The Effect of Obesity, Bariatric Surgery, and Operative Time on Abdominal Body Contouring Outcomes Free

Abstract

Background

Abdominal body contouring procedures are associated with the highest rates of complications among all aesthetic procedures. Patient selection and optimization of surgical variables are crucial in reducing morbidity and complications.

Objectives

The purpose of this single-institution study was to assess complication rates, and to evaluate BMI, operative time, and history of bariatric surgery as individual risk factors in abdominal body contouring surgery.

Methods

A retrospective chart review was performed of all patients who underwent abdominoplasty, circumferential lower body lift, fleur-de-lis panniculectomy (FDL), and circumferential FDL between August 2014 and February 2020. Endpoints were the incidence of venous thromboembolism, bleeding events, seroma, infection, wound complications, and reoperations. Univariate statistical analysis and multivariate logistic regressions were performed. Covariates in the multivariate logistic regression were BMI, procedure time, and history of bariatric surgery.

Results

A total of 632 patients were included in the study. Univariate analysis revealed that longer procedure time was associated with infection (P = 0.0008), seroma (P = 0.002), necrosis/dehiscence (P = 0.01), and reoperation (P = 0.002). These associations persisted following multivariate analyses. There was a trend toward history of bariatric surgery being associated with minor reoperation (P = 0.054). No significant increase in the incidence of major reoperation was found in association with overweight or obese patient habitus, history of bariatric surgery, or prolonged procedure time. BMI was not found to be an individual risk factor for morbidity in this patient population.

Conclusions

In abdominal body contouring surgery, surgery lasting longer than 6 hours is associated with higher incidence of seroma and infectious complications, as well as higher rates of minor reoperation.

Level of Evidence: 4

Patient selection and optimization of surgical variables are crucial in reducing morbidity and complications in abdominal body contouring surgery. Abdominoplasty is associated with the highest incidence of complications among all aesthetic procedures with reported major complication rates being as high as 18.1%.^1-4 These complications include venous thromboembolism (VTE) events, infection, hematoma, seroma, and wound complications. Major risk factors in this patient population include high BMI (especially >30 kg/m²), prolonged operative time, and history of bariatric surgery or massive weight loss (MWL).^2-13

Examination of the abdominal body contouring literature reveals an ongoing evolution of the surgical criteria and patient candidacy for these procedures as new data continue to emerge.¹⁴ Further investigation and reconsideration is thus warranted to critically assess surgical and patient variables and thereby improve patient safety. This is particularly significant considering the increasing prevalence of obesity in the population, in conjunction with the rising number of bariatric surgeries performed nationally, and the increasing tendency to perform multiple combined body contouring procedures that potentially lead to longer operative times.¹⁵

The purpose of this single-institution study was to assess complication rates, and to evaluate BMI, operative time, and history of bariatric surgery as individual risk factors in abdominal body contouring surgery.

METHODS

A retrospective chart review was performed of all patients who underwent abdominoplasty, circumferential body lift, fleur-de-lis panniculectomy (FDL), and circumferential FDL at our surgical center between August 2014 and February 2020. Every procedure was performed under general anesthesia at our American Association for Accreditation of Ambulatory Surgery Facilities (AAAAS)-accredited ambulatory surgical facility. The study conformed to the World Medical Association Declaration of Helsinki; because this was a retrospective chart review of previously established postoperative protocols, formal IRB approval for this study was not sought.^16-18

Patient demographic characteristics and clinical outcomes were collected. The Caprini Risk Assessment Model (2005) was retrospectively calculated and utilized for VTE risk assessment.¹⁹ Intraoperative data included the principal operative procedure, secondary concurrent procedures, and operative time. Patients actively smoking at the time of the first preoperative visit (active smokers) were strongly encouraged to quit smoking for a minimum of 4 weeks prior to surgery. Patients taking contraceptive medication or hormone replacement therapy in any form (pill, cream, ring, intrauterine, injection) at the preoperative visit (positive status) were encouraged to discontinue this for at least 2 weeks prior to surgery, with the exception of low-dose intrauterine devices. Following significant weight loss, secondary to bariatric surgery or via diet and exercise, body contouring procedures are considered only in those patients who have successfully maintained their goal weight for at least 6 months. All patients were tested for factor V Leiden deficiency preoperatively, and those with positive results were referred to a hematologist to optimize their chemotherapeutic regimen.

