Age as a Risk Factor in Abdominoplasty

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1 Age as a Risk Factor in Abdominoplasty Rafael A. Couto, MD, Gregory A. Lamaris, MD, PhD, Todd A. Baker, MD, Ahmed M. Hashem, MD, Kashyap Tadisina, MD, Paul Durand, MD, Steven Rueda, MD, Susan Orra, MD, James E. Zins, MD, FACS

2 Body Contouring Age as a Risk Factor in Abdominoplasty Rafael A. Couto, MD; Gregory A. Lamaris, MD, PhD; Todd A. Baker, MD; Ahmed M. Hashem, MD; Kashyap Tadisina, MD; Paul Durand, MD; Steven Rueda, MD; Susan Orra, MD; and James E. Zins, MD, FACS Aesthetic Surgery Journal 2017, Vol 37(5) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com DOI: /asj/sjw227 Abstract Background: Recent studies reviewing large patient databases suggested that age may be an independent risk factor for abdominoplasty. However, these investigations by design considered only short-term major complications. Objectives: The purpose of this investigation was: (1) to compare the safety of abdominoplasty in an elderly and younger patient population; (2) to determine the complication rates across all spectrums: major, minor, local, and systemic; and (3) to evaluate complications occurring both short and long term. Methods: Abdominoplasty procedures performed from 2010 to 2015 were retrospectively reviewed. Subjects were divided into two groups: 59 years old and 60 years old. Major, minor, local, and systemic complications were analyzed. Patient demographics, comorbidities, perioperative details, adjunctive procedures were also assessed. Results: A total of 129 patients were included in the study: 43 in the older and 86 in the younger age group. The median age of the elderly and young groups was 65.0 and 41.5 years, respectively (P < 0.001). No statistically significant differences in major, minor, local, or systemic complications were found when both age groups were compared. Major local, major systemic, minor local, and minor systemic in the elderly were 6.9%, 2.3%, 18.6%, and 2.3%, while in the younger patients were 9.3%, 4.7%, 10.5%, and 0.0%, respectively (P > 0.05). Median follow-up time of the elderly (4.0 months) was no different than the younger (5.0 months) patients (P > 0.07). Median procedure time in the elderly (4.5 hours) was no different than the younger group (5.0 hours) (P = 0.4). The elderly exhibited a greater American Society of Anesthesiologist score, median body mass index (28.7 vs 25.1 kg/m 2 ), and number of comorbidities (2.7 vs 0.9) (P < 0.001). Conclusions: There was no significant difference in either major or minor complications between the two groups. This suggests that with proper patient selection, abdominoplasty can be safely performed in the older age patient population. Level of Evidence: 2 Editorial Decision date: October 28, 2016; online publish-ahead-of-print January 20, Seniors currently represent the fastest growing sector of the American population. The 60-year age group will nearly double worldwide from 12.0% to 22.0% by the year Furthermore, this age group accounts for a significant portion of the surgical population. Forty percent of all operations 2 and 7.5% of cosmetic interventions in the United States were performed in patients over 65 years of age. 3 Several studies have suggested that age is an independent risk factor with regard to surgical complications in a wide variety of specialties. 4-6 Cosmetic surgery patients may be the exception. Unlike other disciplines, plastic surgeons have the benefit of From the Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH. Dr Zins is the Facial Surgery Section Editor for Aesthetic Surgery Journal. Corresponding Author: Dr James E. Zins, Department of Plastic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA. zinsj@ccf.org

3 Couto et al 551 preselecting those patients who undergo cosmetic procedures. In fact, a recent study demonstrated that with proper selection, patients 65 years and older could undergo facelift surgery with a risk similar to that of a younger patient population. 7,8 However, other studies have suggested that age may independently increase the risk of complications following abdominoplasty Given that older individuals are seeking cosmetic surgery in growing numbers, and that the abdominoplasty carries a greater risk than other cosmetic procedures, this topic, perhaps, deserves further evaluation Therefore, the purpose of this investigation is: 1) to compare the safety of abdominoplasty in an elderly and younger patient population; 2) to determine complication rates across all spectrums: major, minor, local, and systemic; and 3) to evaluate complications occurring before and after postoperative day 30. METHODS After approval by the Cleveland Clinic Foundation institutional review board (IRB), a retrospective review of all patients who underwent an abdominoplasty between January 1, 2010 and December 31, 2015 was