Operative Technique in Plastic Surgery – Kevin C.Chung

been performed over the rectus femoris back toward
the vastus lateralis, and an initial perforator (arrow)
has been identified.
TECH FIG 2 • The rectus femoris muscle of this left
leg has been retracted superiorly and an additional
septocutaneous perforator (arrow) is seen on top of
the vastus lateralis.
■ Deep to the rectus femoris, the descending branch of the LCFA is identified.
The investing fascial layer can be opened above the pedicle. This is
continued proximally to the origin of the pedicle (TECH FIG 3).
■ The main branch to the rectus femoris is often near the origin and can often
be preserved as well.
■ The main motor nerve to the vastus lateralis runs lateral to the main pedicle
and can be dissected free to preserve muscle innervation.
■ The flap perforators are then selected, and dissection is performed within
either the septum or the vastus lateralis, back toward the descending branch
of the LCFA. We recommend performing this dissection before clipping other
branches of the main pedicle as the perforator course is not always direct to
the main pedicle.
■ Distal perforators of adequate caliber are preferred due to the subsequent
increase in functional pedicle length. However, flaps designed around the
“B” or midthigh perforator will adequately reach the umbilicus in most

patients.
■ The ALT can be harvested with vastus lateralis muscle if needed. The distal
portion of the descending LCFA often runs within the muscle, and one can
include the superficial portion of the muscle overlying the pedicle if a
chimeric flap is needed.
TECH FIG 3 • Dissection is performed back to the
origin of the descending branch of the lateral femoral
circumflex trunk.

TECH FIG 4 • The tunnel for the flap should pass
below the rectus femoris and sartorius and then
through the soft tissue.
■ The anterior incision is then tailor-tacked closed. A flap template is designed
base on the abdominal defect. Positioning of the flap around the perforator is
based on the defect and planned location for the tunnel between the thigh and
the abdomen.
■ Flaps up to 9 cm wide and 22 cm long can typically be harvested while still
allowing for primary closure of the donor site.
■ The posterior incision is then made and dissection is performed through the
subcutaneous tissue and muscular fascia with care taken to protect the
perforators traveling into the flap. Prior dissection of the subfascial plan
behind the perforators from the anterior incision allows for rapid flap
elevation at this stage.

■ With the distal pedicle now divided, the flap is isolated on only the main
pedicle and can be evaluated for perfusion.
■ Transposition of the flap from the thigh to the lower abdomen requires a
wide tunnel. The typical tunnel is subrectus femoris, subsartorius, and then
subcutaneous into the defect (TECH FIG 4).
■ The sartorius can also be transected to avoid potential compression in this
area.
■ The flap is transposed through this tunnel once wide enough to easily
accommodate the flap. Note that chimeric flaps will require a much wider
tunnel to accommodate the additional muscle bulk.
■ In cases requiring extended reach of the flap, the pedicle of the flap may
kink around the vascular branch to the rectus femoris, which can be divided
if needed.
■ The flap is then inset into the defect using ideally a three-layer closure (the
superficial fascia, deep dermis, and external skin) in addition to any
abdominal fascia inset.
■ We prefer to use dissolving sutures for the entire inset to avoid the removal
of permanent sutures postoperatively.
■ The donor site is closed in layers over a drain. A compressive dressing is not
placed to avoid compression of the pedicle running across the medial upper
thigh.
Resection of Soft Tissue Sarcoma
■ Resection of a soft tissue sarcoma left the lower abdominal wall soft tissue
defect is pictured in TECH FIG 5A. Preoperative markings for a left ALT
flap are also shown. The subsequently harvested flap is seen in TECH FIG
5B with the vascular pedicle and two perforators seen in TECH FIG 5C. The
flap is then transposed under rectus femoris and sartorius to the suprapubic
defect as seen in TECH FIG 5D with final inset seen in TECH FIG 5E.
■ A vastus lateralis flap in conjunction with a biologic mesh for reconstruction
of a full-thickness lower abdominal wall defect following sarcoma resection
is pictured in TECH FIG 6. There is an acquired defect of the lower
abdominal wall with resection of all myofascial layers (TECH FIG 6A).
After using the omentum to cover the bowel (TECH FIG 6B), a piece of
acellular dermal matrix was used to close the peritoneum/residual posterior
sheath (TECH FIG 6C). A vastus lateralis muscle-only flap was planned
from the right thigh (TECH FIG 6D). After harvest of the vastus lateralis

(TECH FIG 6E), it was transposed underneath the rectus femoris, under the
sartorius, and then subcutaneously over the inguinal ligament to the lower
abdomen (TECH FIG 6F). Inset was performed around the myofascial
defect with the muscular fascia next to the acellular dermal matrix (TECH
FIG 6G). The skin was closed primarily in this case.

TECH FIG 5 • This suprapubic soft tissue defect
resulted from a sarcoma resection. An ALT flap was
harvested for closure. A. Design of the flap axis,
expected location of “A, B, and C” perforators, and the
defect. B. Harvest of the ALT flap with two perforators.
C. Vascular pedicle and perforators to the ALT flap. D.
Transposition of the flap into the defect. E. Final inset
of the ALT flap with de-epithelialization of the buried

portion of the flap.

Rectus femoris Vastus lateralis muscle flap

TECH FIG 6 • This 9- × 13-cm full-thickness defect of
the abdominal is secondary to sarcoma resection. The
defect extended from the pubis (right) to just below the
umbilicus (left). A. The defect after a bladder flap was
used to cover the pubis. B. The defect with the
omentum protecting the bowel. C. A piece of acellular
matrix was used to close the peritoneum/transversalis
layer of fascia. D. Markings for a right vastus lateralis
flap. A vastus lateralis muscle flap was then harvested
based on the descending branch of the lateral femoral
circumflex system (E) and transposed under the
rectus femoris muscle (with the Penrose drain around
the muscle (F). G. The muscle was then inset into the
abdominal wall defect with the fascial side down
against the acellular dermal matrix. The overlying skin
was closed primarily over the reconstruction.
PEARLS AND PITFALLS
Markings
■ Mark the patient preoperatively.
■ Toes should be maintained in neutral.
Positioning
■ Keep toes at neutral for flap harvest (slight internal rotation of the
leg).
■ No bumps under thigh in the OR, as this can distort the soft tissue of
the thigh
Skin
paddle
design
■ For an ALT, cutaneous perforators are most often located 1.5 to 2 cm
posterior to the axis line; keep this in mind when defining your skin
paddle. The incision should be adjusted if other flaps are planned.
Surgical
efficacy
■ Harvesting flaps from the right thigh is optimal for right-handed
surgeons for dissection of this flap if the defect is midline; otherwise,
the leg ipsilateral to the defect should be used if possible to minimize
the distance for flap transposition.

