Explore Plastic Surgery - Dr. Barry Eppley

Abdominoplasty, or a “tummy tuck,” is a well known procedure in plastic surgery that tightens loose rectus muscles and removes excess abdominal skin and fat. This recontouring of the abdominal wall area is exclusively done for cosmetic purposes to create a more flat and firm abdomen.

A panniculectomy, a cousin to the abdominoplasty, is different in that it involves exclusively the removal of a large and/or long overhanging apron of skin and fat in the lower abdominal area. While the pannus produces a stretching of the tissues from the anterior abdominal wall, such effects are not treated by any form of muscle plication as in a tummy tuck. The abdominal pannus occurs exclusively in morbidly obese individuals or following substantial weight loss, most commonly bariatric surgery. For the sake of classification, although this doesn’t change how it is treated,  abdominal pannuses are graded by the American Society of Plastic Surgeons as follows:

 Grade 1: pannus covers hairline and mons pubis but not the genitals  

 Grade 2: pannus covers genitals and upper thigh crease

 Grade 3: pannus covers upper thigh

 Grade 4: pannus covers mid-thigh

 Grade 5: pannus covers knees and below

Unlike an abdominoplasty, a panniculectomy is performed for functional or medical reasons. As a result, it is often covered by insurance. There is little question that Grade 3 through 5 pannuses are almost always covered. Debate frequently ensues from the insurance company in the medical merits of removing Grade 1 and 2 types. This is where documentation of its medical problems is really important. Without adequate written evidence of symptoms, these lower grade abdominal panniculectomies will be viewed as a cosmetic procedure.There is little question that a massive overhanging apron of fat and skin creates chronic and unremitting skin problems underneath it. In addition to the need for enhanced personal hygiene (which is very difficult), treatment of these skin conditions may require antifungal creams and powders and occasionally antibiotics.

Not infrequently, there may be a need for a panniculectomy to be done with other abdominal and pelvic procedures such as hernia repair, hysterectomy, and even gastric bypass surgery. While it may seem obvious that getting rid of an obstructive pannus could only benefit the results of these surgeries, the insurance companies rarely see it this way. Citing that there is ‘insufficient scientific literature’ to support any benefit, these combined procedures are usually denied. How they can not easily see that such benefits  as improved surgical access and less risks for wound healing problems after surgery is a mystery to me. Such concomitant coverage can be obtained if the documentation of skin problems is first obtained however.

Interestingly, an abdominal panniculectomy is not considered medically necessary when the main reason it is being performed is to relieve back, hip and knee pain. Even though the sheer weight of grade 4 and 5 pannuses clearly strain these areas, this consideration alone is insufficient for medical coverage. I have performed over the years numerous panniculectomies that were requested by an orthopedic surgeon to first be done before they would consider knee replacement surgery. Apparently, the musculoskeletal problems that it causes by orthopedic specialists is not sufficient evidence for medical coverage.

One procedure that is never needed and certainly not medically covered as part of a panniculectomy is liposuction. In fact, thinning out of an abdominal skin flap with liposuction can impact its blood supply and create wound healing problems. The wound edges in closing a panniculectomy are already compromised from chronic swelling and lymphedema in many cases. Adding liposuction to it may be ill-advised.

Dr. Barry Eppley

http://www.eppleyplasticsugery.com

Indianapolis, Indiana

The abdominal panniculectomy is a variation to the traditional tummy tuck or abdominoplasty.  The pannus  or abdominal apron is that overhang of skin and fat that extends below one’s waistline. Abdominal pannuses can exist in overweight as well as extreme weight loss patients after bariatric surgery.

The abdominal panniculectomy, historically, refers to the pre-bariatric surgery era when extremely overweight patients had large skin and fat overhangs. Heavy pannuses were surgically removed to relieve the medical symptoms that they caused such as skin irritations and rashes from the moisture and heat that builds up underneath it. With an obese patient, panniculectomies were associated with high wound complication rates due to the size and depth of the cut outs. Such surgical removals of abdominal  overhangs today await weight loss through bariatric surgery first, leaving a smaller pannus on a thinner person.

The abdominal panniculectomy is different than a true tummy tuck in that the skin edges are not as undermined, no muscles are tightened, and no areas are treated by liposuction.  It is simply an amputation of whatever overhangs the waistline. In the obese patient, this pannus may have considerable weight anywhere from 30 lbs or higher. In today’s bariatric patient, the pannus may weigh only from 5lbs. to 10 lbs due to the prior weight loss.

Because of the relief of medical symptoms, the abdominal panniculectomy may be covered by insurance. Since the panniculectomy procedure in the bariatric surgery patient today weighs considerably less and often only involves improvement of an undesired contour, it is often called cosmetic by one’s health insurance. To be considered medically eligible for insurance coverage, there has to be very specific criteria that are met and a documented trail of medical records that substantiate symptoms related to the pannus. Most importantly, photographs must demonstrate that the pannus hangs onto or below the groin creases.

Abdominal panniculectomies remove large surface areas of skin and fat. Because of the amount of excess tissue present, removal may need to extend way into the back and include a vertical cutout as well as that in the horizontal dimension. This does leave long scars but patients with these skin excess problems always feel that it is a good trade-off. The biggest complications from these procedures is a seroma or build-up of fluids which is why drains are needed for several weeks after surgery.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Since the advent of bariatric surgery and the rise in the number of such procedures every year, a traditional body contouring plastic surgery procedure is undergoing a change. That procedure is the abdominal panniculectomy…or the cutting off of one’s overhanging pannus.

Panniculectomy surgery is a reconstructive procedure performed to remove a panniculus, sometimes referred to as a pannus or overhanging abdominal apron. The pannus frequently contributes to a number of health problems, including chronic wounds and skin infections due to the moisture underneath the skin folds. 

In the recent past, prior to weight loss from bariatric surgery, an abdominal pannus was quite large (as was the patient) and quite hefty in weight. Many of these pannuses would hang at least down to the middle of the thighs and often to the knees. I have seen a few that hung well below the knee and one that hung down and rested on the floor. My personal ‘record’ for an abdominal panniculectomy was a patient who weighted 715 pounds and a pannus that weighed 96 lbs. Removing these large pannuses required some clever intraoperative methods to hoost them up (known as the ‘china wall’) just to get underneath it to do the cutting. Because of the magnitude of the abdominal wall resection, wound complications after large abdominal panniculectomies were the norm with fluid build-ups and problems with healing of the incision.

While removal of a massive abdominal pannus solved a few health problems for the very obese patient, it did little for their general well-being or improve longevity. Along came bariatric surgery and we have seen a fortunate change in the large abdominal pannus patient. As bariatric surgery has helped patients lose a lot of weight, so has the size of abdominal pannuses decreased. Most abdominal pannuses that I see today are in the bariatric surgery patient or someone that has lost over 100m lbs. on their own. 

These sizes of abdominal pannuses are much more manageable, have fewer complications after their removal, and the patients are overall much healthier. The typical pannus that is removed today, often part of a circumferential lower body lift, weighs 10 lbs. or less. Such abdominal pannuses are a welcome sight from those large ones in the past. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis