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Will I Need Plastic Surgery After Weight-Loss? Classifying Abdominal Contour Deformities And Severity To Aid In Patient Counseling, A Review of 1006 Patients
Lauren L. Zammerilla, BS, Richard H. Zou, BS, J. Peter Rubin, MD, Jeffrey A. Gusenoff, MD.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Purpose: Abdominal contour deformities after massive weight loss are highly variable, ranging from a mild upper protuberance to a true double pannus. Correction of these deformities is often limited with traditional abdominoplasty. A modified approach involving a vertical skin excision, or fleur-de-lis abdominoplasty, may be required. The incidence of patients presenting with various abdominal deformities is not well defined, and factors influencing these deformities remain to be determined. The objectives of this study are to evaluate the patient population presenting with abdominal deformities, modify the Pittsburgh Rating Scale to accommodate complex abdominal wall deformities, and determine factors that may influence deformity and aid in perioperative counseling.
Methods: All patients who presented for an abdominal contouring procedure between 2002 and 2012 were reviewed. Based on pre-operative photos, deformities were graded using the validated Pittsburgh Rating Scale. A grade of 0 indicated an appearance within a normal range. A grade of 1 indicated redundant skin with rhytids or moderate adiposity without overhang; 2, overhanging pannus; and 3, multiple rolls. The Pittsburgh Rating Scale was modified to address multiple rolls, with 3a representing a double roll with a small upper roll; 3b, a double roll extending to the mid-axillary line; 3c, a double roll extending to the back; and 3d, triple rolls. Data collected for each patient included BMI change (Delta BMI), history of bariatric surgery, operative details, revisions, and complications such as hematoma, seroma, infection, and wound dehiscence.
Results: 1006 patients were evaluated, of which 91.1% were female and 86.3% had prior bariatric surgery. 32 had a Grade 1 deformity, 330 had Grade 2, 386 had Grade 3a, 104 had Grade 3b, 143 had Grade 3c, and 11 had Grade 3d. Delta BMI was positively correlated with deformity grade, with a significant Pearson correlation coefficient of 0.116 (p<0.001). 737 of the presenting patients underwent abdominal contouring surgery, of which 210 (28.5%) had a fleur-de-lis. Fleur-de-lis patients had significantly higher deformity grades than traditional abdominoplasty patients (p<0.001). Fleur-de-lis patients also had a significantly higher change in BMI than traditional abdominoplasty patients (p<0.001) and were more likely to have an additional component to their surgery, such as lower body lift, brachioplasty, or breast reduction (p<0.001). No significant difference in complications existed between fleur-de-lis and traditional abdominoplasty (p=0.328). Delta BMI was significantly larger in patients who had prior bariatric surgery (p<0.001).
Conclusions: Most patients presenting after massive weight loss have high-grade abdominal deformities with a double roll. Delta BMI is positively correlated with deformity grade and can be used to counsel patients on weight loss prior to body contouring. Patients with larger changes in BMI and higher deformity grades most often choose to add a vertical component to improve vertical and horizontal excess tissue. While minimally invasive approaches to bariatric surgery continue to evolve, our data suggests that most patients would benefit from advanced body contouring procedures that involve lengthy scars. These findings can aid plastic surgeons, bariatric surgeons, and patients in discussions regarding abdominal skin excess after massive weight loss.
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