Perforator
selection
■ More distal perforators should be preserved and more proximal
perforators can be sacrificed to optimize pedicle length.
Plan B
■ When using and ALT, expect pedicle variability. Follow the
perforators in a systematic fashion.
■ Vastus lateralis and rectus femoris can be taken for additional bulk
and/or muscle coverage.
■ If no adequate perforators are located, keep in mind that you can
always convert to an anteromedial thigh flap (AMT) before
committing to your lateral incision. The lateral incision should over
the lateral border of the rectus femoris, as most of the AMT
perforators are found there.
Avoid
sensory
deficits
■ Beware of the descending branch of lateral femoral cutaneous nerve.
Preserve as many medial branches as possible to avoid undue
numbness in medial thigh.
Tunnel for
transfer to
the lower
abdomen
■ The shortest path for a lateral thigh flap to the lower abdomen is
subrectus femoris, subsartorius, and then subcutaneous.
POSTOPERATIVE CARE
■ Drain management: Hematomas and seromas can place undue pressure on the
flap and pedicle, therefore compromising flow. Pay careful attention to drain
output, and any hematomas should be drained operatively.
■ Flap monitoring: Nursing staff should monitor the flap overnight, with checks
for capillary refill, color, and warmth every 2 to 4 hours. A Doppler stitch can
be used if needed. Evidence of congestion or ischemia should be noted
immediately. Sometimes, release of sutures can help if undue tension is the
source of the problem. Concerns for vascular compromise should prompt
operative exploration to evaluate kinking or pressure on the pedicle
■ Review the pathology results to confirm margins are negative from the
original resection for all oncologic procedures.
COMPLICATIONS
■ Flap loss: Complete flap loss is due to compromise of the vascular pedicle.
Ideally, this would be discovered soon postoperatively with subsequent
operative salvage. However, in the case of irreversible flap loss, the tissue

should be removed and other reconstructive options should be explored.
■ Wounds: Recipient site wounds are relatively common and most often can be
managed nonoperatively. This would include debridement as needed, local
wound care, and close monitoring. The surgeon should avoid the urge to
debride aggressively or perform additional procedures as most often, these
wounds will heal secondarily.
■ Infection: Most infections can be managed with antibiotics. Interventional
drain placement is helpful for formed abscesses seen on imaging.
■ Hematoma: Hematomas are possible at both the donor and recipient site. Drain
output and physical exam are key. Hematomas should be drained surgically.
■ Seroma: Late seromas can develop at the donor site. Most can be managed
with drains and compression.
REFERENCES
1. Charlton S, Cyna AM, Middleton P, et al. Perioperative transversus abdominis
plane (TAP) blocks for analgesia after abdominal surgery. Cochrane Database
Syst Rev. 2010;(12):CD007705.
2. Jang J, Jeong SH, Han SK, et al. Reconstruction of extensive abdominal wall
defect using an eccentric perforator-based pedicled anterolateral thigh flap: a
case report. Microsurgery. 2013;33(6):482-486.
3. Friji MT, Suri MP, Shankhdhar VK, et al. Pedicled anterolateral thigh flap: a
versatile flap for difficult regional soft tissue reconstruction. Ann Plast Surg.
2010;64(4):458-461.
4. Ibarra-hurtado TR, Nuño-guzmán CM, Echeagaray-herrera JE, et al. Use of
botulinum toxin type a before abdominal wall hernia reconstruction. World J
Surg. 2009;33(12):2553-2556.
5. Yu P, Selber J. Perforator patterns of the anteromedial thigh flap. Plast
Reconstr Surg. 2011;128(3):151e-157e.

12
CHAPTER
Section III: Body
Contouring
Abdominoplasty
Alan Matarasso and Darren M. Smith
DEFINITION
■ Abdominal contour deformity results from relaxation of the abdominal wall
and overlying soft tissues with childbearing, weight gain, aging, or a
combination of the above.
■ Rectus diastasis is the separation of the two rectus abdominis muscles in the
midline; this separation, along with stretching of the abdominal fascia,
constitutes the deepest anatomical layer responsible for the abdominal contour
deformity.
■ Lipodystrophy refers to excess adiposity, superficial to the abdominal wall,
that contributes to the abdominal contour deformity.
■ Skin excess (most frequently present after weight loss or pregnancy) is the
most superficial anatomical component of the abdominal contour deformity.
ANATOMY
■ The abdominal wall can be discussed in terms of three treatable tissue types,
skin, fat, and muscle.
■ Skin (from costal margin superiorly to mons pubis inferiorly, with lateral
borders defined by the anterior axillary line)
■ Fat in the abdominal region is either superficial or deep to the Scarpa fascia.
Some surgeons aggressively excise subscarpal fat from the abdominoplasty
flap, but this is not generally our practice.
■ The rectus abdominis muscles are a paired midline structure that must be
assessed in each abdominoplasty patient to determine the need for plication.

■ Plication is generally indicated except in men and in the massive weight loss
population.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Abdominoplasty patients should be low risk (eg, ASA I) healthy patients.
■ Abdominoplasty patients should ideally have completed their childbearing, as
future pregnancy will distort the result.
■ Massive weight loss patients require heightened vigilance with regard to
medical optimization given their unique risk profile.1
■ In addition to ensuring general good health in the abdominoplasty patient,
special attention should be paid to venous thromboembolism (VTE) avoidance
given the risk of this potentially catastrophic event after this procedure.2
■ In a survey of more than 1100 plastic surgeons on VTE occurrence and
prevention in their practices, VTE was found to occur most frequently with
abdominoplasty and abdominoplasty combined with another procedure
(without a significant difference in frequency between the two).3
■ Thorough history taking and patient-specific risk reduction strategies based on
the literature are critical in VTE avoidance.2,4
■ The physical exam should focus on identifying the degree to which the
treatable tissues of the abdomen (skin, fat, and muscle) contribute to a given
patient’s abdominal contour deformity.
■ Pre-existing scars should be evaluated with regard to their effect on blood
supply to the abdominoplasty flap and to determine the best way to incorporate
them into the incision design if they cannot be excised.
IMAGING
■ No preoperative imaging is routinely performed prior to abdominoplasty.
■ If hernias is suspected based on history or physical exam, an abdominal
computed tomogram (CT) is indicated.
SURGICAL MANAGEMENT
■ Choice of operation from the abdominolipoplasty system of classification and
treatment5 based on physical exam findings with respect to the treatable tissues
of the abdomen (skin, fat, and muscle) (FIG 1):
■ Type I (liposuction alone): Minimal skin laxity, excess adiposity, minimal
rectus diastasis
■ Type II (mini abdominoplasty): Mild skin laxity, excess adiposity, lower

rectus diastasis
■ Type III (modified abdominoplasty): Moderate skin laxity, excess adiposity,
lower with or without upper diastasis
■ Type IV (full standard abdominoplasty with or without liposuction): Severe
skin laxity, excess adiposity, complete rectus diastasis
■ Patients can be “downstaged” to less invasive options if they cannot accept a
given scar or desire minimized recovery time, but it should be explained that a
downstaged procedure cannot deliver the same result as the procedure that is
indicated by the abdominolipoplasty system of classification and treatment.
Preoperative Planning
■ Several red flag patient characteristics emerged from our experience that apply
to combining abdominoplasty with any procedure.
■ Pulmonary conditions, history of or propensity for VTE, cardiac
insufficiency, peripheral vascular disease, hypertension, obesity, bleeding
diathesis, smoking, exposure to secondhand smoke, and diseases affecting
microcirculation (diabetes, lupus, chronic fatigue syndrome) should be
investigated and dealt with prior to abdominoplasty.

