sequence can be used if focus on the anterior and lateral contour is prioritized over the posterior [36, 37]. Proper padding is crucial when the patient is in the prone or lateral decubitus positions. The anterior component of the operation is performed as described previously for a traditional abdominoplasty or a fleur-de-lis. The posterior dissection can be performed at different depths depending if the buttock is overprojected or underprojected. Generally though, massive weight loss patients present with a ptotic underprojected buttock, while patients with a high BMI present with an overprojected buttock. If overprojected, dissection is performed at the level of the muscle fascia; and if underprojected, dissection is at the level of the superficial fascia in order to leave as much adipose tissue behind. Leaving adipose tissue posteriorly results in autologous augmentation of the gluteal tissue upon closure, stacking the tissues [40–42]. Proper closure of the posterior-lateral dissection results in lifting of the lateral thighs and buttock. Specifically, the soft tissue below the incision can be suspended superiorly by using anchoring sutures to the superficial fascial system (SFS). The SFS is a subcutaneous network of connective tissue that binds skin and adipose tissue to the underlying musculoskeletal structure. In 1991, Lockwood first described the SFS and its utility in lower body lifts [43, 44]. Since then, the principle of SFS suspension has greatly impacted posterior lower truncal contouring by improving long term aesthetic outcomes and minimizing complications [36–38, 45, 46].

Post-operatively, the patient is transferred from the operating table in a flexed position. Over-flexion and under-flexion have to be balanced to avoid undue tension on the anterior and posterior incisions. Although patients can be discharged home the same day of surgery, many surgeons will advocate one to two nights of hospitalization to ensure proper pain control and ambulation. The patient records the drain output, and the drains are removed when the daily output is less than 30 cc. A compression garment can be applied once the drains are removed. Strenuous activity and exercise is avoided for 4 weeks.

Despite advancements in peri-operative management, abdominal plastic surgery procedures have been associated with complications, a few of which can be life threatening [47, 48]. The most common complications of abdominoplasty include: hematoma, seroma, wound healing problems, infection, and skin flap necrosis [49–51].

Some research studies have shown that abdominoplasty may increase the likelihood of complications if done with other gynecologic or pelvic operations, or bariatric surgery compared to when performed alone [52, 53].

Lievain et al. reported on 238 patients of which 114 were post bariatric patients, and showed that the risk of complications in post bariatric patients is much higher (55.3% vs 26.6%) than patients who have abdominoplasty procedures alone [48]. Obesity, long operative times, and post-operative drainage compromise might be the reasons for increased risk of complications in this group of patients [48]. Another study conducted by Smith et al. looked at 300 patients (of which 75.3% cases were combined surgeries) to find out the increased risk associated with concurrent abdominoplasty and liposuction. They found no increased risk of post-operative complications for these concurrent surgeries as long as the perforator vessels remained intact to keep a consistent blood supply to the central abdomen [53].