Abdominoplasty was first described by Kelly COSMETIC

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1 COSMETIC Outcomes of Traditional Cosmetic Abdominoplasty in a Community Setting: A Retrospective Analysis of 1008 Patients Keith C. Neaman, M.D. Shannon D. Armstrong, M.D. Marissa E. Baca, M.D. Mark Albert, M.D. Douglas L. Vander Woude, M.D. John D. Renucci, M.D. Grand Rapids, Mich. Background: Abdominoplasty is one of the most commonly performed cosmetic operative procedures. Few large studies have examined outcomes of cosmetic abdominoplasty in a community setting. The authors explored postoperative outcome and the preoperative and intraoperative factors that may contribute to these complications. Methods: A retrospective review of consecutive patients undergoing abdominoplasty over an 11-year period was performed. Baseline patient demographics, intraoperative technique, and postoperative outcomes were recorded. Preoperative and intraoperative characteristics were analyzed to determine characteristics that predispose patients to complications and undesirable outcomes. Results: The 1008 study patients underwent either a full or modified abdominoplasty with a total complication rate of 32.6 percent. The most common complication was seroma (15.4 percent). Liposuction of the abdominal flap was performed in 469 patients (46.5 percent) and liposuction of the flanks was performed in 555 patients (55.1 percent). Chi-square analysis followed by logistic regression revealed that liposuction of the flanks and abdomen was independently associated with seroma formation in addition to major and minor complications (p 0.05). Conclusions: Seroma formation following abdominoplasty is the most common complication. Concomitant liposuction of the flanks and abdomen with the addition of aggressive undermining leads to higher seroma rates. This association is likely multifactorial and may be secondary to increased resorptive demands placed on the abdominal lymphatics in the setting of greater dead space and larger fluid shifts as a result of liposuction. To reduce seroma rates, surgeons should avoid aggressive liposuction and undermining, particularly in high-risk patients. (Plast. Reconstr. Surg. 131: 403e, 2013.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III. From the Grand Rapids Medical Education and Research Center and the College of Human Medicine, Michigan State University, and Plastic Surgery Associates, P.C. Received for publication May 21, 2012; accepted September 27, Presented at the 56th Annual Meeting of the Plastic Surgery Research Council, in Louisville, Kentucky, April 28 through 30, 2011; the Plastic Surgery Senior Resident s Conference, in Nashville, Tennessee, January 20 through 22, 2011; the 49th Annual Meeting of the Midwestern Association of Plastic Surgeons, in Chicago, Illinois, May 15 through 16, 2010; and the 89th Annual Meeting of the American Association of Plastic Surgeons, in San Antonio, Texas, March 20 through 23, Copyright 2013 by the American Society of Plastic Surgeons DOI: /PRS.0b013e31827c6fc3 Abdominoplasty was first described by Kelly in The technique addressed lower abdominal tissue excess through simple wedge excision. Later modification of the technique by Babcock included a vertical component to the abdominal incision. 2 The modern low-transverse incision with wide undermining was developed by Pitanguy, who reported his large series in Grazer later modified the Pitanguy technique by adding plication of the rectus diastasis without incising the anterior rectus sheath. 4 Since its inception, abdominoplasty has become increasingly popular. According to the American Society of Plastic Surgeons, abdominoplasty is one of the top five most commonly performed cosmetic surgery procedures. 5 Attempts at classifying the types of abdominal deformity have been made by Bozola and Psillakis. 6 In addition, Matarasso classified the Disclosure: The authors have no financial interest to declare in relation to the content of this article e