At our practice, unless there is a contraindication to anticoagulation, postoperative chemoprophylaxis is employed routinely for VTE risk reduction in abdominal body contouring surgery with rectus abdominis muscle plication. The standard regimen is 10 mg rivaroxaban once daily for 7 days, starting on postoperative day (POD) 1. To maintain homogeneity, patients who did not receive the aforementioned chemoprophylactic regimen, except in cases of a bleeding event, were excluded from the final analysis.

Intraoperatively, lower-extremity sequential compression devices are used routinely. Physiologically optimal body temperature and intravascular volume is vigilantly maintained with warming blankets and aggressive administration of intravenous fluids. Prophylactic intravenous antibiotics are administered preoperatively (single dose), intraoperatively, and postoperatively at our recovery unit, followed by oral antibiotics, for a total of 7 days.

The majority of patients spend 1 night in our recovery room, where they receive one-to-one nursing, aiming to enhance postoperative monitoring, early ambulation, and pulmonary toilet, and to optimize hydration and analgesia. Sequential compression devices are maintained for their overnight stay. Patients are discharged on POD 1, and are followed-up in our clinic on or around POD 2, 7, 14, 30, 90, 180, and then yearly. Patients discharged on the day of surgery are typically those undergoing abdominoplasty without concomitant procedures except low-volume liposuction.

Our endpoints were the incidence of VTE, bleeding events, seroma, infection, wound complications, and reoperations. The complication profiles of the concomitant procedures were not examined. A standardized analysis of outcomes of concomitant procedures in the setting of major abdominal body contouring was beyond the scope of this study.

Statistics

Univariate statistical analysis was performed with t tests for continuous variables and chi-squared tests for categoric variables. Univariate statistics were calculated in Microsoft Excel (Redmond, WA).

Multivariate logistic regressions were then performed for the outcomes that had significant independent variables on univariate analysis. Covariates in the multivariate logistic regression were BMI, procedure time, and history of bariatric surgery. BMI as an independent variable was converted into an ordinal variable with categories of <25, 25 to 30, 30 to 35, and >35 kg/m². Procedure time as an independent variable was converted into an ordinal variable with categories of less than 3 hours, 3 to 6 hours, and greater than 6 hours. Multivariate logistic regressions were performed with JASP version 0.12.2 software (JASP Team 2020). Significance for all statistics was defined as P < 0.05.

RESULTS

A total of 632 patients who underwent abdominoplasty, circumferential body lift, FDL, or circumferential FDL with rectus abdominis muscle plication at our surgical center, between August 2014 and February 2020, were included in this study; 596 (94.3%) patients were female and 36 (5.7%) were male. Their average age was 43.7 years (range, 18-80 years). Mean follow-up time was 434 days (range, 84-1540 days).

In terms of technique, infiltration of a large volume of tumescent fluid containing adrenaline in order to achieve a tumesced or turgid state was employed prior to liposuction.²⁰ In the majority of abdominoplasty cases, skin flap dissection was aggressive and extended to the costal margins to allow for wide rectus abdominis plication. In a minority of patients, the lipoabdominoplasty technique that preserves the superolateral perforators was employed.²¹ Skin flap undermining was not performed in the posterior portion of circumferential body lift or in FDL cases. Quilting sutures were not routinely used. Two drains were used in the abdomen. One drain was used in the posterior trunk following liposuction, and 2 drains following posterior skin excision.

Eight patients had their rivaroxaban held or delayed as a precaution due to prolonged sanguineous output from the drains during the early postoperative period. None of these patients required re-exploration, intervention, or other treatment, and there were no sequelae related to this.

Table 1 summarizes the patient characteristics and operative data. Overall, 521 (82.4%) patients underwent abdominoplasty, 56 (8.9%) patients underwent circumferential body lift, 31 (4.9%) patients had FDL resection, and 24 (3.8%) patients underwent circumferential FDL resection. Concomitant aesthetic procedures were performed in 497 (78.6%) patients (Table 2).