performed. Abdominoplasty was defined as the resection of abdominal skin and subcutaneous soft-tissue, with undermining up to the xiphoid process, and included transposition of the umbilicus. Mini-abdominoplasty patients, abdominoplasty following massive weight loss (MWL) greater than 100 lbs, and abdominoplasty patients in whom the umbilicus was not transposed (ie, panniculectomy) were excluded from the study. Patients were divided into two groups: 59 years old and 60 years old and stratified according to the year of their surgical procedure. A minimum of 1 month of follow up was required for study entry. Since the younger patients far exceeded the older ones, we utilized a younger subgroup equal to twice the number of the elderly patients in the data analysis. Younger age group patients were randomly selected from the list of all younger individuals undergoing abdominoplasty using randomization software (SPSS v.16, Chicago, IL). Each patient s electronic medical record was reviewed, including preoperative history and physical examination, preoperative medical clearance, operative reports, anesthesia records, and all postoperative notes for the duration of the follow up period. The primary outcomes were occurrence of major and/or minor complications. Major complications were defined as those that required either a return to the operating room, or an unanticipated hospitalization. Minor complications were included as those problems managed in the office setting and did not required return to the operating room or hospitalization. Major and minor complications were further divided into local and systemic. Local complications were defined as those related to the abdominoplasty wound per se (ie, seroma, hematoma, wound healing problems). Systemic complications referred to medical issues arising from the operation, including, but not limited to, cardiopulmonary events and deep vein thrombosis. For each group, the incidences of major and minor complications were recorded. Predictive variables analyzed in this study were: age, American Society of Anesthesiologist (ASA) score, comorbidities, body mass index (BMI), ethnicity, smoking history, previous surgery, type of abdominoplasty (ie, standard, extended, fleur-de-lis abdominoplasty), whether or not rectus plication was performed, use of drains, number and type of adjunct procedures performed during the abdominoplasty, revision procedures, use and type of prophylactic anticoagulation, perioperative antibiotics, length of surgery, and hospital stay. Cardiac comorbidities were defined by history and included documentation of myocardial ischemia/infarction and/or structural/electrical heart pathology. Use of postoperative antibiotics was documented and stratified as follows: (1) <24 hours; (2) 24 hours; or (3) 48 hours after surgery. The use of sequential pneumatic compression devices (SCD) and prophylactic anticoagulation medications (eg, aspirin, heparin, low-molecular heparin) were documented. Pharmacological prophylaxis during the procedure and length of treatment was also documented. An adjunct surgery was defined as any ancillary procedure performed at the time of the abdominoplasty. Revision surgery referred to any secondary procedure performed to improve the results of the primary surgery. Categorical variables were analyzed using frequencies and percentages, while continuous variables were examined using medians and ranges. The relationship between group and categorical variables was described using Pearson s chi-square and Fischer s Exact tests, while the relationship between group and continuous variables was described using Mann-Whitney U and Kruskal-Wallis tests. Complication rates were further characterized with logistic and Poisson regression models, and results are presented with odds ratios. To control for possible confounding effects from groups with differing baseline characteristics a propensity score model was fit predicting group membership. The linear predictors from the propensity score model were then included in the logistic and Poisson regression models. A two-sided α <0.05 was considered statistically significant. Analyses were performed using SAS Software (version 9.1; Cary, NC) and GraphPad Prism 5 for Mac OSX (GraphPad Software, Inc.). The authors have no disclosures. RESULTS Demographics A total of 129 patients were included in the study: 43 in the elderly and 86 in the younger age groups. The median age of the older and younger age groups was 65.0 years (range, years) and 41.5 years (range,