FIG 1 • The abdominolipoplasty system of classification
and treatment. Type I, liposuction alone. Type II, mini
abdominoplasty. Type III, modified abdominoplasty.
Type IV, full standard abdominoplasty with or without
liposuction. Types I and II are limited abdominoplasties.
Pink, suction-assisted lipectomy; yellow, undermining;
green, excision; blue cross-hatching, fascial plication;
arrows, transitional area.

■ A history of surgical site infections (especially involving methicillin-resistant
Staphylococcus aureus [MRSA]) should also be addressed.
■ With regard to VTE prevention, our patients discontinue the use of all female
hormones (including drug-eluting patches and intrauterine contraceptive
devices) and nicotine in the preoperative period. They are offered
prothrombogenic blood test screening and postoperative venous Doppler
testing.
FIG 2 • The Miami beach chair position. The surgeon
must verify that the operating table can reach full flexion
prior to beginning the case.
■ Those at high risk for VTE based on history (Rubin’s group offers a good
review of criteria with which to assess historical risk6) are referred for
hematologic workup.
■ All of our patients are liberally hydrated and placed in compressive stockings
and sequential pneumatic compression devices prior to the induction of
anesthesia.
■ A history of surgical site infection (especially those involving MRSA) should
also be addressed.
■ We routinely utilize nostril mupirocin ointment (GlaxoSmithKline, Research
Triangle Park, NC) in the perioperative period, along with oral and intravenous
antibiotics and antimicrobial body scrubs. Alcohol-based prep solutions are
utilized at the time of surgery.
Positioning

■ Prior to surgery, it is confirmed that the operating room table can reach a full
beach chair position (FIG 2).
■ The operation begins with the patient in the supine position.
■ The symmetry and angle of the arm boards is confirmed, and the arms are
secured to the arm boards with a gauze wrap.
Approach
■ The operation is performed under systemic anesthesia (spontaneous ventilation
general anesthesia, or spinal/epidural) administered by a board certified
anesthesiologist in a certified ambulatory surgery facility.
■ A Foley catheter is inserted and thromboembolic precautions are taken as
discussed above.
■ If multiple procedures are to be performed, the abdominoplasty is usually
performed last.
T E C H N I Q U E S
■ Abdominoplasty
Markings
■ The abdominoplasty incision is marked with the patient wearing their
preferred undergarment to ensure it covers the proposed incision.
■ The abdominal excision, essentially an ellipse of tissue between the
umbilicus and mons pubis, is determined by assessing the ease in which the
lower abdominal skin (from umbilicus to hairline) can be excised after
grasping the pannus with both hands in an attempt for the fingers to touch the
thumbs.
■ The pannus is held slightly upward and the lower incision is designed to
traverse the natural lower skin crease, slightly below its normal position
extending in length to just beyond the lateral skinfolds (noted in a sitting
position) and approximately 5 to 7 cm above the vulva cleft.
■ The upper incision is demarcated passing over the umbilicus to encompass
the old umbilical site and only higher if there is obviously sufficient loose
skin, forming an ellipse when joining the upper and lower incisions; a
flexible ruler bent to trace the lower incision and flipped along its horizontal

axis can be helpful in designing this incision.
■ Bisecting perpendicular lines are marked through it to line up the skin edges
for closure.
■ The incision for umbilical circumscription is drawn and its four quadrants
marked.
Liposuction
■ The abdomen is infiltrated with approximately 1 L of superwet anesthesia (1
L Ringer lactate, 1 mL 1:1000 epinephrine, 20 mL 1% lidocaine).
■ Liposuction is then performed as indicated.
Verifying Incisions
■ The incisions are checked for symmetry by placing 0-silk sutures in the
midline at the xiphoid and the mons below the lower incision.
■ The sutures are crisscrossed and grasped with a clamp.
■ The clamp is then moved to either side of the midline at various points on
the upper and lower skin incision lines to confirm symmetry.
Incisions and Dissection
■ The abdominoplasty commences by freeing the umbilicus from the rest of
the ellipse to be excised during the abdominoplasty.
■ The pannus is then prepared for pre-excision in a vest-over-pants fashion by
sharply incising the upper limb of the ellipse to the level of the rectus fascia
while beveling the cut inward at a 45-degree angle.
■ The upper abdominal flap is then completely undermined with electrocautery
in a narrow tunnel (inverted V) corresponding to red suction area 3 (the zone
of complete undermining) (TECH FIG 1).
Selective Undermining and Suctioning
■ An intact zone surrounding this tunnel (yellow area in TECH FIG 1A,B,
which corresponds to suction area 2 or the zone of selective undermining in
TECH FIG 1C) is undermined as necessary to decrease skin bunching after
muscle closure.
■ This pattern of dissection maintains intercostal blood supply sufficient to
achieve rectus muscle plication.
■ Dissecting in this manner maintains a broad intact subcostal perforator blood
supply (green area in TECH FIG 1A,B or zone of discontinuous
undermining in TECH FIG 1C, of axial blood supply corresponding to

suction area 1) that has been discontinuously undermined by the liposuction.
■ The entire flap can thereby be suctioned during full abdominoplasty, giving
rise to the term lipoabdominoplasty.
■ This operative sequence serves as a standard template and is adjusted
according to individual patient needs unless they do not require liposuction,
in which case it is not performed.
Confirming Height of Lower Incision
■ The operating room table is then flexed and the upper skin flap is pulled over
the pannus to verify that it reaches the proposed lower skin incision (TECH
FIG 2A).
■ If the flap does not reach, it can be stretched, further undermined as
appropriate, Scarpa fascia scored, or adjustments in the height of the lower
incision can be made, if necessary.
■ The lower incision is made to the level of the fascia after it has been
determined that the upper flap can reach it for closure.