2 Plastic and Reconstructive Surgery March 2013 type of abdominoplasty procedure as mini, modified, or full abdominoplasty. 7 The type of procedure selected was based on preoperative patient abdominal wall, fat, and skin characteristics. Full abdominoplasty has become one of the most commonly performed types of cosmetic abdominoplasty performed by plastic surgeons, 8 and is frequently performed in combination with other procedures. Because of the popularity of cosmetic full abdominoplasty, it is prudent for the surgeon to be cognizant of potential complications associated with the procedure. Complications most commonly include seroma, hematoma, wound dehiscence, and wound infection. 9 The most common complication associated with abdominoplasty is seroma, with reported rates ranging from 3.0 to 37.3 percent However, the actual complication rate in cosmetic abdominoplasty remains elusive because of the paucity of large studies examining outcomes. Many of the studies with high power are survey-based and therefore subject to the many statistical weaknesses inherent in those study types. 8,9 The purpose of our study was to retrospectively examine a large group of patients undergoing full cosmetic abdominoplasty in a private practice setting and identify preoperative and intraoperative factors predisposing patients to complications. PATIENTS AND METHODS A retrospective review of 1008 consecutive patients who underwent full abdominoplasty (defined as undermining of skin to the level of the xiphoid with plication of rectus fascia) or a modified-abdominoplasty (defined as undermining approximately to the level of the umbilicus without umbilicoplasty and limited undermining to the xiphoid process to allow plication) over an 11-year period (January of 1998 to December of 2008) at a single plastic surgery practice was conducted. All operations were performed by one of six plastic surgeons in the practice, with little variation in each individual surgeon s operative technique over the past decade. The average length of follow-up was 592 days (19.4 months). The medical records of each patient were reviewed to identify characteristics such as age, sex, race, body mass index (in kilograms per square meter), smoking status, comorbidities, and previous abdominal operations. Seroma was defined as any clinically detectible fluid collection typically diagnosed at the time of follow-up. Documentation was made of any surgical revision, ranging from simple scar revision to an additional abdominoplasty. Finally, the length of postoperative follow-up was recorded. This study was approved by the regional institutional review board. Statistical analysis of the data was conducted with SPSS for Windows version 14.0 (SPSS, Inc., Chicago, Ill.). Chi-square test, independent t test, logistic regression, and the Pearson coefficient were used. Significance was assessed at p Operative Technique Several technical aspects were universally adopted by all of the surgeons in the study. A modified transverse incision was used in all patients. Conventional liposuction with a superwet tumescent technique (1:1 ratio of tumescence to aspirate) was used in all patients who underwent liposuction. Quilting sutures or fibrin glue was not used. Postoperative therapy involved the use of an abdominal binder in all patients for approximately 4 weeks. Liposuction when performed on the abdomen encompassed the abdominal flap and along the costal margins. Liposuction of the flanks represented suction restricted to the area surrounding the superior iliac spine. Elevation of the abdominal flap was to the level of the costal margin in all patients. The number of drains and duration of drain placement differed for each procedure; however, drains were generally removed when the output was less than 30 cc/day. Table 1 further clarifies each surgeon s technique used during the abdominoplasty. Differences not mentioned in Table 1 include initial prone positioning when liposuctioning the flanks (surgeons C and F). Chemoprophylaxis for thromboembolism [Lovenox (Sanofi US, Bridgewater, N.J.) 15 mg subcutaneously] was given to all patients starting in 2004 (Figs. 1 and 2). RESULTS Patient Demographics All 1008 patient charts contained sufficient data to be included in the study. Of the patients reviewed, 977 (96.9 percent) were women and 31 (3.1 percent) were men. The average patient age was 44 years (range, 18 to 76 years). The average patient body mass index was Significant medical history is depicted in Table 1. Obesity is de- Table 1. Medical History Condition No. of Patients (%) Obesity 256 (25.6) Smoking 108 (10.7) Hypertension 107 (10.6) Diabetes 26 (2.6) 404e