The mean operative time was 272 minutes (range, 67-636 minutes). The procedure lasted less than 180 minutes in 166 (26.3%) patients, between 180 and 360 minutes in 320 (50.6%) patients, and longer than or equal to 600 minutes in 146 patients (23.1%).

The mean BMI was 27.2 kg/m² (range, 18-43 kg/m²). There were 226 (35.8%) patients with normal BMI (<25 kg/m²), and 222 (35.1%) patients were overweight (BMI 25-30 kg/m²). A total of 184 (29.1%) patients were obese (BMI >30 kg/m²). Of these, 52 (8.2%) patients were morbidly obese (BMI >35 kg/m²), and 6 patients had a BMI ≥40 kg/m². Furthermore, 112 (17.7%) patients had undergone bariatric surgery, in the form of gastric bypass, gastric banding, or sleeve gastrectomy.

The majority of patients (59.3%) were at moderate risk for VTE based on their Caprini score. The risk was low in 14.1% of patients and high in 26.6% of patients (Caprini score ≥5). In 57 patients (9.0%) the Caprini score was ≥7. In addition, 22 (3.5%) patients had a known genetic predisposition, including factor V Leiden mutation (all heterozygous), all of whom received rivaroxaban for at least 7 days postoperatively. Lastly, 51 (8.1%) patients reported a family history of VTE event, and 9 (1.4%) patients had suffered a VTE event in the past.

A total of 4 (0.6%) VTE events took place in the cohort (Table 3). Two (0.3%) patients suffered a pulmonary embolism and 2 (0.3%) patients suffered a lower-extremity DVT. Following a therapeutic anticoagulation regimen, they all recovered without sequelae. A 43-year-old man suffered a pulmonary embolism on POD 11 following abdominoplasty alone (Caprini score 4, BMI 39.7 kg/m²), and a 40-year-old woman suffered a pulmonary embolism on POD 12 following circumferential body lift, liposuction, fat grafting to the buttocks, and mastopexy (Caprini score 3, BMI 25.1 kg/m²; no hormone therapy). A 43-year-old man was diagnosed with DVT 2 months following abdominoplasty, liposuction, and chest contouring for gynecomastia (Caprini score 4, BMI 29 kg/m²). He was subsequently found to be positive for an antiphospholipid syndrome variant. Finally, a 50-year-old woman was diagnosed with DVT on POD 13 following an abdominoplasty, liposuction, and fat grafting to the buttocks (Caprini score 4, BMI 30.3 kg/m²; no hormone therapy).

A total of 22 (3.5%) patients suffered complications related to bleeding. Of these, 4 (0.6%) were stable, small hematomas that were managed by bedside aspiration, whereas 2 (0.3%) patients suffered small hematomas that liquefied and resolved without intervention. None of these patients required blood transfusion. Hematomas requiring operative intervention for control and evacuation occurred in 16 (2.5%) patients. Of these, 9 (1.4%) events occurred during the patients’ recovery in our postoperative unit within the first 23 postoperative hours, and prior to administration of rivaroxaban. Two of the patients who suffered early hemorrhage were transferred to hospital, following successful operative control and evacuation of the hemorrhage, for blood transfusion and further monitoring. The remaining 7 patients did not require transfusion of blood products and were discharged from our recovery unit in a stable condition. Every patient made a full recovery.

In addition, 5 (0.8%) of the bleeding events occurred during the patients’ 7-day postoperative prophylactic rivaroxaban regimen, and 2 (0.3%) occurred following completion of the regimen (POD 10 and 12). Of these, 2 patients were transferred to hospital, following successful operative control and evacuation of the hemorrhage, for blood transfusion and further monitoring. The remaining 5 patients did not require transfusion of blood products and were discharged from our recovery unit in a stable condition. Every patient made a full recovery.