TECH FIG 1 • A. The abdominal blood supply before
and after abdominoplasty. B. Suction areas (SA) 1 to
4 are determined by these patterns of blood supply.
Suction area 4 is not suctioned; it is excised. C. The

types of undermining in abdominoplasty can be
divided into zones. Complete undermining is
performed only as much as necessary to allow for
abdominal plication. Note how these zones
correspond to the abdominal blood supply detailed in
(A) and (B).
Excision of the Pannus
■ Although some have suggested that leaving a thin layer of fibrofatty tissue
on the fascia reduces seroma formation, this is not our practice.
■ Special care must be exercised during the dissection in the massive weight
loss population as a large pannus can distort the anatomy and bring the
spermatochord into the field.
■ The pannus is then grasped with Allis clamps and excised en bloc, from right
to left.
■ An ocular conformer is sutured to the umbilicus to facilitate later
identification, and removed when the umbilicus is later exteriorized.
■ The surgeon and assistants are actively achieving hemostasis at each step of
the operation.
Rectus Plication
■ Next, the rectus diastasis is marked in a long vertical ellipse from xyphoid to
pubis such that it can be closed without excessive tension (TECH FIG 2B).
■ The section above and then below the umbilicus is plicated in layers, first
with running 0-loop nylon sutures and then a second layer of buried
interrupted 2-0 Neurolon sutures.
■ Puckering developing in the upper skin flap where it is still attached to the
underlying muscle after fascial closure (TECH FIG 2C) is gently freed by
selective blunt and sharp dissection (zone of discontinuous undermining).
■ Small amounts of bunching (resolves in early postoperative period) are
tolerated and indeed desirable as this is indicative of preserved lateral
intercostal blood supply.
Preparing for Flap Inset
■ At least 30 minutes after lidocaine administration and prior to wound
closure, Exparel (1.3% bupivacaine liposome suspension, Pacira

Pharmaceuticals, Parsippany, NJ) is injected linearly using a threading
technique at strategic submuscular points and in the wound edges.
■ The supplied 20-cc single-use vial of Exparel is diluted in 80 cc of
preservative-free normal saline; 0.25% Marcaine can be added if desired and
safe dosage levels allow.
■ The cavity is irrigated, and final inspection and hemostasis are performed.
Closure
■ The table is returned to the degree of beach chair position necessary for
wound closure.
■ Closure commences with placement of a 2-0 Vicryl suture in the midline.
■ Staples are used to align the wound edges and minimize dog-ear formation.
■ A 2-0 PDO bidirectional barbed suture (Quill SRS, Angiotech, Vancouver,
Canada) is run in the deep layers from the Scarpa fascia to the dermis on
either side of the midline.
■ When most of the wound is closed, the ocular conformer on the umbilicus is
palpated below the flap and marked on the skin in the midline slightly
cephalad to its natural position.
■ A second layer of 3-0 monoderm Quill is run in the subcuticular layer.
■ Closed suction drains are placed in the incision (3 to 5 cm from the lateral
extent of each side) and are secured with 3-0 nylon sutures.
Exteriorization of Umbilicus
■ To exteriorize the umbilicus, the patient’s midline is verified with the silk
marking sutures and by observing the position of the vulva cleft.
■ The new umbilical site is determined and marked as a 2.5-cm inverted V in
the midline.
■ The upper and (more so) lower skin edges of the umbilical opening are
defatted.
■ The umbilicus is exteriorized and the ocular conformer is removed.
■ The umbilicus is sewn to the skin flap with deep absorbable sutures, and the
umbilical skin is closed with 3-0 nylon sutures.
Application of Dressings and Binder
■ A strip of Xeroform gauze is used to pack the umbilicus.
■ The wound is covered with antibiotic ointment, and it is covered with a Telfa
dressing.

■ An abdominal binder can placed be used if desired.
TECH FIG 2 • A. The upper flap is pulled down to the
proposed lower incision before the lower incision is
made so that the ability to close is ensured. B. The
plication is marked as an ellipse above and below the
umbilicus, shown here sutured to an ocular conformer.
C. The arrows highlight skin puckering evident after
abdominal wall plication. This is released selectively
by blunt and sharp dissection (zone of discontinuous
undermining).
■ Achieving a Narrower Waistline
■ Abdominoplasty patients frequently request a narrower waistline, but this
result cannot be guaranteed.
■ Appropriate rectus plication will achieve maximal waistline narrowing,
although two maneuvers (selective waistline liposuction and, in patients with
minimal visceral fat, horizontal waistline sutures) can contribute a modest
improvement (TECH FIG 3).

TECH FIG 3 • The rectus fascia has been plicated in
two layers from xyphoid to pubis. Anatomic landmarks
are highlighted: 1, toward the xyphoid; 2,
supraumbilical region; 3, arcuate line of Douglas; 4,
pubic bulge; 5, level of waistline suture (if indicated).
PEARLS AND PITFALLS
Multiple
procedures
■ Abdominoplasty is frequently combined with other
procedures.2
■ If multiple procedures are planned in a surgery,
abdominoplasty is usually the last to be performed.
Venous
thromboembolism
■ Abdominoplasty is the ambulatory plastic surgery procedure
most frequently associated with venous thromboembolism;
precautionary measures should be taken pre-, intra- and
postoperatively.
Hemostasis
■ It is prudent to for the surgeon and assistants to ensure
hemostasis at each stage of the procedure.
Communication
■ Review the areas so be addressed with the patient prior to
surgery.
■ This conversation is critical in maximizing the chances of a
positive outcome for the patient and success for the surgeon.
POSTOPERATIVE CARE

■ The patient is transferred to a stretcher in the maximally flexed position used
for closure.
■ Patients should ambulate that day as if using a walker and over the next few
days begin to walk fully upright.
■ The first 24 to 48 hours after surgery are spent in a hotel-like facility under the
care of an experienced registered nurse.
■ Blood pressure management, pain control, fluid and foot intake, ambulation,
hygiene, and pulmonary care are carefully protocolized.
■ Drains are removed as early as permitted by character and volume of drainage.
■ Patients are inspected frequently for seroma formation, as untreated seromas
can result in a variety of sequelae and late contour irregularities such as
pseudobursa formation.
■ Any concern for thromboembolic events prompts an immediate workup.
■ Appropriate pain management is essential not only in enhancing the patient’s
experience but also in avoiding a host of serious problems such is paralytic
ileus and hematoma formation.7
OUTCOMES
■ Abdominoplasty patients are generally very happy with the result of their
operation.
■ Perhaps the most common cause of dissatisfaction with abdominoplasty is
poor communication between patient and surgeon prior to the operation.
■ It is particularly important to discuss anatomic boundaries with patients so
there is a clear mutual understanding of the areas to be treated (eg, soft tissue
laxity in the flanks requires a flankplasty) (FIG 3).
■ Clear communication is essential to ensure that:

FIG 3 • Preoperative (A,B) and postoperative (C,D)
images of a patient who underwent abdominoplasty
with flankplasty. The flankplasty is a prime example of a
procedure that underscores the importance of
discussing anatomic boundaries with the
abdominoplasty patient. To address the flanks (lateral to
the vertical lines in C and to the left of the line in D), the
abdominoplasty incision must be extended.
■ The proper operation is selected and that if downstaging is to occur, its full
repercussions are understood.
■ The anatomic limits of the abdomen and surrounding aesthetic units are
defined, especially with regard to liposuction to avoid misplaced expectations
in terms of areas to be treated.
COMPLICATIONS
■ Abdominoplasty carries the highest complication rate (4.7%) of all aesthetic
surgery.5
■ Seroma is the most common complication after abdominoplasty5 and is
avoided by using closed suction drains and maintaining postoperative
vigilance.