3 Volume 131, Number 3 Abdominoplasty and Liposuction Outcomes Fig. 1. (Above) Photographs of a 48-year-old woman (G4P4) who underwent a full abdominoplasty with liposuction of the flanks. (Below) Photographs obtained at 11 months postoperatively. fined as a body mass index greater than or equal to 30.0 and smoking included those who smoked at the time of surgery or quit within 3 months before surgery. A breakdown of patient body mass index categories is shown in Table 2. The majority of patients [n 950 (94.2 percent)] underwent a full abdominoplasty, with the remainder of patients having a modified abdominoplasty [n 58 (5.8 percent)]. Location of previous surgical incisions and surgical history pertinent to the abdomen, including those who underwent previous bariatric surgery, are listed in Table 3. A majority of abdominoplasties were performed on an outpatient basis in the practice s surgical suites [n 903 (89.6 percent)], with the remainder performed in the hospital [n 105 (10.4 percent)]. Most cases were performed under general anesthesia [n 997 (98.9 percent)]. Pertinent intraoperative details are listed in Table 4. Complications and Interventions Complications were designated as major and minor complications to categorize all adverse outcomes. Major complications [182 of 1008 (18.1 percent)] were defined as seromas requiring aspiration, hematomas requiring evacuation, deep venous thrombosis/pulmonary embolism, and infections requiring antibiotics. Minor complications [322 of 1008 (31.9 percent)] were defined as seromas and hematomas not requiring intervention, stitch abscess, fat necrosis, wound dehiscence, umbilical necrosis, and hypertrophic scarring. All types of complications are listed in Table 5. Seroma was the most frequent complication, affecting 155 patients (15.4 percent). Most were treated conservatively with in-office aspiration (95.4 percent). On average, patients were treated with two bedside aspirations (range, one to eight), with a mean aspiration volume of 190 ml (range, 10 to 2250 ml). Twenty-eight patients with seromas required more involved treatment. Eighteen seromas (5.8 percent) required operative intervention after failed resolution with aspiration alone. Another 18 of the seromas (5.8 percent) became infected and required antibiotic therapy, later resolving with aspiration. In addition, 10 patients (9.0 percent) required image-guided drain placement after failed conservative management; these 405e

4 Plastic and Reconstructive Surgery March 2013 Fig. 2. (Above) Photographs of a 41-year-old woman (G0P0) who underwent a modified abdominoplasty with liposuction of flanks. (Below) Photographs obtained at 10 months postoperatively. Table 2. Body Mass Index Classification Group BMI (kg/m 2 ) No. of Patients (%)* Underweight (1.1) Normal weight (43.9) Overweight (35.3) Obese (18.6) Morbidly obese (0.9) BMI, body mass index. *Based on all patients with a valid BMI. Table 4. Intraoperative Interventions Intervention No. of Patients (%) Liposuction of the abdomen 469 (46.5) Liposuction of the flanks 555 (55.1) Tumescent without liposuction 349 (34.6) Midline rectus plication 859 (85.2) Umbilicus Transposed 720 (71.4) Floated 230 (22.8) Table 3. Surgical History of the Abdomen Procedure No. of Patients (%) Previous bariatric surgery 107 (10.6) Previous abdominoplasty 30 (3.0) Previous abdominal liposuction 34 (3.4) Previous subcostal incision 40 (4.0) Previous midline incision 111 (11.2) patients went on to resolution of their seroma following drain placement. Risk Factors Men were at an increased risk for developing major and minor complications and postoperative seroma (p 0.001, p 0.046, and p 0.001, respectively). Patients suffering from morbid obesity (body mass index 40) were more likely to develop a major complication and seroma (p Table 5. Complications Complication No. of Patients (%)* Seroma 155 (15.4) Hypertrophic scar 78 (7.7) Stitch abscess 51 (5.1) Cellulitis 38 (3.8) Wound dehiscence 30 (3.0) Hematoma 26 (2.6) Fat necrosis 25 (2.5) Abscess 4 (0.4) Thromboembolism 3 (0.3) Umbilical necrosis 2 (0.2) *Percentages are based on the total population and p 0.043, respectively). However, those with a body mass index between 30.0 and 39.9 showed no increased risk of complications. Initial univariate analysis also demonstrated increased major complication, minor complica- 406e

