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Archive for the ‘abdominoplasty’ Category

OR Snapshots – The Abdominal Panniculectomy (Apron Removal)

Tuesday, January 3rd, 2017

 

The abdominal panniculectomy procedure is well known to be a ‘big’ operation. It is the supersized version of the traditional tummy tuck and is often judged by the weight of the pannus removed. The largest abdominal pannus I have ever removed is 85lbs and that was back in the pre-bariatric surgery era…when the abdominal panniculecomy was the only form of bariatric or weight loss surgery.

abdominal-panniculectomy-surgery-dr-barry-eppley-indianapolisOne of the challenges in this operation is to manage the considerable soft tissue mass, removing the most abdominal tissue that one can while still being able to close the wound without creating after surgery healing problems. When removed the abdominal pannus looks even bigger than when it is attached and hanging on the patient. The term ‘pannus’ is often associated with the word ‘apron’. It is easy to see why it might have that name as seen in this intraoperative picture where it could be worn like an apron once removed.

Beyond the light-hearted clothing analogy, the abdominal panniculectomy produces a dramatic improvement for the patient in many ways. It eliminates chronic skin infections and sores that develop underneath it and removes stressful weight from the back and knees that have to support and carry it around. It also allows the patient better clothing options, often allowing them to find outfits that fit better.

The abdominal panniculectomy is often thought of as a tummy tuck…and it is. But it is an operation that is much bigger in magnitude than most traditional tummy tucks as can be seen by the type of patient on which it is performed. White it is associated with a relatively significant rate of complications, like fluid collections and wound healing issues, these are often self-resolving issues and do not ultimately detract from the huge benefit that patients receive as a result from undergoing the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Good Riddance Abdominal Panniculectomy

Thursday, December 29th, 2016

Cosmetic surgery of the abdomen and waistline is one the most common body contouring surgeries for either women or men. Women in particular are inclined to undergo these surgeries as they are victims of a lot of body changes from pregnancy and/or weight gain/loss. Liposuction and tummy tucks make up the bulk of these surgeries as they fall into the norm of the type of body changes that need to be treated.

But amongst tummy tuck surgeries there is a ‘supersize’ version due to the magnitude of the tissues that need to be removed. This enlarged version of a tummy tuck is known as an abdominal panniculectomy. The abdominal panniculectomy differs from all forms of a  tummy tuck as it removes a large segment of overhanging tissues known as a panniculus. Also known as an abdominal apron, this is a large amount of abdominal tissue that overhangs the waistline down on the thighs. In large abdominal pannuses it can even hang down as low as the knees!

abdominal-panniculectomy-indianapolis-dr-barry-eppleyThe abdominal pannus and its weight causes a constellation of problems for the person from chronic skin infections and moisture underneath it to the strain of its weight on the back and knees. This is not to mention the limitations imposed on clothing options to hold it in or try and hide it. It is no surprise then that when the day comes for their abdominal panniculectomy surgery there are no regrets in losing a bit of oneself!

While an abdominal panniculectomy may not be as eloquent as an operation as many smaller tummy tucks, patients are usually even more grateful.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Abdominal Panniculectomy

Tuesday, November 15th, 2016

 

The surgical procedure ‘abdominal panniculectomy’ is the bigger cousin to the more common tummy tuck or abdominoplasty procedure. What differentiates it is the size of the abdomen and the amount of tissue removed which is often substantially larger than the typical cosmetic abdominoplasty.

The abdominal panniculectomy procedure is a removal of excess waistline tissue. While often call an abdominal pannus, this is really an inaccurate term. The proper term is a panniculus. Medically, a pannus is an abnormal later of fibrovascular or granulation tissue and is commonly referenced to eye conditions of the cornea. A panniculus describes a collection of excess subcutaneous fat in the lower abdomen that hangs over the waistline like an apron. It almost always occur from pregnancy or a lot of weight loss.

abdominal-panniculectomy-dr-barry-eppley-indianapolisCutting off this apron of abdominal tissue often produces large segments of tissue as specimens. They often can be impressive and far exceed what is removed in a more ‘simple’ tummy tuck. While an abdominal panniculectomy creates tremendous improvement in a patient’s medical symptoms (skin infections, comfort, fitting of clothes), the waistline reduction result is never quite as good as many less extensive tummy tucks. But then the original abdominal problem is also much bigger.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Vertical Tummy Tuck

Wednesday, July 6th, 2016

 

Background: Tummy tuck surgery is the most aggressive form of abdominal reshaping. By removing large segments of skin and fat, improvement of the waistline shape is inevitable. The horizontal excision pattern ensures that there is a vertical tightening effect on the central abdomen. Differing lengths of the excision pattern will determine how far to the sides of the waistline this effect will occur.

