Without question, the number one concern of bariatric surgery patients after their weight loss is abdominal reshaping. When the weight loss is in the neighborhood of 75 to 100 lbs., the abdominal skin does not redrape or shrink back down. Rather, a large amount of redundant skin results which both hangs and has multiple rolls.
The traditional tummy tuck or abdominoplasty is almost always inadequate to create the best abdominal result in the massive weight loss patient. This is because the excess skin exists in a true three-dimensional fashion, being excessive in both horizontal and vertical dimensions. As a result, I almost always use the combined vertical and horizontal tummy tuck procedure known as the fleur-de-lis abdominoplasty in my Indianapolis plastic surgery practice for bariatric patients. This results in abdominal scars that have a midline vertical and a low horizontal line, known as the anchor scar pattern. Adding the vertical part to the traditional tummy tuck does require more surgery time for dissection and closure, but most relevantly increases the amount of deep space underneath the skin after closure.
In theory, the fleur-de-lis abdominoplasty should be associated with more complications than a traditional abdominoplasty. It takes longer to do and has incisions that meet at an inverted-T area. It also removes a very large segment of skin which leaves more dead space uinderneath. To investigate if this seemingly truth is reality, the May 2010 issue of the journal Plastic and Reconstructive Surgery published a study on this very question. Over 400 abdominoplasty patient were evaluated of whom 154 (31%) had a fleur-de-lis abdominoplasty operation. The overall abdominal complication rate was 26%. This included all types of complications of which 5% would be considered major. (requiring further surgery) Traditional horizontal excision abdominoplasties and fleur-de-lis abdominoplasties were very similar in complication rates with the exception of a higher rate of wound infections in the more extensive abdominoplasty.
My Indianapolis plastic surgery experience is slightly different than that reported in this very extensive and thorough study. I have seen no greater incidence of wound infection between the two types but have certainly seen more wound openings/separations at the inverted-T area. A traditional abdominoplasty does not have this zone and, as a result, significant wound openings are very uncommon. The dead space in the fleur-de-lis abdominoplasty is managed with an extra drain and I am more conservative about their removal, keeping at least one in place for two weeks after surgery.
The fleur-de-lis creates a better abdominal result in the bariatric patient if they feel that the trade-off of a vertical scar is worth an improved upper abdominal area. In days gone by with open gastric bypass surgery, a vertical scar already was present so the decision for the fleur-de-lis was easy. With laparoscopic gastric bypass today, the patient must consider a new obvious vertical scar.
Another consideration for bariatric patients considering the fleur-de-lis abdominoplasty is insurance coverage. If one’s health insurance will provide an abdominoplasty coverage, that does not include the vertical component of the fleur-de-lis. The insurance company covers the horizontal abdominal excision only. There will be an extra out-of-pocket charge for adding the vertical component to the procedure.
Dr. Barry Eppley
Indianapolis, Indiana