5 Volume 131, Number 3 Abdominoplasty and Liposuction Outcomes Table 7. Co-procedures Performed at the Time of Abdominoplasty Co-procedure No. of Patients (%)* Seroma Rate Liposuction 292 (28.9) 62 (21.2) Breast 214 (21.2) 33 (15.2) Facial aesthetic 79 (7.8) 11 (13.9) Hernia repair 64 (6.3) 10 (15.6) Other 50 (4.9) 9 (18.0) Body contouring 14 (0.13) 2 (14.2) *Percentages are based on the total population. Percentages are based on number of patients within the co-procedure group. Reached statistical significance when compared with those without a co-procedure (p 0.002). Including brachioplasty, thighplasty, and others. tion, and seroma rates in patients undergoing concurrent flank liposuction (p 0.012, p 0.000, and p 0.003, respectively) and/or concurrent abdominal wall liposuction (p 0.015, p 0.001, and p 0.003, respectively). Logistic regression analysis indicated that both liposuction of the abdomen, in addition to flanks, showed a significant correlation with seroma formation (Table 6) in addition to major and minor complications (p 0.05). Co-procedures other than flank and abdominal liposuction led to an increased risk of major complications, minor complications, and seroma formation (p 0.038, p 0.046, and p 0.008, respectively). When a logistic regression analysis was performed, the addition of a co-procedure only trended toward increased complication rates, including seroma formation. Co-procedures were then divided into the following categories: liposuction other than the flanks and abdomen, breast surgery, facial aesthetic surgery, and body contouring other than liposuction (Table 7). When each co-procedure was analyzed individually by means of a chi-square analysis, those patients who underwent liposuction were more likely to develop a major complication, minor complication, and/or seroma (p 0.021, p 0.029, and p 0.002, respectively), whereas all other procedures were not associated with increased complications. When tumescence was used for hemostasis and not in conjunction with liposuction, patients experienced a decreased rate of seroma formation and major and minor complications (p 0.049, p 0.048, and p 0.012, respectively). In addition, the use of tumescent did decrease postoperative hematoma rates (0.9 percent versus 3.5 percent, p 0.012). Liposuction volumes were not reported consistently and thus were not included for analysis. The routine use of Lovenox was initiated in Interestingly, the rate of deep venous thrombosis/pulmonary embolism (0.2 percent versus 0.4 percent), and the rate of postoperative hematoma (2.6 percent versus 2.6 percent), did not significantly change after initiation of chemoprophylaxis (before versus after Lovenox, respectively). It must be noted that the dose administered was 15 mg subcutaneously administered preoperatively. Smoking, obesity, diabetes, history of bariatric surgery, history of previous abdominoplasty/abdominal liposuction, history of previous abdominal surgery, or type of anesthesia used were not associated with an increased risk of complications or seroma formation. In addition, duration of closed suction drains, number of drains, and method of dissection (Bovie versus sharp) showed no correlation with increased seroma rates. Revisions and Associated Risk Factors The total revision rate was 36.0 percent (n 363). Eighty-five patients (8.4 percent) underwent a second revision, with 25 of those patients (2.6 percent) undergoing a third revision. The causes of the initial revision are listed in Table 8. Repeated abdominoplasties were performed in 11 patients (1.0 percent), including eight miniab- Table 6. Factors Associated with Increased Rates of Seroma Formation Logistic Regression Factor Seroma Rate (%) 2 Analysis (p) Odds Ratio (95% CI) p Male sex ( ) History of bariatric surgery ( ) 0.09 Co-procedure ( ) Liposuction flanks ( ) Liposuction abdomen ( ) Smoking NS 0.73 History of abdominoplasty NS 0.82 Tumescence NS 0.74 Obesity NS 0.40 NS, not significant. 407e

6 Plastic and Reconstructive Surgery March 2013 Table 8. Reason for Revision* Reason No. of Patients (%) Scar 254 (25.1) Revision liposuction 176 (17.4) Umbilicus 10 (0.9) Other 17 (1.6) *Some patients underwent revision for multiple reasons. Percentages are based on the total populations. dominoplasties and three full abdominoplasties. Patients with a history of previous bariatric surgery were less likely to undergo a revision (20.6 percent versus 37.8 percent, p 0.000), whereas patients who had experienced a seroma were more likely to undergo a revision (46.5 percent versus 34.1 percent, p 0.003). Surgical Technique and Seroma Formation There was no statistically significant difference in patient age, sex, body mass index, or smoking history between the patient cohorts of each surgeon (Table 9). Patients whose abdominoplasty was performed by surgeon A were more likely to experience a seroma (26.7 percent versus 12.4 percent, p 0.000). Conversely, patients whose abdominoplasty was performed by surgeon E were less likely to experience a seroma (7.4 percent versus 17.1 percent, p 0.001). Surgeon E was also noted to have, on average, the longest duration