There were 105 (16.6%) patients who suffered an abdominal seroma, 89 (14.1%) of whom were treated with bedside aspiration. Seroma eventually requiring exploration and resection of seroma pseudobursa occurred in 10 (1.6%) patients. The seroma became infected in 6 (0.9%) patients, requiring incision and drainage either at the bedside or in the operating room. Wound complications were encountered in 20 (3.2%) patients, of whom 2 (0.3%) suffered full-thickness ischemia, requiring significant wound care and revisions. The remaining wound complications were minor, and were managed with basic wound care.

Table 3 lists the reoperations performed. The total reoperation rate was 18.2%, although the majority (14.1%) of these were interventions safely performed under local anesthesia (minor reoperations). A total of 26 (4.1%) patients underwent reoperation for control of bleeding, or exploration of persistent seroma with excision of pseudobursa, which was categorized as a major reoperation. Table 3 also lists the complications and reoperations in obese patients (BMI >30 kg/m²).

Table 4 summarizes the univariate analyses. Longer procedure time was associated with infection (P = 0.0008), seroma (P = 0.002), necrosis/dehiscence (P = 0.01), and reoperation (P = 0.002). History of bariatric surgery was also associated with reoperation (P = 0.02). With regard to reoperation, these associations were not found upon assessment focused on major reoperations.

Table 5 summarizes our multivariate analyses. Significantly increased odds for infection (odds ratio [OR] = 8.6, P = 0.046), seroma (OR = 2.7, P = 0.002), necrosis/dehiscence (OR = 11.3, P = 0.024), and reoperation (OR = 1.9, P = 0.027) was associated with procedure time longer than 6 hours. History of bariatric surgery was associated with increased odds of reoperation but did not reach statistical significance (OR = 1.6, P = 0.054). Similarly, with regard to reoperation, these associations were not found upon assessment focused on major reoperations.

Discussion

This study investigates the collective complication and reoperation profiles of the 4 major abdominal contouring procedures performed at our practice, namely abdominoplasty, circumferential body lift, FDL, and circumferential FDL. The collective analysis of these procedures resulted in an accurate representation of our practice’s patient population. In turn, this allowed for the examination of the impact of bariatric surgery, BMI, and procedure time as individual risk factors in the morbidity associated with these procedures.

We found that procedures lasting longer than 6 hours were associated with a significantly greater incidence of infection, seroma, and necrosis or wound dehiscence, as well as higher rates of minor reoperation. There was trend toward history of bariatric surgery being associated with increased risk of minor reoperation. Interestingly, BMI did not significantly impact morbidity. None of the variables had an association with respect to VTE and bleeding events.

Recently, there has been controversy with regard to the safety of abdominoplasty in overweight and obese patients. Seth et al failed to demonstrate an increase in total complications in patients with BMI >30 kg/m² undergoing various abdominoplasty techniques.¹⁴ On the other hand, two studies utilizing the CosmetAssure database (Birmingham, AL) indicated that overweight and obese patients were at an increased risk for both VTE and VTE plus infection.^22,23 Hammond et al evaluated the safety of these procedures in this population and found an acceptable reoperation rate; they reported their major reoperation rate to be 8.7%.²⁴

Our major reoperation rates in patients with BMIs ≥25 and ≥30 kg/m² were 5.0% and 5.5%, respectively; moreover our multivariate analysis did not identify BMI as an independent predictor of any of the adverse outcomes that were studied. This finding contradicts the traditional consensus in the plastic surgery literature, and we anecdotally believe that several factors significantly contributed to this, including the expert and efficient execution of these procedures at our high-volume center, the extensive patient education regarding all aspects of postoperative care, compliance with our practice’s postoperative protocol, and early emphasis on ambulation, hydration, pulmonary toilet, incisional care, and close patient follow-up. Our findings support the safety of abdominal body contouring surgery in overweight and obese patients, and it is our hope that these findings will help to shift the paradigm of patient selection, considering the potential for these procedures to improve patients’ quality of life, psychological and functional well-being, and to help them achieve their health-related goals.^24-29 On that note, this study would have benefited from the implementation of the validated BODY-Q patient-reported outcomes assessment tool.³⁰

Prolonged operative time and MWL have been reported to increase the risk of VTE in body contouring surgery.^31-34 Weight loss was not assessed as a variable in this study; instead history of bariatric surgery was utilized to assess this patient parameter. Neither operative time nor history of bariatric surgery, when assessed individually, was found to be a risk factor for VTE. Our 7-day rivaroxaban-based postoperative VTE protocol has been studied and analyzed in this patient population previously.¹⁷ In addition, the majority of our patients spend the first postoperative night in the recovery unit of our outpatient facility, where in addition to physiologic optimization and monitoring, early ambulation is of paramount importance.