The history of midline abdominal incisions from either intra-abdominal surgery or c-sections is waning. Laparoscopic surgery has replaced most midline incisions for open intra-abdominal access and most c-sections today are done with a low horizontal incision.

But occasionally a vertical midline abdominal scar is seen. The most common reason it exists today is because the patient either had abdominal surgery as an infant or child or an emergency c-section was done. Such a scar can end up as a midline depression either due to scar contracture or because fat has accumulated around it with weight gain. The combination of a depressed midline scar and thicker sidewalls due to fat thickness creates the impression of a ‘buttocks’ appearance on the stomach

Case Study: This 50 year-old female had a history of multiple intra-abdominal surgeries as an adult through a midline vertical incision from above the umbilicus down to the pubis.  Her vertical scar was stuck down to the abdominal wall and the umbilicus was distorted. Even though she was not overweight, the combination of more normal fat thickness on her abdomen with an indented scar created the frontal buttocks appearance.

Vertical Tummy Tuck markings Dr Barry Eppley IndianapolisUnder general anesthesia she had power-assisted liposuction (PAL) performed on her full abdomen and love handle areas. removing a total of nearly 800cc of aspirate. A vertical excision of skin and fat was done down to the abdominal wall. The umbilicus was reconstructed to a midline location within the closure with a more normal shape.

Vertical Tummy Tuck result Dr Barry Eppley IndianapolisHer three months after surgery results show significant improvement in the shape of her lower abdomen and the elimination of the buttocks appearance. Her scars were slightly hypertrophic which may settle down as they mature over the next year.

The role of the vertical tummy tuck is usually limited to treating pre-existing proboematic abdominal scars. Eve when scars exist between the umbilicus and the pubis, they would be excised with a more traditional horizontal tummy tuck provided there is enough tissue laxity to do so. In this patient’s case her thinner frame and tighter skin precluded the horizontal tummy tuck option.

Highlights:

1) A vertical tummy tuck is a very uncommon abdominal reshaping procedure.

2) It is most commonly used when a pre-existing depressed midline abdominal scar is present with an associated umbilical deformity.

3) A vertically-oriented tummy tuck  allows for simultaneous liposuction, muscle tightening and an umbilicoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Large Abdominal Panniculectomy

Monday, May 23rd, 2016

 

Background: The abdominal pannus is a well known medical condition of a large overhanging apron of skin and fat that extends well beyond the waistline. Technically the proper term is a panniculus but it is far more commonly referred to as a pannus. What defines a pannus is how large the actual overhang is.

There are five degrees of an abdominal pannus from a grade 1 that rests on the mons pubis to a grade 5 that hangs down to the knees. While no abdominal pannus is pleasant for the patient the grade 5 pannus is the most disabling. It not only obstructs the urinary stream and causes associated hygiene issues but its sheer weight makes mobility difficult. It causes tremendous strain on the back and knees and leads to early deterioration of both.

An abdominal panniculectomy procedure should not be confused with a more traditional tummy tuck. The scope of the problem being treated would indicate such but how the operation is performed and under what circumstance is also vastly different. This is no more manifest than in the massive type 5 abdominal panniculectomy operation.

Case Study: This 40 year-old male reached out from Canada because he could not find a surgeon to perform his abdominal panniculectomy procedure.  He had a prior gastric bypass which dropped his weight from over 500 lbs down to 325lbs.  This resulted in the creation of a massive type 5 pannus. Surprisingly he had no otherwise medical problems. Because of chronic skin infections and urinary obstruction he had been to the hospital numerous times. But despite his obvious need for a surgical solution, he stated that no one would take on his case because it was too dangerous or difficult.

Large Abdominal Panniculectomy flaps intraop Dr Barry Eppley IndianapolisLarge Abdominal Panniculectomy tissue removals initraop Dr Barry Eppley IndianapolisUnder general anesthesia a large portion of his abdominal pannus was removed in two sections.  Its total weight was 40 lbs.  It was determined before surgery not to reconstruct his umbilicus. The long umbilical stalk and the umbilical hernia created by its removal were repaired. Closure was done over a large single drain.

Large Abdominal Panniculectomy result intraop Dr Barry Eppley IndianapolisLarge Abdominal Panniculectomy result intraop right oblique view Dr Barry Eppley IndianapolisLarge Abdominal Panniculectomy intraop result left oblique view Dr Barry Eppley IndianapolisHe stayed overnight in the facility and was released to a hotel the morning after. He remained in town for one week for monitoring and flew back to Canada thereafter. His drain will be removed at home after two weeks.