of drain placement and subjectively was the least aggressive with regard to resection amount and closure tension. The remainder of surgeons experienced no difference in seroma rates. DISCUSSION An awareness of patient and technical risk factors for complications is essential for reducing the complications associated with abdominoplasty. Seroma remains the most common complication in patients undergoing cosmetic abdominoplasty. Understanding the cause of seroma formation following abdominoplasty is vital to the development of preventative measures and the technical modifications necessary in decreasing seroma rates. Undoubtedly, seroma formation is multifactorial, as evidenced by the variety of techniques and seroma rates among the different surgeons in this study. Our data suggest that liposuction of the abdominal flap in conjunction with aggressive undermining increases seroma formation. The abdominal wall is composed of two layers of fat, referred to as superficial and deep, which is defined according to its relationship to the Scarpa fascia. Huger previously identified three vascular zones of the abdomen, which can be used to help identify the blood supply to the abdominal flap following elevation. 20 It is based on these zones that Matarasso further identified safe liposuction areas. He advocated cautious liposuction of the abdominal flap with avoidance of the segmental perforators from the intercostal, subcostal, and lumbar arteries. 21 Numerous authors have agreed with the concept of lipoabdominoplasty, which advocates aggressive liposuction of the abdomen with limited undermining ranging from 4 to 7.5 cm lateral of the midline. 7,22,23 With a full understanding of these anatomical concepts, aggressive liposuction of the superficial fat of the abdominal flap while undermining to the costal margin will invariably leave large portions of devitalized subscarpal fat. When the abdominal flap is inset, this larger partially devitalized tissue may lead to decreased adherence and therefore more potential space for fluid accumulation and less capacity for local fluid resorption. Of note, this remains theoretical and warrants more rigorous anatomical studies. Regardless of technique, the intercostal perforators should be preserved to maintain blood flow to the deep fat of the abdominal wall. Recently, Saldanha et al. have advocated leaving the deep layer of fat on the rectus fascia, thus preserving the deep lymphatic channels, resulting in a decrease of seroma formation from 60 percent to 0.4 percent. 22,23 Although this may serve as a reasonable alternative, the key to this technique is limited undermining laterally up to the costal mar- Table 9. Operative Technique among Six Surgeons Surgeon A Surgeon B Surgeon C Surgeon D Surgeon E Surgeon F No. of procedures Seroma rate, % Co-procedures, % No. of drains* Drain duration, days* BMI* Method of dissection Bovie Bovie Bovie Sharp Bovie Mixed Liposuction of abdomen Yes Yes No Yes No No *Mean SD. 408e

7 Volume 131, Number 3 Abdominoplasty and Liposuction Outcomes gin. Furthermore, the cause of reduced seroma formation with a subscarpal plane of dissection has been brought into question because of the lack of good anatomical studies delineating postabdominoplasty lymphatic flow. 24 In the literature, there has been confusion with regard to performing liposuction of the flanks and its effect on seroma formation. 25,26 In our cohort, liposuction of the flanks was found to increase seroma rates. Although not necessarily compromising abdominal flap circulation, flank liposuction may increase fluid absorptive demands placed on the abdominal flap by recruiting serous drainage from the flanks and back as the pockets created by liposuction extend anteriorly. In addition, subcutaneous spaces are created in the flanks and abdomen because of the liposuction channels, potentially allowing pooling of serous fluid. Another important contribution to seroma formation is the performance of additional procedures at the time of abdominoplasty. Various other authors have investigated this issue and found it to be a safe and efficacious way of addressing a patient s multiple concerns in one sitting. When individual procedures were examined, the performance of liposuction in other areas of the body not directly related to the abdominoplasty was found to increase seroma formation. This is likely secondary to patients having liposuction of the thighs and back. Liposuction of these areas generates a larger area of lymphatic disruption; this combined with immediate postoperative swelling and third spacing potentially contributes to seromatous fluid collections under the abdominal flap. Various preventative measures have been devised to decrease dead space and seroma formation. The use of thrombin gel/spray, quilting sutures, and progressive-tension sutures have all been advocated. 