A panniculectomy is an operative procedure used for abdominal wall contouring, changing the shape and form of the abdomen by removing significant excess skin and subcutaneous adipose tissue en bloc. This procedure is performed on patients with a large overhanging abdominal panniculus. The goal of panniculectomy surgery is to remove hanging skin and fat from the lower abdomen to create a smoother abdominal contour. The management of abdominal panniculus should not be thought of solely as a cosmetic procedure. To achieve good outcomes, the goals and objectives of a panniculectomy must be defined.
What is a Panniculectomy?
A panniculectomy is a surgical procedure designed to remove excess skin and fat from the lower abdomen. A panniculus is an apron of excess skin and fat hanging from the abdomen below the waistline. This excess skin and fat are secondary to weight gain and can sometimes cover the anterior thighs, hips, and knees. A large panniculus can lead to severe impacts on patients' mobility and activities of daily life. Skin infections and rashes are common complaints of patients with a substantially large panniculus due to constant irritation and sweating.
The size of a panniculus varies and can be graded on a scale of 1 to 5, which correlates with how far it extends. Grade 1 reaches the mons pubis, while grade 5 extends to or reaches past the knees. A panniculectomy is performed to relieve these symptoms and restore formal function. During a panniculectomy, the excess skin and fat are removed. Tightening or plication of the abdominal wall muscle is not performed, which differentiates this procedure from an abdominoplasty - a cosmetic procedure, usually involving fascial plication or otherwise addressing the underlying fascial and muscular layers of the abdomen.
Reasons for Considering Panniculectomy
There are many reasons why an individual can develop excess skin and fat in the lower abdomen. The most common causes are:
- Age
- Hereditary
- Pregnancy
- Prior surgery
- Massive weight loss
The most common indication for panniculectomy is after the patient experienced a dramatic weight loss, with the resultant excess lower abdominal skin overhanging the groin and pubic regions. This is often seen in patients following bariatric surgery. The risk of formation of a large panniculus post-bariatric surgery is higher in older patients and patients with a higher pre-operative Body Mass Index.
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In severe cases, the panniculus can strike against the thighs as the patient walks, causing significant discomfort and irritation. This can severely limit patients' mobility and predispose them to refractory weight gain. Bariatric surgery patients typically achieve stable weight loss in 12 to 18 months, but some patients present in as few as six months for panniculectomy due to interference from the overhanging skin.
A panniculectomy is best suited for people who have lost a significant amount of weight and have excess skin because of that weight loss. The surgery can remove the excess fat that hangs over your genitals and thighs. Exactly how much fat you can safely remove will depend on your health and circumstances.
Panniculectomy vs. Tummy Tuck
A panniculectomy differs from a tummy tuck in that the abdominal muscles are typically not tightened during a panniculectomy. Panniculectomy differs from an abdominoplasty in several ways. The amount of skin and adipose tissue undermining superior to the tissue being excised (panniculus) is extremely limited in panniculectomy. This is because the large abdominal flaps formed after massive weight loss often demonstrate a relatively compromised vascular status, owing to the increased distance of the skin from the vascular supply origin, essentially a watershed effect. Significant undermining in this situation is associated with a high rate of skin loss and seroma formation, both due to relative hypo-perfusion at the distal edges of the flap. The excision can almost be thought of as a wedge excision of the tissue to be removed. Previous scars must be carefully noted because these also predispose to tissue loss. If the tissue needed to be removed extends above the umbilicus, a umbilectomy is also discussed with the patient.
What a Panniculectomy Cannot Do
A panniculectomy is not a substitute for weight loss or an appropriate exercise program. A panniculectomy cannot correct stretch marks, although these may be removed or somewhat improved if they are located on the areas of excess skin that will be excised. Keep in mind that a panniculectomy is not a weight loss procedure, and it cannot tighten abdominal muscles.
Although the results of a panniculectomy are technically permanent, the positive outcome can be greatly diminished by significant fluctuations in your weight. For this reason, individuals who are planning substantial weight loss would be advised to postpone a panniculectomy. If you continue to lose weight after a panniculectomy, you may see signs of excess skin again, so being close to your ideal weight before the surgery is important.