Large abdominal panniculectomies are challenging for a variety of reasons. Their sheer size makes intraoperative positioning and maneuvering difficult. There are many large blood vessels that supply the abdominal pannus and intra- as well as postoperative bleeding is always a risk. The operation needs to be performed as expeditiously as possible to get the patient off the operating room table as soon as possible. When performing the operation as just an overnight stay, the patient must have few other medical problems and be motivated to get up and moving as soon as possible after surgery. Drains are always needed and should stay in at least several weeks. For the out of town patient this means that they will have to get some medical care at home to get it removed.

Highlights:

1) Large abdominal panniculectomies can be safely done in an outpatient surgery center if the patient is otherwise healthy.

2) Enough abdominal pannus is removed to relief the obstruction on the pubic area and eliminate any overhang on the groin creases.

3) The most likely complication from any abdominal panniculectomy is a seroma or fluid collection.

Dr. Barry Eppley

Indianapolis, Indiana

The Body Lift or Extended Tummy Tuck

Thursday, February 11th, 2016

 

A tummy tuck is a well recognized body contouring operation because it has been around for many years. It is generally perceived as a hip to hip excisional and tightening abdominal operation as it only affects the front side of the torso. The term ‘body lift’ however is less well defined in the eye of the patient and can be open to interpretation.

It is recognized that a body lift is more than just a tummy tuck but how much more can be debated. It is an operation that is closely associated with managing the abundant loose and hanging tissues in the extreme weight loss patient, whether the weight loss was surgically induced or not. In this context, a body lift is a circumferential or 360 degree operation removing tissues completely around the waistline.

Body Lift Dr Barry Eppley IndianapolisBut a modification of the body lift can be used in non-weight loss patients. Rather than going completely around the waistline or 360 degrees, the excision extends about halfway between the spine and the side of the waist. (270 or 300 degrees) This captures more loose skin that might otherwise not be adequately addressed by liposuction. This extended skin excision is best done in patients with poor quality skin with little contractile ability around into the back, when a large skin rolls extends into the back and/or when sagging skin exists over the outer thighs.

In the February 2016 issue of the journal Plastic and Reconstructive Surgery, an article was printed entitled the ‘Cosmetic Body Lift’. In this paper the author reviewed 72 patients over a ten year period who had a body lift defined as a  270 degree extended lipoabdominoplasty. (tummy tuck) The amount of liposuction aspirate removed was just over 3,000cc. Complications included a near 3% incidence of seroma (drains were used),  a 4% infection occurrence, and skin necrosis in 4%.  No hematomas occurred. One patient developed a deep vein thrombosis. (DVT) Secondary revisions were done in 18%

Extended Tummy Tuck of Body Lift Indianapolis Dr Barry EppleyThis series demonstrates that the body lift procedure in non-weight loss patients can be done safely and with a similar low rate of complications as that of standard tummy tuck. The critical question for most patients who may benefit from having this ‘bigger’ tummy tuck is whether the extra scar length is perceived as a good trade-off.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Extended Tummy Tuck

Friday, January 22nd, 2016

 

Background: The well known tummy tuck or abdominoplasty procedure is most commonly used in women who have had abdominal shape changes due to pregnancy or some moderate weight loss. But since the era of bariatric surgery, large amounts of weight loss have created skin excesses who require modified forms of tummy tuck surgery.

Since the skin rolls often extend around the hips in extreme weight loss patients, a tummy tuck must go beyond its normal parameters to adequately remove it. Such an extended tummy tuck design can have an extension anywhere from the back of the hips to the whole way around the back. (known as a belt lipectomy or a circumferential tummy tuck) While these type of tummy tucks are extensive, the severe weight loss has made the tissues relatively thin and straightforward to manipulate.

More moderate weight loss patients (35 to 50 lbs for example) generate abdominal skin rolls but they are often thicker. Manipulating these thicker abdominal and back tissues is more difficult because the tissues are ‘stiffer’ and slightly hard to move. Liposuction is usually used concurrently with the tummy tuck to help thin the tissues and help create a better overall result.

Case Study: This 44 year-old female wanted to get rid of her abdominal overhang and narrow her waistline around into her back. She had lost about 50 lbs on her own with diet and exercise. She was now at a weight which she felt was comfortable and able to be maintained.

