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Posts Tagged ‘abdominal panniculectomy’

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

Healing and Wound Complications in Supersize Abdominal Panniculectomy Surgery

Wednesday, September 17th, 2014

 

The abdominal pannus is a stomach deformity where any amount of tissue hangs over the waistline. The term, pannus, is derived from a latin word for apron so it is fitting that any overhang is referred to as such. In days before bariatric surgery, abdominal panniculectomy surgery was very common and it was almost always associated with morbid obesity. Because of bariatric surgery, the most common abdominal panniculectomy today is much smaller and is done after large amounts of weight loss. These pannuses are largely skin and the overall health of the patient is generally good since they are more weight appropriate for their height.

Abdominal Panniculectomy Indianapolis Dr Barry EppleyBut despite the popularity and widespread availability of bariatric surgery, not every obese patient undergoes it or is eligible to do so. This still leaves certain patients who are overweight that suffer from a large pannus with all of its associated symptoms. There has been some understandable reluctance to operate on such overweight patients due to the increased risk of complications that is known to occur .

In the October 2014 issue of the Annals of Plastic Surgery, an article was published entitled “Supersize” Abdominal Panniculectomy: Indications, Technique, and Results’. In this paper, the authors reviewed a series of 26 patients over a six year period that had abdominal panniculectomies performed that weighed over 10 kgs. (22 lbs), hence the term supersized pannus. The indications for surgery were typical including a large amount of overhanging abdominal skin and fat (hangs down to mid-thigh level) that was associated with underlying chronic skin infections, history of panniculitis, and the presence of a hernia. Of the 26 patients, the mean pannus weight removed was over 15 kgs with a followup period of over a year. The overall wound complication rate for the “supersize” panniculectomy over 40%. (11/26 patients). The rate of major complications, defined as those complications requiring a return to the operating room, was just over 10%. (3/26 patients).

Abdominal Pannus Removal Indianapolis Dr Barry EppleyThe relevance of this paper is that it demonstrates that larger abdominal panniculectomies can be done and offer a dramatic improvement in mobility and function of the patient. However, it creates a large abdominal incision and has a lot of ‘dead space’ inside to heal. As a result, wound complications are common (and to be largely expected) and  revisits to the operating room for their management are not rare. This type of abdominal surgery should be confused in this regard with the more common tummy tuck. A CT scan done before surgery can help discover a hernia which can be very difficult if not impossible to pick up on a physical examination of a large pannus.

This paper of larger abdominal panniculectomies supports what I tell my patients…the operation will be highly successful and can be life-changing but there is a very high incidence of wound complications and the need for further surgery/hospitalization is not rare. In the long run it will be very much worth it but expect a healing period of two to three months for a full recovery.

Dr. Barry Eppley

Indianapolis, Indiana

The Differences Between a Cosmetic Abdominoplasty and a Medically Necessary Abdominal Panniculectomy

Sunday, August 22nd, 2010

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

Indianapolis, Indiana

Understanding the Abdominal Panniculectomy

Sunday, September 6th, 2009

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
Indianapolis, Indiana

 

The Changing Size of the Abdominal Panniculectomy Procedure

Monday, February 2nd, 2009

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. This is a more extensive form of a tummy tuck.

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

Indianapolis, Indiana

The Abdominal Panniculectomy vs Tummy Tuck in the Extreme Weight Loss Patient

Sunday, November 9th, 2008

A panniculectomy is a very close cousin to a tummy tuck or abdominoplasty.  The term pannus refers to a large apron of skin and fat that hangs over the waistline.

 The abdominal panniculectomy, surgical removal of a pannus, is a somewhat historic term now as it really refers to the pre-bariatric surgery era when obese individuals  had a large pannus that hung down. At that time, many abdominal panniculectomy procedures were done to relieve the medical symptoms that the pannus caused. Specifically, skin irritations and rashes (known as panniculitis) resulted from the always present moisture and heat in the underlying skin fold. In some cases, the size of the pannus and its amount of overhang actually cut off some of the blood supply and lymphatic outflow resulting in swelling and infection. Surgically removing the pannus was common then but the complication rate was high due to the patient’s obesity. Today, surgical removal of any abdominal overhang would await weight loss through bariatic surgery.

The abdominal panniculectomy refers to simply cutting off the pannus. This 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. (the largest I have removed was 96 lbs) In today’s bariatric patient, the pannus may weigh only from 5lbs. to 10 lbs due to the prior weight loss.

In the historic obese patient, there was a significant improvement in the patient’s quality of life as the skin and infectious symptoms that it caused were eliminated as well as the weight removal improved back and knee pain. Because of the relief of medical symptoms, the abdominal panniculectomy  was often 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. Often times even with solid medical evidence, it will be denied coverage.

Most simple abdominal panniculectomy procedures are largely done in men. Men don’t need muscle tightening and a simple skin overhang removal is often enough. Women usually require a true tummy tuck to get the abdominal contour that they desire.

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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