■ The most dreaded complication of abdominoplasty is pulmonary embolism,
which occurs in 0.19% of abdominoplasties, underscoring the importance of
the anti-VTE measures discussed earlier.5
■ Tissue ischemia can be minimized by exercising meticulous technique, an
awareness of blood supply, and good judgment in reconciling the extent of
liposuction with tension on wound closure.
■ Avoidance of tissue ischemia can be further ensured by paying close attention
to the method and extent of undermining performed.
■ All wounds are examined for signs of ischemia the night of surgery and the
next morning.
■ If ischemia is noted, any reversible causes such as fluid collection, cellulitis,
infections, or wound tension (that can be relieved by suture removal) are
addressed.
■ If signs of ischemia progress, dimethyl sulfoxide or nitroglycerine ointment
may be employed.
■ Should frank necrosis evolve, standard wound management principles apply.
REFERENCES
1. Michaels J, Coon D, Rubin JP. Complications in postbariatric body
contouring: strategies for assessment and prevention. Plast Reconstr Surg.
2011; 127(3): 1352-1357.
2. Matarasso A, Smith DM. Combined breast surgery and abdominoplasty:
strategies for success. Plast Reconstr Surg. 2015; 135(5): 849e-860e.
3. Spring MA, Gutowski KA. Venous thromboembolism in plastic surgery
patients: survey results of plastic surgeons. Aesthet Surg J. 2006; 26: 522-529.
4. Matarasso A, Smith DM. Strategies for aesthetic reshaping of the postpartum
patient. Plast Reconstr Surg. 2015; 136(2): 245-257.
5. Matarasso A, Matarasso DM, Matarasso EJ. Abdominoplasty: classic
principles and technique. Clin Plast Surg. 2014; 41: 655-672.
6. Friedman T, Coon DO, Michaels J, et al. Hereditary coagulopathies: practical
diagnosis and management for the plastic surgeon. Plast Reconstr Surg. 2010;
125: 1544-1552.
7. Constantine FC, Matarasso A. Putting it all together: recommendations for
improving pain management in body contouring. Plast Reconstr Surg. 2014;
134: 113S-119S.

13
CHAPTERAbdominal Panniculectomy
Devra B. Becker
DEFINITION
■ Abdominal panniculus derives from the Latin pannus (cloth, garment), the
diminutive of which is panniculus (piece of cloth).
■ Pannus was used to describe “wrinkled or flabby skin” by the Roman Pliny,
but is distinct from the Greek panus, meaning swelling (panus inguinalis).
Pannus is defined in modern usage as an abnormal layer of granulation tissue
covering the eye or synovial space.
■ Panniculus morbidus was described in Petty and colleagues’ 1992 article that
reported on eight patients who had restored function after wedge resection.1
■ A symptomatic panniculus can be graded by function2:
■ Grade I: chronic skin problems confined to the lower abdomen
■ Grade II: chronic skin problems around the naval or under a supraumbilical
panniculus as well as an infraumbilical panniculus
■ Grade III: abdominal panniculus without chronic skin problem
ANATOMY
■ An abdominal panniculus is so defined by redundant skin of the abdomen that
can have both horizontal and vertical excess.
■ There are three vascular zones of the abdomen as described by Huger.3
■ In Zone 1 (bounded craniocaudally from xiphoid to pubis and laterally by the
lateral extent of the rectus sheath), the blood supply is the deep epigastric
arcade.
■ In Zone 2 (bounded craniocaudally from a line drawn from the anterosuperior
iliac spine [ASIS] to the pubis, and laterally by the inguinal creases), the
blood supply is the superficial branches of the circumflex iliac and external

pudendal vessels.
■ In Zone 3 (bounded craniocaudally by the costal margin to the ASIS and
laterally extending from the lateral rectus sheath to the midaxillary line), the
blood supply is intercostal, subcostal, and lumbar arteries.
■ Nerve supply to the abdominal wall is segmental and dermatomal, from T7-
L1.
■ The lateral femoral cutaneous nerve from L2-L3 innervates the anterolateral
thigh and travels medial to the ASIS.
■ The iliohypogastric and ilioinguinal nerves pierce the internal oblique muscle
and travel along the external oblique muscle to provide sensation to the inner
thigh and the groin and symphysis pubis.
PATHOGENESIS
■ Risk factors for development of abdominal panniculus after bariatric surgery
include a higher pregastric bypass body mass index (BMI) and advanced age.4
NATURAL HISTORY
■ Symptomatic panniculitis is characterized by intertrigo that is refractory to
conservative management with desiccants such as powder and topical
antifungals.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ For patients who have had bariatric surgery, the surgeon should assess the type
of bariatric surgery the patient had (restrictive, or restrictive and
malabsorptive), time from surgery, total weight loss, and length of time that
weight has been stable.
■ Nutritional status should be addressed, including protein needs and any
micronutrient deficiency.
■ History should be assessed for patient reports of functional impairment,
particularly with activities that require hip flexion such a cycling or walking up
stairs, intertrigal rashes refractory to conservative management with desiccants
and antifungals, and back pain.
■ Physical exam should include inspection for scars and extent of panniculus,
relationship of panniculus to the symphysis pubis, scars, abdominal striae,
quality of skin, mons pubis edema and ptosis, intertrigal rashes or ulceration,
intertrigal hyperchromia, vertical and horizontal excess, and asymmetry.
■ The abdomen should be palpated to assess for hernia, rectus diastasis, skin

elasticity, and extent of subcutaneous fat (FIG 1).
■ Factors important to surgeons are different from factors important to insurance
companies.5
■ Surgeons value stability of weight for 6 months, and time from bariatric
surgery of 18 months, whereas insurance companies value chronic maceration
of skinfolds.
■ There is no consensus on the most appropriate BMI at which to perform
panniculectomy, but postoperative events increase with increasing BMI.
■ Panniculectomy can be safely combined with other procedures.
■ In hysterectomy, panniculectomy can decrease wound dehiscence and
increase ease of hygiene6 without increasing complications,16 as well as
increase exposure of the pelvis.
■ In cases of uterine cancer, concurrent panniculectomy can result in greater
total lymph node counts.7
■ When combined with hernia repair, it can decrease recurrence.8
FIG 1 • Physical exam should include inspection as well
as palpation. The relationship of the panniculus to the
pubis should be assessed, as well as intertrigo.
Photographs with the panniculus lifted help to identify
hyperchromia and intertrigo.
IMAGING
■ Routine imaging is not necessary in the presence of an adequate physical
exam, but CT should be obtained in the case of hernia (FIG 2).
NONOPERATIVE MANAGEMENT
■ Nonoperative management should be aimed at improving function.