4 552 Aesthetic Surgery Journal 37(5) Table 1. Patient Demographics and Comorbidities Table 2. Perioperative Data Age 59 years (n = 86) (n = 43) P value* Age 59 years (n = 86) (n = 43) P value* Demographics Median age, years (range) 41.5 (26-49) 65 (60-77) <0.001* Female gender (%) 82 (97.6) 40 (93.0) 0.33 Median BMI (range) 25.1 ( ) 28.7 ( ) 0.05* Caucasian, n (%) 83 (96.5) 42 (97.3) 0.13 ASA classification I: n, (%) 25 (29.1) 0 (0.0) <0.001* II: n, (%) 53 (61.6) 25 (58.1) III: n, (%) 8 (9.3) 18 (41.9) Comorbidities Median number conditions, (range) 0 (0-6) 3 (0-8) <0.001* Prior abdominal surgery, n (%) 47 (54.7) 34 (79.1) <0.01* Hypertension, n (%) 17 (19.8) 26 (60.5) <0.001* Diabetes mellitus, n (%) 3 (3.5) 7 (16.3) 0.05* Cardiac diseases, n (%) 0 (0.0) 7 (16.3) <0.001* Peripheral vascular disease, n (%) 2 (2.3) 3 (7.0) 0.33 Obstructive sleep apnea, n (%) 1 (1.2) 9 (20.9) <0.001* Asthma, n (%) 9 (10.6) 0 (0.0) <0.03* COPD, n (%) 1 (2.3) 3 (3.5) 0.70 Smoking history Never, n (%) 61 (70.9) 23 (53.5) 0.08 Previous, n (%) 19 (22.1) 20 (46.5) <0.001* Active, n (%) 6 (7.0) 0 (0.0) 0.18 ASA, American Society of Anesthesiology; BMI, body mass index; CAD: coronary artery disease; COPD: chronic obstructive pulmonary disease. * Statistically significant P < years), respectively (P < 0.001). The median BMI in the older group (28.7 kg/m 2 ; range, kg/ m 2 ) was greater than the one of younger patients (25.1 kg/m 2 ; range, kg/m 2 ) (P = 0.05). The most common ethnicity was Caucasians in both older (97.3%) and younger (96.5%) groups (P = 0.1). The overwhelming majority of subjects in both the older (93.0%) and younger (97.6%) age patients were female (P = 0.3) (Table 1). Preoperative When compared with the younger patients, the older groups were more likely to have a higher ASA score Lower extremity SCD, n (%) 85 (98.8) 43 (100.0) 1.0 Antibiotics preoperative, n (%) 84 (97.7) 42 (97.7) 0.99 Antibiotics intraoperative, n (%) 41 (47.7) 22 (51.2) 0.71 Antibiotics postoperative, n (%) 71 (82.6) 42 (97.7) 0.02* Anticoagulation, n (%) 35 (40.7) 19 (44.2) 0.70 Heparin, n (%) 16 (45.7) 7 (36.8) 0.54 LMWH, n (%) 18 (51.4) 10 (52.6) Aspirin, n (%) 1 (2.9) 1 (5.3) Adjunct procedures performed, n (%) 50 (65.1) 23 (53.5) 0.34 Median procedure time 5 ( ) 4.5 ( ) 0.36 Pain management Subcutaneous pain catheter, n (%) 16 (18.6) 5 (11.6) 0.01* Transversus abdominis pain (TAP) catheter, n (%) (P < 0.001) (Table 1). The median number of comorbidities was greater in the older age group (3.0; range, 0-8) when compared to the younger (0.0; range, 0-6) (P < 0.001). See Table 1 for a detailed list of comorbidities. The most common indications for surgery in older and younger age patient groups was unacceptable cosmetic appearance (76.7% and 86.0%, respectively), followed by weight loss (14.0% and 9.3%), and obesity (9.3% and 4.7%) (P = 0.4). Intraoperative 0 (0.0) 4 (9.3) No pain catheter, n (%) 70 (81.4) 34 (79.1) Median length of otay, overnight days (range) 0 (0-6) 0 (0-6) 0.79 Median follow up, months (range) 5 (1-30) 4 (1-24) 0.07 LMWH, low molecular weight; SCD, sequential compression device. * Statistically significant P < A standard abdominoplasty including skin undermining and umbilical transposition was the most common procedure performed in the elderly and younger age group (76.7% and 87.2%, P = 0.03), followed by an extended abdominoplasty (14.0% and 7.0%) and fleur-de-lis (9.3% and 5.8%). The majority of the patients in the elderly (90.7%) and younger (94.2%) group underwent rectus plication (90.7% and 94.2%, P = 0.5) and received abdominal subcutaneous drains (100.0% and 91.9%, P = 0.1) (Table 2). Pneumatic sequential compression device was used in 100.0% and 98.7% of patients in the

5 Couto et al 553 Table 3. Ancillary Procedures Table 4. Complication Rates Age 59 years (n = 56) (n = 22) P value Age 59 years (n = 86) (n = 43) P value* Hernia repair, n (%) 12 (21.4) 6 (27.3) >0.05 Breast, n (%) 9 (16.1) 3 (13.6) >0.05 Liposuction, n (%) 33 (58.9) 10 (45.5) >0.05 Blepharoplasty, n (%) 0 (0.0) 1 (4.5) >0.05 Obstetric/gynecologic, n (%)* 2 (3.6) 2 (9.1) >0.05 Major Complications, n (%) 12 (13.9%) 4 (9.3%) 0.4 Local, n (%) 8 (9.3%) 3 (6.9%) 0.4 Systemic, n (%) 4 (4.7%) 1 (2.3%) 0.5 Minor complications, n (%) 9 (10.5%) 9 (20.9%) 0.3 Local, n (%) 9 (10.5%) 7 (18.6%) 0.3 Systemic, n (%) 0 (0.0%) 1 (2.3%) 0.2 * colpexy, hysterectomy older and younger age groups, respectively (P = 1.0). A significantly increased utilization of prophylactic antibiotics during the postoperative period was observed among older patients (97.7%) when compared to the younger cohort (82.6%) (P = 0.02). Use of perioperative anticoagulation occurred according to patient specific risk factors at the surgeon s discretion without any significant differences between groups (P = 0.5) (Table 2). The majority of patients in both the older (51.1%) and younger (65.1%) age groups underwent adjunctive surgical procedures (P = 0.06) (Table 3); liposuction was the procedure most frequently combined with abdominoplasty in both the elderly (23.3%) and younger (38.4%) groups (P = 0.5) (Table 3). The median procedure time was comparable between the elderly (4.5 hours; range, hours) and younger patients (5.0 hours; range, hours) (P = 