12,27 29 In this series, the surgeons did not rely on dead space obliteration; thus, we cannot comment on the efficacy of such techniques. However, cost and time issues have slowed its acceptance among our surgeons. Given increased seroma rates with the addition of liposuction of the flanks and other co-procedures, our surgeons are now less likely to perform such procedures in high-risk patients. In addition, they rarely combine liposuction of the abdominal flap when undermining up to the costal margin. Our study found no change in the hematoma or deep venous thrombosis/pulmonary embolism rate after institution of enoxaparin therapy preoperatively. Although recent publications have advocated chemoprophylaxis for abdominoplasty procedures, 30 we did not experience an increase in hematoma or a risk reduction in deep venous thrombosis/pulmonary embolism. The likely reasons for this are twofold. First, the occurrence of clinically significant deep venous thrombosis/pulmonary embolism is a rare event, and this study likely lacked the power to identify this small difference to a significant level. Second, the 15-mg subcutaneous dose of enoxaparin used in this study is below the recommended prophylactic dose. Interestingly, this decreased dose may be the reason for no change in hematoma rate after the initiation of chemoprophylaxis. In contrast to previous studies showing an increase in wound healing complications in smokers, our study concurs with the findings of Samra et al. that showed no increase in complication rates when comparing smokers with nonsmokers. 14,22,31,32 This is particularly intriguing given that the surgeons in this series undermined the abdominal flap to the level of the costal margin. This finding could be related to the limited liposuctioning of the abdominal flap. Despite these findings, abdominoplasty should still be performed with caution in patients actively using tobacco. One major drawback to this study is the inclusion of multiple surgeons, each with techniques that have been individualized over years of practice. Interestingly, despite demographically matched cohorts, surgeon A appeared to have a statistically higher rate of seroma formation, whereas surgeon E experienced a lower seroma rate. Although concrete conclusions cannot be drawn, anecdotally, these findings are multifactorial, indicating that it is a combination of various techniques that likely leads to higher or lower complication rates. In general, surgeon A tended to elevate the abdominal flap in a subscarpal plane, use higher electrocautery settings, combine procedures, aggressively liposuction the abdominal flap, and use only one drain. Surgeons need to carefully examine their individual operative technique, looking for the potential additive effects of each operative step. CONCLUSIONS Seroma is the most common complication following abdominoplasty. Liposuction of the abdominal flap in conjunction with aggressive undermining leads to higher seroma rates and should be performed cautiously. In addition, liposuction of the flanks contributes to seroma formation and should be used sparingly in high-risk patients. Concomitant procedures do lead to significantly higher complication rates. Undoubt- 409e

8 Plastic and Reconstructive Surgery March 2013 edly, seroma formation is multifactorial, prompting surgeons to closely examine their technique with the hope of decreasing the morbidity of this frequent complication. However, seromas generally present with limited morbidity and, overall, abdominoplasty is safe and efficacious. John D. Renucci, M.D. Plastic Surgery Associates Grand Plaza Place 220 Lyon Street NW, Suite 700 Grand Rapids, Mich ACKNOWLEDGMENTS The authors thank Alan Davis, Ph.D., Tracy Frieswyk, and Allen Shoemaker, Ph.D. REFERENCES 1. Kelly HA. Excision of the fat of the abdominal wall-lipectomy. Surg Gynecol Obstet. 1910;10: Babcock WW. The correction of the obese and relaxed abdominal wall with especial reference to the buried silver chain. Am J Obstet. 1916;74: Pitanguy I. Abdominal lipectomy: An approach to it through an analysis of 300 consecutive cases. Plast Reconstr Surg. 1967; 40: Grazer FM. Abdominoplasty. 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