MWL is associated with a higher incidence of postoperative complications.^14,35 Wound-related complications in particular have been found to occur at higher rates regardless of the method of MWL—diet and exercise, gastric bypass surgery, gastric banding, or sleeve gastrectomy—although gastric bypass surgery placed patients at higher risk.¹² In this study, there was trend towards statistical significance in terms of history of bariatric surgery leading to significantly higher rates of total reoperations, although the majority of these were minor reoperations or interventions safely performed under local anesthesia in the surgical clinic. Restrictive and malabsorptive bariatric procedures lead to nutritional deficiencies, whereas MWL through diet often results in malnutrition. The paramount importance of preoperative assessment of nutritional status in this patient population in order to provide adequate nutritional and micronutritional supplementation is well-recognized in the literature.^13,27,36-39

Procedure time over 6 hours was identified as an independent predictor of infectious complications, wound complications (necrosis and dehiscence), seroma, and total reoperation—although not major reoperation. It has been shown that combined procedures increase the risk of complications in abdominoplasty, but it is not known whether our findings with regard to procedure time have been confounded by the higher occurrence of combined procedures in this subgroup.² Nonetheless, an effort to complete abdominal body contouring surgery in less than 6 hours should be made, including measures such as the utilization of co-surgeons, or staging rather than combining procedures. Although not statistically significant, it is notable that 3 of the 4 VTEs in our study occurred in the setting of combined procedures.

Surgeons have employed numerous techniques and strategies to reduce the incidence of seroma formation, the most intriguing being the use of progressive tension sutures. The use of progressive retention sutures eliminates trauma due to shearing forces, and reduces the dead space. Several studies have shown reduced seroma rates associated with this technique, often eliminating the need for drain placement.^40-43 We have had extensive experience with progressive tension sutures over the years. Anecdotally, we have not experienced a dramatic reduction in seroma rates in order to justify the contour irregularities and longer operative time associated with the placement of progressive tension sutures, and therefore we do not routinely place them.

Lastly, this study is limited by its retrospective design. In addition, matching for procedure was not feasible because it would underpower the study. Preoperative weight loss was not one of the variables assessed because detailed data on this were not consistently available.

Conclusions

In abdominal body contouring surgery, surgery lasting for longer 6 hours is associated with higher incidence of seroma and infectious complications, as well as higher rates of minor reoperation. There was a trend toward an increased risk of minor reoperation being associated with a history of bariatric surgery. No significant increase in the incidence of major reoperation was found in association with overweight or obese patient habitus, history of bariatric surgery, or prolonged procedure time. BMI was not found to be an individual risk factor for morbidity in this patient population.

Disclosures

Drs Kortesis and Bharti are consultants for Medshift (Charlotte, NC) and BTL (Boston, MA); key opinion leaders for Luminary (New York, NY), Allergan (Dublin, Ireland), Biom’UP (Lyon, France), Apyx Medical (Clearwater, FL), Inmode (Lake Forest, CA), and Motiva (Houston, TX) and investigators for RXI (Marlborough, MA). Dr Hunstad is an investigator for Becon Medical (Naperville, IL); a stockholder at TouchMD (Cedar City, UT) and Hint MD (Pleasanton, CA); receives royalties from Elsevier (Amsterdam, the Netherlands), Black & Black Surgical, Inc. (Turner, GA), and Johnson & Johnson (Byron Medical; Tucson, AZ); and is a research study coordinator and participant for Cohera (Raleigh, NC), Mentor (Santa Barbara, CA), Allergan, Covidien (Dublin, Ireland), Pfizer (New York, NY), RXI, and Pacira Pharmaceuticals (Parsippany-Troy Hills, NJ). The other authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

References

Author notes