0.4) (Table 2). Among the entire cohort of patients, a significant increase in operating time was observed for combined surgical procedures (5.0 hours; range, hours) compared to abdominoplasty alone (4.0 hours; range, hours) (P < 0.001). Postoperative The median length of follow up was similar in the younger and older age groups (4 months; range, 1-24 months) and (5 months; range, 1-30 months) (P = 0.07), respectively (Table 2). No statistically significant differences in major, minor, local, or systemic complications were found when the older and younger age groups were compared. What follows is a detailed summary of those findings. Although the younger age group, had a higher incidence of total major complications (13.9%) compared to the elderly (9.3%), this was not statistically significant (unadjusted odds ratio 0.57, P = 0.4). After adjusting for baseline differences (ie, ASA scores, BMI, number of comorbidities) between groups, no statistically significant differences among the elderly and young age groups, as reflected in the adjusted odds ratios for total major complications, was observed (odds ratio 0.33, P = 0.2). When total major complications were further analyzed into local and systemic complications, the younger age group exhibited a non-statistically significant increase in major local (9.3% vs 6.9%, P = 0.4) and major systemic (4.7% vs 2.3%, P = 0.5) complications compared to the older age group (Table 4). The most common major local complication in the younger age group was delayed wound healing (ie, infection, necrosis), followed by diastasis recurrence; whereas hematoma, seroma, and tissue necrosis were evenly distributed in the elderly (Table 5). The median size of tissue necrosis in the younger age group was 0.85 cm 2 (range, cm 2 ). In the elderly group, only one patient exhibited tissue necrosis, and the size was 3.3 cm 2. No statistical significant difference was observed between the two groups (P = 0.9). The elderly cohort experienced no incidence of venous thrombembolism, while there were two cases of pulmonary embolism in the younger age group (1.2%). However, this finding was not statistically significant (P > 0.02). One subject from each age group exhibited both a major local and systemic complication (Table 5). Total minor complications were higher in the old age group (20.9% vs 10.5%); however, this was not statistically significant (unadjusted odds ratio 1.6, P = 0.3), even after adjusting for differences between the two groups (odds ratio 1.25, P = 0.7) (Table 4). Furthermore, a non-statistical significant increase in minor local (18.6% vs 10.5%, P = 0.3) and minor systemic (2.3% vs 0.0%, P = 0.2) complications was observed in the elderly when compared with the young age group (Table 4). The most common minor local complications in the younger age group related to delayed wound healing (ie, infection, dehiscence, hypertrophic scarring), followed by seroma. The median size of wound dehiscence in this group was 0.48 cm 2 (range, cm 2 ) and the median number of seroma aspirations and volume drained were 2.0 (range, ) and 40 cc (range, cc), respectively. In contrast, the most common minor local complication in the elderly patients was seroma, followed by wound problems (ie, dehiscence, infection, tissue necrosis). In the older age group, the median size of wound dehiscence was 1.0 cm 2

6 554 Aesthetic Surgery Journal 37(5) Table 5. Types of Complications Major complications, n (%) Local Age 59 years (n = 86) (n = 43) P value Hematoma, n (%) 1 (8.3%) 1 (33.3%) 0.4 Seroma, n (%) 1 (8.3%) 1 (33.3%) 0.4 Wound, n (%) 4 (33.3%) 1 (33.3%) 0.8 Diastasis recurrence, n (%) 2 (16.7%) 0 (0.0%) 0.4 Total 8 3 Systemic Dehydration, n (%) 0 (0.0%) 1 (33.3%) 0.4 Pulmonary emboli, n (%) 2 (50.0%) 0 (0.0%) 0.2 Shortness of breath, n (%) 1 (25.0%) 0 (0.0%) 0.3 Hypotension, n (%) 1 (25.0%) 0 (0.0%) 0.3 Total 4 1 Minor complications, n (%) Local Seroma, n (%) 2 (22.3%) 4 (50.0%) 0.3 Wound, n (%) 7 (77.7%) 4 (44.4%) 0.5 Total 9 8 Systemic Urinary tract infection, n (%) 1 (100.0%) 0 (0.0%) 0.3 Total 1 0 (range, cm 2 ) and the median number of seroma aspirations and volume drained were 1.0 (range, ) and cc (range, cc), respectively. No statistical significance was observed in either finding between the two groups (P = 1.0). Only one minor systemic complication was recorded in the study, which was a urinary tract infection in an elderly patient (Table 5). With regard to the time of occurrence of major local and/or systemic complications the median postoperative day of occurrence in the elderly and younger age group was 15.0 days (range, days) and 7.5 days (range, days), respectively. This was not statistically significant (P = 0.7). One out of the 4 (25.0%) major local and/ or systemic complications observed in the elderly group occurred after postoperative day 30. This was a seroma that was evacuated on