■ Weight loss, physical therapy for muscle rebalancing, and hygiene for
intertrigo reduction are nonoperative strategies that should be trialed for
several months.
SURGICAL MANAGEMENT
■ If the umbilical stalk is greater than 5 cm or if it is involved in a hernia, it may
need to be sacrificed. Discussion of the umbilicus should be frank (FIG 3).
■ Blood transfusions are often not necessary, but some blood loss is expected.
Transfusion rates have been reported from 9% to 12%.9
■ Risks of the procedure include bleeding, hematoma formation, skin flap
necrosis, fat necrosis, and asymmetry.9
■ If a wedge excision is planned, whether the umbilicus will remain is
determined based on its location cephalad to the panniculus.
■ The main objective of the operation is to reduce the redundant skin and
subcutaneous fat inferior to the umbilicus that creates the panniculus.
FIG 2 • CT scan can help delineate the extent of a
hernia and can help with preoperative planning.

■ The luminal diameter of vessels is increased in obese patients, and there is
some evidence that the luminal diameter remains increased with massive
weight loss.
■ Surgeons should be mindful of the larger caliber vessels encountered in
panniculectomy, even in massive weight loss patients.
■ The ability to close should be determined prior to resection.
Preoperative Planning
■ Patients are assessed by Caprini score for deep vein thrombosis (DVT) risk
assessment.10
■ CT scans are obtained if there is clinical concern for hernia. If a hernia is
present, a combined hernia repair and panniculectomy is planned.
■ Patients often have some asymmetry of the panniculus; this is identified and
discussed with the patient.
■ Best practices in planning panniculectomy in the bariatric population are
■ Ensuring realistic expectations11
■ Allowing for at least 12 months after bariatric surgery to allow for nutritional
and metabolic homeostasis
■ Allowing for a stable weight for at least 6 months
■ Surgery should be performed by a board-eligible or board-certified surgeon.11
■ Postoperative events have been shown to be lower when the procedure is
performed by plastic surgeons compared with general surgeons.8
Positioning and Anesthesia
■ The operation is performed with the patient in the supine position.

FIG 3 • The umbilicus should be assessed. In this case,
the umbilicus is within the panniculus, and the stalk is
likely greater than 5 cm. It may need to be sacrificed.
■ If the lateral extent of the planned resection cannot be reached in the supine
position, the patient is placed on a beanbag for intraoperative adjustment.
■ SCDs are placed prior to induction of anesthesia.
■ The authors do not use a Foley urinary catheter unless the operation is going
to be longer than 5 hours.
■ General anesthesia is used.
■ A transversus abdominis plane block can be used as an adjunct.
■ Normothermia is important in the operating room. Operative hypothermia is
associated with increased seroma formation and blood loss.
T E C H N I Q U E S
■ Abdominal Panniculectomy with Umbilical
Transposition
Markings and Incision
■ The patient is marked in the standing position, and the lateral extent of the

panniculus is marked (TECH FIG 1A,B).
■ The authors use a measuring tape to confirm the distance of the lateral
extent of the scars from the midline.
■ To avoid a dog-ear, an inflection point is made, transitioning the scar from a
horizontal vector to a vertical vector (TECH FIG 1C–F).
■ Use staples to mark the midline cranial to the umbilicus and at the midline of
the mons.
■ The inferior incision is often placed in the lower abdominal crease.
■ The authors prefer to make the incision slightly cranial to that crease,
which avoids a step-off between the abdominal skin and the mons pubis
(TECH FIG 1G).
■ Vessels are cauterized with electrocautery or tied with suture and divided.
Vessels within the panniculus can often be large.
Dissection
■ Scarpa fascia is identified and divided with electrocautery.
■ The fat superficial to Scarpa fascia is often lobular, and deep to Scarpa fascia
often has a stromal appearance. The deep fatty layer is often very thin
(TECH FIG 2A,B).
■ The rectus fascia is identified. Although the fascia itself can be skeletonized,
we leave a thin layer of tissue over the rectus fascia.
■ Perforators are divided several millimeters superficial to the fascia,
because once divided, they will retract, and bleeding can be better managed
if they have not retracted within the muscle.
■ Leave fat along the ASIS to protect the lateral femoral cutaneous nerve
(TECH FIG 2C).

TECH FIG 1 • A. The lateral extent of the incision can
be measured in both directions from the midline to
increase symmetry. B. It can also be measured from
the umbilicus, which provides a reference on both the
mediolateral dimension as well as the craniocaudal
dimension, although if the umbilical stalk is long, it
may not be midline at the time of measurement. C–F.
Creating an inflection point can help reduce dog-ears.
Shown is the transition medial to the lateral extent or
the panniculus. G. Marking the inferior incision slightly
superior to the fold helps to avoid a step-off between
the mons and the abdominal flap.

TECH FIG 2 • The fat superficial to Scarpa fascia is
more lobular than the fat deep to it, and the deep fatty
layer can be thin. A. Upper forceps demonstrate fat
superficial to Scarpa fascia, and the lower forceps
demonstrate fat deep to Scarpa fascia. B. The forceps
indicate Scarpa fascia. C. A layer of fat can be left
over the ASIS to protect the lateral femoral cutaneous
nerve. It can also be identified visually. Forceps
indicate level of ASIS.
Umbilical Transposition
■ If umbilical transposition is planned, the dissection is continued cranially
until there is approximately 2 cm of subcutaneous fat inferior to the
umbilicus to prevent inadvertent disruption of umbilical blood supply.
■ Use a surgical marker to mark out the umbilicus. The authors mark in the
natural fold of the umbilicus (TECH FIG 3A,B).
■ The stalk of the umbilicus is separated from the surrounding subcutaneous
fat using either Metzenbaum scissors or electrocautery.
■ The authors do not skeletonize the stalk, and if the stalk is long, they leave

a generous amount of fat on the stalk to avoid separating perforators
(TECH FIG 3C).
■ Once the umbilicus has been isolated, the dissection continues superiorly to
the xiphoid process.
■ The dissection plane becomes more difficult to identify as there is more
adherence between the rectus abdominis fascia and the subcutaneous tissue.
■ In the case of umbilical sacrifice, the umbilicus is taken as part of the
resection specimen, and the stalk is cauterized or tied off.
TECH FIG 3 • A. The umbilicus is marked in its natural
fold. An umbilicus that is too small can be difficult to
clean. B. A suture is placed at 12 o’clock to ensure
proper orientation at inset and can aid in traction
during incision. C. When the patient has a long
umbilical stalk but the umbilicus is being preserved
and transposed, a generous layer of fat can help
preserve blood supply.
■ Flap Advancement and Skin Resection