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Preparing for Panniculectomy
Before a panniculectomy, you’ll meet with your surgeon. They’ll evaluate your general health, including any preexisting health conditions, and discuss your expectations for the procedure. Your provider may take photographs of your abdomen from the front and the side (profile) for your medical record.
Tell them about any previous surgeries you’ve had, as well as any prescription or over-the-counter medications you take, including herbal supplements. Aspirin, anti-inflammatory drugs and certain herbal supplements may increase your risk of bleeding.
They’ll also examine the size of your pannus and grade it depending on how far it hangs from your abdomen.
Your provider will also give you specific instructions to follow before the date of your surgery. This may include:
- Making changes to the medications you take (don’t make changes unless your provider approves them)
- Not eating the night before surgery
- Getting certain tests done
- Not smoking
If you have any questions about the procedure or what to expect, make sure you ask them before the date of your procedure. Undergoing a surgical procedure can be stressful, but you can make it easier on yourself by turning to professionals.
Read also: Paying for Bariatric Surgery Out-of-Pocket
The Panniculectomy Procedure
You can expect the following during a panniculectomy:
- An anesthesiologist will give you general anesthesia. This will put you to sleep so you won’t feel any pain.
- Your surgeon will make a cut (incision) just above your pubic area. The cut extends out toward your hips. The size of this incision depends on how much skin your surgeon will remove.
- Your surgeon will pull down your skin above the incision and remove any excess skin. Depending on the size of the pannus, the procedure may pull down or completely remove your belly button (navel). Your provider may or may not need to reposition and stitch your navel back into place.
- Your surgeon will pull your skin together and stitch the incision site closed.
- Your surgeon may place small tubes in your abdomen to drain any blood or fluid.
The time it takes to complete this procedure depends on many factors. It may take from one to three hours. Your surgeon will give you the best time estimate.
Recovery After Panniculectomy
You’ll move to a recovery room, where healthcare providers will wait for you to wake up and monitor your overall health.
A provider will cover your incisions with bandages. They may also wrap your abdomen with an elastic bandage or a compression garment after surgery or later in your recovery. This helps minimize swelling and support your abdomen as it heals. Compression garments should be worn to prevent seroma formation while drains are present. Once the output of the drain is less than 30 mL/day, they can be removed, and compression garments can be continued for patient comfort.
Most panniculectomies are outpatient procedures. This means you can go home the same day that you have surgery.
Postoperatively, patients are instructed to remain bent at the waist 30 degrees in a semi-Fowler position for a week and thereafter to slowly return to the full upright position, often with the use of abdominal dressings or binders. The slow return to a standing position allows the wound to form scar tissue gradually, absorbing the mechanical loads of the over- and underlying tissues as the posture returns to upright, preventing the sutures from bearing the entire weight of the repair in an upright position, which can lead to failure and dehiscence. Patients should be instructed about careful ambulation during the first few weeks postoperatively.
Ideal Candidates
A panniculectomy is best suited for people who have lost a significant amount of weight and have excess skin because of that weight loss. Although there is no set weight that you have to be to get a panniculectomy, having a body mass index of 30 or lower will reduce your risks of developing a complication after surgery.
You must also be a non-smoker or be willing to stop if you are and be in good overall health. Any medical conditions need to be under control for you to be able to undergo surgery. You must also have realistic expectations of the results and have a body mass index in an acceptable range.
You must have a panniculus that overhangs the pubis and present evidence of having chronic rashes, ulcers, cellulitis, or infections for at least three months that do not respond to traditional treatment options. If symptoms or physical difficulties continue after a large amount of weight loss that has remained stable for six months or if you have documents proving you tried to lose weight without success, you might also qualify for a panniculectomy.
Contraindications
Panniculectomy is an elective procedure where medical problems must be well-controlled before considering the operation. Cigarette smoking affects blood supply and wound healing, and surgery should be avoided in active smokers and any patient with uncontrolled cardiac disease, lung disease, or diabetes. Any immunocompromised state is also a relative contraindication, owing to poorer wound healing.
Patients with morbid obesity who are postbariatric have more severe deformities, excess skin, laxity, and poor tone. These patients are at greater risk of complications with medical comorbidities, surgical scars, and nutritional deficiencies.