postoperative day 37. In the younger age group, 1 out of 12 (8.3%) major local and/or systemic complications occurred after the first month of operation; a diastasis recurrence that was repaired on postoperative day 135. No statistical significant difference was observed between the two groups (P = 1.0). The median time required for these major local and/or systemic complications to resolve in the elderly and younger age group were 1.0 days (range, days) and 2.5 days (range, 2-25 days), respectively. No statistical significant difference was observed between the two groups (P = 1.0). The median postoperative day that minor local and/or systemic complications occurred in the older (22.0 days; range, days) and younger (42.0 days; range, days) was not statistical significant different (P = 0.1). In the elderly group, 4 out of 9 (44.4%) minor complications occurred after the first month of surgery. These were all seromas that required aspiration in the clinic in postoperative day 34 to 48. In the younger age group, 6 out of 9 (66.7%) minor complications after postoperative day 30. These included four cases of hypertrophic scarring, one wound infection, and one wound dehiscence. No statistical significant difference was observed between the two groups (P = 0.1). The median time of resolution of these minor local and/or systemic complications in the older and younger age groups were 19.0 days (range, days) and 22.0 days (range, days), respectively. No statistical significant difference was observed between the two groups (P = 0.8). The revision rate of the younger patients (10.5%) was higher than the older age group (0.0%) (P = 0.03). The most common revision procedure was excision of dog ear (50.0%), followed by residual abdominal tissue excess (25.0%) and scar (25.0%) revision. DISCUSSION Several recent studies have suggested that age may be an independent risk factor for complications following abdominoplasty surgery Using the CosmetAssure database, abdominoplasty was found to be the only aesthetic procedure that demonstrated an increased incidence of complications in the 65 years and older group. 10 Winocour et al further suggested that age 55 or greater was also an independent risk factor for this procedure. 11 In addition to age being an independent risk factor for overall complications, Massenburg et al, using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), also suggested that age may be an independent risk factor for thromboembolic and pulmonary complications in particular. 9 If, indeed age represents an added risk for complications in the older age group this should, perhaps, be part of the informed consent. While the studies described above provide important and useful information using a large cohort, they paint a picture using broad strokes. These studies by necessity document only major complications and limit their review of complication to 30 days, perhaps underestimating

7 Couto et al 555 complications overall. Our review, on the other hand, provides a more in depth picture of the morbidity of the operation by analyzing not only major complications, but further dividing problems into major, minor, local, and systemic for both age groups. We found no difference in either major or minor complications in our two patient cohorts. In addition, the total major complication rate in our older age group (9.3%) approximated the reported major complication rate in previous studies (5.9%). 10,11 Although Neaman et al did not specifically evaluate the complication rate in the elderly, their investigation is one of the few studies to assess the incidence of minor complications following abdominoplasty. 12,13 The minor complication rate in our elderly group (20.9%) was lower than their reported incidence (26.7%-31.9%). 12,13 This difference in minor complication rate may be explained by the difference in the patient cohort, since there studies included massive weight loss patients, a population with greater risk postoperative complications. 14 It may seem counterintuitive to have similar complication rates in these two age groups, given the higher ASA scores in the older age population. In addition, the lack of association between a greater ASA score and complications in the current study is contrary to the majority of studies in other surgical specialties and most recently, in plastic surgery. 9 A direct comparison, however, to these studies is perhaps inaccurate, since their overall ASA scores were significantly higher than the ASA score in our study. In addition, when we compare our results to Massenburg et al, two different patient populations are being compared. NSQIP is based exclusively on inpatient data, which may represent a less healthy patient population. This can be appreciated from the percentage of patients with ASA greater than 3 (31.5%). Furthermore, patients undergoing panniculectomy were also included in their study. 