■ Once the flap is fully dissected (TECH FIG 4A), it is advanced inferiorly
and the amount to be resected is determined. If needed, the patient can be
placed in a slight reflex position.
■ Indocyanine green can be used intraoperatively to assess viability of flaps
and can predict wound healing complications.
■ The excess panniculus is resected and passed off the table to be weighed.
■ If there is a vertical component, the skin can be imbricated with staples to
determine a safe amount of resection (TECH FIG 4B-F).
■ Drains (19-French round hubless channel drains) may be placed underneath
the flaps, although progressive tension closure using barbed suture has been
demonstrated to be an alternative to drains.
■ The receiving bed for the umbilicus is created by measuring the actual size
of the umbilicus and drawing a template on the abdominal wall.
■ The template is placed where the umbilicus is positioned when the stalk
projects orthogonal to the abdominal wall, and the distance from the mons
is measured to ensure that there is adequate skin (TECH FIG 4G).
Closure
■ The Scarpa layer can be closed using either interrupted or running suture, but
it is not always necessary.
■ The skin is closed in layers using 3-0 poliglecaprone 25 or glycomer 631 for
both the deep dermal and the subcuticular layers.
■ The umbilicus is repaired using 3-0 poliglecaprone 25 or glycomer 631 for
the deep layers and either 4-0 poliglecaprone 25 or glycomer 631 in a
running subcuticular stitch of 5-0 fast as a running baseball stitch.
■ All incisions are waterproofed with a cyanoacrylate tissue adhesive.
■ An abdominal binder is placed.

TECH FIG 4 • A. The fully dissected flap. B–D. If there
is a fleur-de-lis component, the skin can be imbricated
to determine a safe amount for resection. A marking
pen is used to reinforce the boundaries (E), and the

staples are removed and the skin is resected (F). G.
The receiving bed for the umbilicus is placed at the
position of the umbilicus as it projects from the
abdominal wall. The surgeon places a hand under the
flap to demonstrate the location of the umbilicus.
PEARLS AND PITFALLS
Physical
findings
■ Intertrigo is common and should be assessed. Asymmetry of the
panniculus is common and should be identified and discussed with
the patient preoperatively.
Technique
■ Dog-ears can be reduced by transitioning the direction of the scar
at its lateral extent.
■ A layer of fat left on the ASIS can help prevent injury to the lateral
femoral cutaneous nerve
■ When performing an umbilical transposition, marking a receiving
bed for the umbilicus based on the measured dimensions of the
umbilicus will result in a natural-appearing umbilicus.
■ Indocyanine green techniques can be employed to determine flap
viability.
■ The best position for the umbilicus is along a line drawn between
the iliac crests. If the umbilicus is not transposed but remains in
situ, a 10-cm flap of skin should remain between the umbilicus and
the mons.
■ Consider a fleur-de-lis approach if there is both vertical and
horizontal skin laxity.12
Postoperative
■ DVT prophylaxis should be considered.
■ Adequate fluid resuscitation is critical, particularly in bariatric
surgery patients.
POSTOPERATIVE CARE
■ Patient should wear an abdominal binder for 6 weeks.
■ Drains should remain until output is less than 30 cc/d.
■ Postbariatric patients should have fluid status monitored closely—because of

decreased gastric volume, they cannot orally resuscitate at the same rate as
nonbariatric surgery patients.
■ Ambulate the day of surgery. Most procedures are performed as outpatient
procedures or 23-hour observation.
■ Postoperative analgesic medication as needed
■ DVT prophylaxis should continue. American Society of Plastic Surgery
consensus guidelines are 1 month of postoperative chemoprophylaxis.
OUTCOMES
■ Functional outcomes of panniculectomy are often good (FIG 4).
■ Patient satisfaction is high, regardless of technique used.9
■ Body image and quality of life are improved after body contouring in bariatric
surgery patients.13,14
COMPLICATIONS
■ Some studies have shown that postoperative events are correlated with BMIs
greater than 30.9
■ Patients who have had weight loss surgery are at increased risk of
postoperative events when compared to patients who have not; the most
common events are wound healing problems, wound infection, hematoma, and
seroma.15
■ It is unclear if the likelihood of bariatric surgery patients being more likely to
have a history of diabetes mellitus, more likely to be smokers, or more likely
to have a higher ASA class, is contributory.
■ Undiagnosed vitamin deficiency can lead to postoperative events.
■ Contour deformity can occur, and scar asymmetry can be seen. Scar
asymmetry may be difficult to assess in initial marking, particularly with a
large panniculus.
■ The skin quality of the massive weight loss patient is not the same as in
nonmassive weight loss patients.

FIG 4 • Preoperative (left) and postoperative (right)
views of a patient who had a combined panniculectomy
and hernia repair. She noted improved mobility and
decreased rashes after the procedure.

REFERENCES
1. Petty P, Manson PN, Black R, et al. Panniculus morbidus. Ann Plast Surg.
1992;28(5):442-452.
2. Gurunluoglu R, Williams SA, Johnson JL. A classification system in the
massive weight loss patient based on skin lesions and activity of daily living.
Eplasty. 2012;12:e12.
3. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am J Surg.
1979;45:612.
4. Chung CW, Kling RE, Sivak WN. Risk factors for pannus formation in the
post-bariatric surgery population. Plast Reconstr Surg. 2014;133(5):623e-627e.
5. Stephanie E, Dreifuss SE, Rubin JP. Insurance coverage for massive weight
loss panniculectomy: a national survey and implications for policy. Surg Obes
Relat Dis. 2016;12(2):412-416.
6. Hardy JE, Salgado, CJ, Matthews MS, et al. The safety of pelvic surgery in
the morbidly obese with and without combined panniculectomy: a comparison
of results. Ann Plast Surg. 2008;60(1):10-13.
7. Eisenhauer EL, Wypych, KA, Mehrara BJ. Comparing surgical outcomes in
obese women undergoing laparotomy, laparoscopy, or laparotomy with
panniculectomy, for the staging of uterine malignancy. Ann Surg Oncol.
2007;14(8):2384-2391.
8. Koolen PG, Ibrahim AM, Kim K, et al. Patient selection optimization
following combined abdominal procedures: analysis of 4925 patients
undergoing panniculectomy/abdominoplasty with or without concurrent hernia
repair. Plast Reconstr Surg. 2014;134(4):539e-550e.
9. Cooper JM, Paige KT, Beshlian KM Abdominal panniculectomies: high
patient satisfaction despite significant complication rates. Ann Plast Surg.
2008;61(2):188-196.
10. Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis
Mon. 2005;51:70-78.
11. Apovian CM, Cummings S, Anderson W, et al. Best practice updates for
multidisciplinary care in weight loss surgery. Obesity. 2009;17:871-879.
12. Friedman, T, Obrien Coon D, Michaels J, et al. Fleur-de-lis abdominoplasty:
a safe alternative to traditional abdominoplasty for the massive weight loss
patient. Plast Reconstr Surg. 2010;125(5):1525-1535.
13. Pecori L, Serra Cervetti GG, Marinari GM, et al. Attitudes of morbidly obese
patients to weight loss and body image following bariatric surgery and body
contouring. Obes Surg. 2007;17:68-73.