Potential Complications
Postoperative complications are associated with comorbidities, higher pre-operative BMI, and previous bariatric surgery.
Wound healing is the most common group of complications after a panniculectomy. This group of complications includes cellulitis, wound dehiscences, and tissue necrosis. The underlying pathophysiology is relative hypo-perfusion of the expanded abdominal tissue and flaps, as well as the overall poor blood supply of adipose tissue. Conservative management and wound care are usually the treatments of choice, but some patients require surgical intervention in the form of wound debridements or revision closures of dehiscent wounds, with tension-bearing sutures or closure devices occasionally required in severe dehiscences. Blood supply to the wound is essential for optimal wound healing.
Seromas are the single most common complication of panniculectomy, especially after a larger dissection. Once a flap is created, the body tries to fill the empty space with fluid, which is why suction drains are placed during the procedure in an attempt to evacuate fluid build-up in an ongoing fashion and facilitate the apposition of the dissected layers. This is also related to the relative hypo-perfusion of adipose tissue, both with blood vessels and lymphatics; both are significantly disrupted in panniculectomy. The best preventative management is the preservation of the Scarpa fascia with minimal dissection. Postoperatively, compression garments and activity reduction can reduce seroma occurrence in select patients, particularly those with smaller-volume panniculectomy and lower overall BMI. Once a seroma occurs, management involves close observation and serial aspirations. Some patients require catheter insertions or sclerosing agents. When performing serial aspirations of seromas, there is a risk of introducing bacteria with each needle puncture. The practitioner must weigh the risks versus the benefits and ensure meticulous sterile technique before aspirating this hypo-vascular field to relieve a seroma.
Simple cellulitis is a skin infection that responds to antibiotics and close follow-up. Complicated cellulitis is refractory to appropriate medical treatment and may result in abscess formation that could require surgical drainage and washout of the operative wound. Infected seromas are pseudo-abscesses and require intravenous antibiotics and surgical drainage.
A hematoma is the accumulation of blood under the abdominal flap. Surgical drains placed during the operation do not prevent hematoma but allow the surgeon to track the amount and rate of postoperative bleeding to facilitate recognition of a hematoma early, hopefully, before the vascularity of the overlying flaps becomes compromised by an expanding blood collection. The drains may sufficiently evacuate a hematoma, particularly a low-volume and low-flow venous hematoma, and management in this situation is conservative. Surgical exploration is required to achieve hemostasis if the bleeding does not spontaneously stop, the hematoma is expanding, or the blood visualized in the drain is bright red.
Wound dehiscence is the premature separation of a wound which can occur at any level.
Equipment and Personnel
A standard plastic surgery tray or large soft-tissue tray should be opened. In large-volume panniculectomy, a body-contouring retractor system may be employed. These systems consist of rigid tubular frames secured to the operative bed and provide a bar or ring above the patient from which massive panniculus can be suspended with specialized retractors or hooks to facilitate exposure and allow for the design of tension-free flaps and excision lines.
Monopolar diathermy is essential, and bipolar cautery can also be useful for cauterizing smaller perforator vessels.
This operation is typically performed under general anesthesia, induced and monitored by a qualified anesthetist.
The surgery is facilitated by an assistant, who can be another surgeon or other first-assistant-trained personnel. A scrub nurse or tech and a circulator/scout nurse are also required.
Surgical Technique
An incision is made in the patient's natural suprapubic crease (often, this will be the inferior base fold of the panniculus). The incision is extended laterally towards the anterior superior iliac spine, stopping at the lateral edges of the pubic hair. The incision is deepened, and dissection is continued through the Scarpa fascia and down to the muscle.
Following the musculoaponeurotic fascial plan superiorly, the abdominal skin and subcutaneous tissue are excised. The wound is closed in multiple layers, with attention paid to the Scarpa fascia, deep dermis, and intradermal layers. Permanent or long-lasting absorbable sutures are used in these strength layers.
Avoiding dog ears on the lateral aspect when closing the wound is very important. Before the wound is closed, suction drains are placed under the flap and brought out through a small incision in the pubic region.
Insurance Coverage
A panniculectomy can receive coverage from an insurance company in many instances.