9 Although the ASA scores in our elderly group were higher than the young age comparison group, our patient population represented a relatively healthy cohort. Eighty percent of the subjects had an ASA score between 1 and 2, and no patients had an ASA score greater than 3. It is suggested that preselection may explain the difference seen between our review and those in different specialties assessing the effect of age on complication rate. That is plastic surgery has the luxury of deferring surgery for those individuals in poor health. Evaluating the patient s postoperative course beyond 30 days enabled us to examine abdominoplasty revision rates. Our total revision rate (7.0%) was lower than that in previous reported (24.8%-36.0%). 12,13 All the revisions in our study were performed in the younger patient group (10.5%). This discrepancy might suggest higher expectations by the younger patients on the final cosmetic appearance. Alternatively, the absence of revisions in the elderly group may be due to an increased threshold for performing revision procedures in the older age population. The retrospective nature of this study represents a limitation of this investigation. Furthermore, we recognize that differing baseline characteristics exist in our two study groups (ie, ASA scores, BMI, number of comorbidities), which can lead to a confounding effect. Therefore, we attempted to correct for these differences using a propensity score model and adjusted logistic and Poisson regression models. We did not perform ASA score matching, since the two groups showed no difference in complication rates. The number of elderly subjects in our report is limited. This did not come as a surprise as elderly patients are more likely to undergo facial operations than breast and body cosmetic procedures. 10 Therefore, it is possible that the elderly group may have an undetected increased risk due to our small sample size. Although the age of 65 years is generally recognized as elderly, this definition varies greatly in the surgical literature Sixty years old was utilized in our study as the defining age of an elderly patient because of the limited number of subjects in the older age group. As a result, the median ages of younger compared to elderly group was 42 and 65 years old, respectively. Thus, preventing a wider age spread which would have returned more clinically relevant information. Alternatively, a retrospective multicenter review can address this issue. Several patients with BMI in the morbidly obese range were included in both the young and older age groups, this is a reflection of our referred patient population. As stated in the methods section, these patients underwent undermining of the skin flap up to the xiphoid process, umbilical transposition, and/or rectus plication. Lastly, both our investigation and the studies 9-11 cited addressed complications only. The aim of this study was to determine if abdominoplasty could be safely performed in the elderly patient with a complication risk that is comparable to the younger population. Comparing patient satisfaction or patient outcomes between these two groups was not addressed. These questions remain unanswered. Our effort differs from recent abdominoplasty reviews 9-11 by analyzing the morbidity of this operation in a broader spectrum: major, minor, local, and systemic complications. The presented results suggest that with proper patient selection, abdominoplasty can be safely performed on the studied elderly population with a complication rate that approximates the younger age population. CONCLUSIONS We found no significant difference in either major or minor complications following formal abdominoplasty when the older age patient group (60 years and older) was compared to our younger age patient group (59 years and younger). Furthermore, both groups studied had an acceptably low

8 556 Aesthetic Surgery Journal 37(5) major and minor complication rates. This suggests that with proper patient selection, abdominoplasty can be safely performed on this older age patient population with a complication rate that approaches the younger age population. Stated another way, physiologic age is perhaps more important than chronologic age. Our older age group was limited to 60 years and older. Whether or not patients 65 or 70 years of age can be preselected and operated on with similar low morbidity cannot be answered by our review due to our limited sample size. This question remains unanswered. Careful screening and patient specific preoperative assessment enabled us to exclude those elderly individuals with significant comorbidities; thus, potentially reducing our number of complications. We hope this investigation stimulates further interest in the study of abdominoplasty in this increasing patient population. 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