Realistic Extended Tummy Tuck result front view Dr Barry EppleyUnder general anesthesia, she had a large extended tummy tuck done exclusively from the supine position. Liposuction was performed in the pubic region as well as the flanks into the back and the upper abdomen, removing 2.2 liters of aspirate.

Realistic Tummy Tuck result oblique view Dr Barry Eppley IndianapolisRealistic Extended Tummy Tuck result side view Dr Barry Eppley IndianapolisHer postoperative results at one year after surgery show a dramatic change in the shape of her stomach and her waistline. While her stomach was not flat, it was not predicted to be so before surgery. Her thicker abdominal tissues, which could only be modestly treated by liposuction due to safety concerns, as bound to leave her with an abdominal convexity above the the most narrow portion of her stomach at the waistline where her scar was located.

Moderate weight loss patients with thick skin rolls pose challenges in tummy tuck surgery that bariatric or more extreme weight loss patients do not. These thicker skin rolls require more extended incisions. Liposuction will have a impact on the size of the sin rolls and the wasitline shape but a secondary lipsuction surgery may still be needed to maximize the reduction in the subcutaneous fat layer. This is why, when possible, that patients should maximize their weight loss before undergoing tummy tuck when possible.

Highlights:

  1. A conventional tummy tuck is often not enough to adequately improve abdominal rolls that extend around the waistline.
  2. An extended tummy tuck is usually needed in women that have lost some weight but still remain with significant fat layers and skin rolls.

3. A extended tummy tuck removes skin and fat around the hip area into the back.

Dr. Barry Eppley

Indianapolis, Indiana

Tummy tuck with Abdominal Liposuction

Sunday, May 31st, 2015

 

A tummy tuck is a major abdominal operation that usually removes a large horizontal ellipse of lower abdominal skin and fat. While tremendously effective, many patients having the procedure have excess fat beyond the zone of the tummy tuck excision whose reduction would improve the overall abdominal contouring result. While liposuction of the flanks is commonly done with a tummy tuck, liposuction of the abdominal area above the cut out has been frowned upon because of concerns of impairing healing of the tummy tuck excision.

Tummy Tuck without Abdominal Liposuction Dr Barry Eppley IndianapolisAvoidance of any upper abdominal liposuction at the time of a tummy tuck is certainly the safest approach as there is no chance of vascular compromise by not doing so. But this can leave an upper abdominal fullness that protrudes out beyond the more inwardly located tummy tuck scar the entire lower abdominal area. Many patients interpret this postoperative finding as swelling only to discover it never goes away. This is due to a simple anatomic fact the thickness of the upper abdominal fat largely remains the same while the lower abdominal contour is better because a large segment of tissue has been removed.

In the May 2015 issue of the journal Plastic and Reconstructive Surgery, an article appeared in print entitled ‘Safely Combining Abdominoplasty with Aggressive Abdominal Liposuction Based on Perforator Vessels: Technique and a Review of 300 Cases’.  A retrospective review of 300 consecutive patients who had a tummy tuck combined with liposuction. The tummy tuck was performed saving several perforators from the deep superior epigastric artery.  The abdominal liposuction was fairly aggressive removing an average of 660cc. Their overall complication rate was 17% (52 patients) of which the vast majority of the patients suffered minor complications (the need for scar revision, seroma evacuations, and non-surgical treatment of incisional dehiscences being the most common) and 1% encountered major complications. (non-fatal pulmonary embolus, severe infection and need for blood transfusion)

Tummy Tuck with Abdominal Liposuction Dr Barry Eppley IndianapolisCombining extensive liposuction with a tummy tuck has been a somewhat controversial combination since the early 2000s. What has changed since then is a better appreciation of the blood supply to the abdomen. This study uses a tummy tuck technique that preserves perforator vessels to the central abdominal  skin flap. This then permits the central abdominal area to safely undergo liposuction with impairing perfusion to the central abdominal skin above the incision line.

In the standard lipoabdominoplasty technique the liposuction is performed first followed by the tummy tuck. The liposuction loosens up enough of the upper abdominal tissues that extensive abdominal flap undermining is not needed and all perforators are preserved. This tummy tuck technique performs the liposuction after the tummy tuck. The difference is that some upper abdominal flap undermining is done and the perforators are deliberately seen and preserved.

Dr. Barry Eppley

Indianapolis, Indiana

The Occurrence of Seromas in Tummy Tuck Surgery

Monday, March 30th, 2015

 

Tummy Tuck results front view Dr Barry Eppley IndianapolisA tummy tuck is one of the most commonly performed aesthetic body contouring procedures performed. In many ways it is a ‘big’ operation when one looks at the size of the tissue segment removed and the amount of abdominal surface area manipulated. Despite the magnitude of the surgery, most patients heal remarkably well and suffer no major complications.