14. Song AY, Rubin JP, Thomas V, et al. Body image and quality of life in post
massive weight loss body contouring patients. Obesity (Silver Spring).
2006;14:1626-1636.
15. Greco JA, Castaldo ET, Nanney LB, et al. The effect of weight loss surgery
and body mass index on wound complications after abdominal contouring
operations. Ann Plast Surg. 2008;61(3):235-242.
16. Forte AJ, Tuggle CT, Berlin NL, et al. Hysterectomy with concurrent
panniculectomy: a propensity-matched analysis of 3-day outcomes. Plast
Reconstr Surg. 2015;136(3):582-590.

14
CHAPTER
Abdominal Panniculectomy
in Super Obese Patients
David J. Rowe
DEFINITION
■ Over 60% of the US population is overweight.
■ Over 30% is obese by BMI stratification.
■ Super obese is classified as BMI greater than 50, super-super obese is BMI
above 60.
ANATOMY
■ The anatomy of the abdominal panniculus is discussed in Chapter 13.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The preoperative evaluation for a patient with super obese panniculus includes
a detailed history as well as documentation of pertinent physical
manifestations.
■ Physical examination
■ Large abdominal panniculus
■ Intertriginous rashes
■ Chronic infection
■ Ulcerations
■ Fistulous tracts
■ Physical limitation
■ Presence of hernia: difficult given overlying tissue
IMAGING AND OTHER DIAGNOSTIC STUDIES
■ If hernia is suspected, CT scan with contrast is warranted (FIG 1).
■ Preoperative laboratory values: patients who have had previous gastric bypass
will need a preoperative workup that will be discussed more in detail in other

chapters. Given the likely comorbidities of the super obese, nutritional
parameters may also be evaluated in the workup of all patients.
■ Nutritional parameters: albumin, prealbumin
■ Lab workup: CBC, basic chemistry
NONOPERATIVE MANAGEMENT
■ The primary decision in the instance of panniculectomy in the super obese
patient is the possibility of weight loss or gastric bypass prior to surgery.1
■ In the case of panniculus morbidus, the pannus may still be present following
weight loss.2
■ In the case of combined surgery for cancer extirpation, etc., ideal weight loss
may not be achieved.
SURGICAL MANAGEMENT
■ Indications for surgery include overhanging panniculus interfering with
ambulation and undergoing combined abdominal operations (eg, hysterectomy,
tumor extirpation, hernia repair; FIG 2).
■ Risks to the patient include an increase of overall complication rate given the
extremely high BMI, increased risk of prolonged hospitalization, need for
further surgical intervention, wound healing complications, and increased
bleeding when compared to traditional panniculectomy.
FIG 1 • A. Presence of hernia on CT scan. B.
Intraoperative view of hernia.

FIG 2 • A,B. Morbidly obese panniculectomy. Patient is
a 53-year-old woman, BMI 52, with biopsy-proven
cervical cancer and need for hysterectomy.
■ Given the patient’s preoperative risks, surgical intervention may include
excision of the panniculus with closure or excision without total closure and
use of negative pressure dressings.
■ Brown et al. found that in instances of panniculectomy, patients who
underwent excision and wound care via vacuum-assisted closure (VAC)
therapy required significantly less readmissions and less reoperations.3
■ The mons area is usually significantly redundant and must be assessed at this
time as well.
■ Given the risk of surgery in super obese patients, an anesthesia and medicine
clearance is warranted prior to surgery.
■ Deep vein thrombosis (DVT) risk assessment via the Caprini score is
performed.
Preoperative Planning
■ Markings
■ Midline
■ Inferior incision line to accommodate mons lift (if being performed) as well

as general avoidance of attenuated skin at the actual crease. Given the actual
size of the pannus, the surgeon may need additional assistance with this
marking.
■ General area to be resected may also be marked with the understanding that
this may change depending on intraoperative findings.
■ Patients should be typed and cross-matched prior to the procedure.
T E C H N I Q U E S
■ Preparation and Transection of the Pannus
■ Following induction and the administration of weight-based antibiotics, the
pannus is prepped for elevation.
■ At the most dependent portion of the pannus, several large Steinmann pins
are placed through the pannus and attached to a mechanical lift (TECH FIG
1).
■ A Foley catheter is now placed if it is warranted.
■ Access for the Foley placement is considerably easier following
displacement of the large pannus.
■ The caudal incision is then marked again approximately 2 to 3 cm above the
pannicular crease.
■ Sharp electrocautery dissection is performed through the skin; subcutaneous
tissue to the abdominal fascia is performed in a caudal to cephalic direction.
■ Given the large size of the superficial venous system, care is used in
dissection in this plane.
■ The author uses medium and large clip appliers for ligation of these
vessels; however, suture ligation may be used as well.
■ Attention is then turned to the cephalic incision once visual inspection
confirms enough skin to close the incision primarily.
■ In super obese panniculectomy, the umbilicus is usually transected, given
the large and tortuous stalk.

TECH FIG 1 • Hoyer lift is employed for retraction.
Steinmann pins are placed under sterile conditions
and attached to Kocher clamps.
■ Closure
■ During closure, two 19-Fr Jackson Pratt drains are used.
■ Meticulous hemostasis is performed with patient at the preoperative blood
pressure.
■ The Scarpa fascia is usually quite attenuated and may be approximated with
3-0 Vicryl suture if an adequate layer is available.
■ Skin is closed with 4-0 Monocryl or staples depending on surgeon’s choice
(TECH FIG 2A).
■ An incisional VAC may be used to aid healing (TECH FIG 2B).