Tummy tucks do, however, have numerous minor early postoperative issues or complications. I hesitate to call them ‘complications’ as these minor wound healing issues rarely necessitate a return to the operating room for correction. The single greatest complication in tummy tuck surgery is that of seroma. This fluid collection which usually appears within weeks of the surgery can develop in ‘drainless’ tummy tucks as well as those that even use a drain.

In the April 2014 issue of the journal Plastic and Reconstructive Surgery, a paper was published entitled ‘Natural Evolution of Seroma in Abdominoplasty’. In this clinical study the aim was to evaluate when seromas after tummy tucks occur and how they progress. Using twenty one (21) female tummy tuck patients, abdominal ultrasound was performed in five abdominal wall regions at five different time points after surgery at four, eleven, eighteen, twenty-five and thirty-two days. Their findings shows that the incidence of seroma was roughy 5% percent on postoperative day 4, 38% percent on day 11, 33% percent on day 18, 24% percent on day 25, and 19 % on day 32. The left iliac fossa region had the highest volume of fluid collection on postoperative day 4, as did both the right iliac fossa and left iliac fossa regions on postoperative day 11. At other time points, the relative volume of fluid collection was significantly higher in the right iliac fossa region.

Large Tuck results side view Dr Barry Eppley IndianapolisWhile very annoying to patients, seromas are usually self solving problems aided by the use needle aspiration (tapping) in the office under local anesthesia. Rarely does a drain need to be inserted (or reinserted) to help solve it. What I always tell the tummy tuck patient that has developed a problematic seroma (which usually becomes evident 10 to 21 days after surgery) is that it will require tapping once a week for about a month before the fluid collection is solved. This study shows that seromas become most evident around two weeks after surgery and are still evident even at a month after surgery…supporting that these fluid collections are not quick to stop accumulating.

The location of the seromas is not always in the midline as one would suspect since this is the ‘bottom of the well’ so to speak. They often develop/persist more to the sides near the hips which is why they can be sometimes problematic to aspirate and why it is helpful to turn the patient on one side or the other to successfully tap them.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Long Terms Effects of Tummy Tuck Surgery

Monday, March 16th, 2015

 

Tummy Tuck abdominal reshaping Dr Barry Eppley IndianapolisBackground: Tummy tuck surgery can be an incredibly effective body contouring procedure. It achieves its effects through the removal of a large segment of loose skin and fat often combined with liposuction fat removal in areas beyond the zone of the cut out tissue segment. The benefits of tummy tucks can easily be seen in numerous plastic surgeon’s before and after photos.

But an interesting tummy tuck question is how long does the result last? Do the impressive early results persist and, if so, for how long?

Recent studies have shown that tummy tuck surgery may lead to significant and persistent weight loss for many women, particularly those who were overweight before surgery. (February 2013 issue of the journal Plastic and Reconstructive Surgery) It is postulated that this weight loss is due to a feeling of greater satiety after eating or other neuroendocrine mechanisms that may promote weight loss after surgery. It may be that the large loss of fat cells from the excised tissue segment may cause a lowering of certain hormonal levels that affect appetite. This is a plausible but unproven theory.

Case Study: This 38 year-old female wanted to get rid of her stomach rolls and reshape her waistline. She was not at an ideal weight but needed something to get her going in a positive direction and  decided that surgery would be a good impetus for it.

Long term Tummy Tuck result front view Dr Barry Eppley IndianapolisUnder general anesthesia, a full tummy tuck was performed along with liposuction of her flanks. She recovered well and after six weeks recovery and a few follow-up appointments was not seen again…until ten years later when she returned for breast reshaping surgery.

Long Term Tummy Tuck result oblique view Dr Barry Eppley IndianapolisLong Term Tummy Tuck result side view Dr Barry Eppley IndianapolisHer long-term tummy tuck results showed an overall body that was thinner and much more shapely than before surgery. It was clear she had continued to lose weight and get in better shape beyond what the initial tummy tuck surgery had achieved. This may have ben the result of a neuroendocrine effect but the psychological effects of increased patient motivation can not be denied as a contributing cause as well.

Case Highlights:

1) Tummy tuck surgery can dramatically change the shape of one’s stomach and waistline through a combined excisional and fat extraction approach.

2) Many tummy tucks will have a sustained and long-term effect through the removal of loose skin and fat cells in the excisional segment.

3) Some tummy tuck patients will go on to even improve their tummy tuck results through additional weight loss and body toning efforts.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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