Aesth. Plast. Surg.

30:42 46, 2006

DOI: 10.1007/s00266-005-0126-9

Abdominoplasty with Total Abdominal Liposuction for Patients with Massive

Weight Loss

Antonio Espinosa-de-los-Monteros, M.D., Jorge I. de la Torre, M.D., Laurence Z. Rosenberg, M.D.,

Leonik A. Ahumada, M.D., Alexander Sto, M.D., Eric H. Williams, M.D., and Luis O. Vasconez, M.D.
Division of Plastic Surgery, University of Alabama at Birmingham and The Center for Advanced Surgical Aesthetics, 510
20th Street, South, Birmingham, AL 35294, USA

Abstract.
Background: Massive weight loss after bariatric surgery is
associated with signicant skin excess, laxity, and ptosis
over the abdomen. Good results have been achieved with
abdominoplasty and circumferential lipectomy. However,
blood transfusions are sometimes needed, and patients may
require long hospital stays. Furthermore, morbidity rates
are high. Total abdominal liposuction performed with abdominoplasty allows for the preservation of lymphatic
vessels below Scarpas fascia and eliminates the need for
upper ap undermining. This study aimed to evaluate this
technique in patients with anterior abdominal redundancy
attributable to massive weight loss after bariatric surgery.
Methods: The charts of 60 patients treated between
December 2001 and October 2004 were retrospectively reviewed. All the patients had undergone previous bariatric
surgery as well as subsequent total abdominal liposuction
and abdominoplasty.
Results: The average amount of wetting solution used was
3.1 l, and the average total aspirate was 2.5 l. The mean
pannus weight was 3,649 g, and the average dimension was
48 25 6 cm. No patient required a blood transfusion.
The median in-hospital stay was 1 day, with 42% of the
patients treated as outpatients. The median follow-up period was 3 months. Morbidity was 22%. Factors associated
with the development of complications were weight of the
pannus, transverse dimension of the pannus, and body
mass index. All the patients were satised with the results.
Conclusions: Total abdominal liposuction followed by abdominoplasty is adequate treatment for anterior abdominal
redundancy for patients with massive weight loss.
Correspondence to Jorge I. de la Torre, M.D., FOT 1102,
1530 3rd Avenue South Birmingham, AL 35294-3411,
USA; email: jdlt@uab.edu

Key words: Abdominal redundancyAbdominoplasty

Bariatric surgeryMassive weight lossTotal abdominal
liposuction

Bariatric surgery has evolved as a very eective

therapy for morbid obesity. Patients who undergo
bariatric surgery lose an average of 40% to 84% of
their excess weight over 12 to 18 months [17]. Bariatric surgery improves abnormal lipid levels, controls
hypertension, and reduces the risk of diabetes by as
much as 75%. Overall, mortality from obesity-related
problems can be decreased as much as 24% [7,21,23].
Unfortunately, these patients experience signicant
skin excess, laxity, and ptosis in multiple areas, which
may lead to postural, functional, hygenic, dermatologic, and aesthetic impairment.
Typically, these patients initially pursue body
contouring out of concern for excess abdominal laxity, but other aected areas are the trunk, hips,
thighs, arms, and breasts. The abdominal deformity
can be corrected with many techniques including
abdominal dermolipectomy, full abdominoplasty
with or without liposuction, belt lipectomy, highlateral-tension abdominoplasty, and vertical abdominoplasty [1,3,5,14,15]. Traditionally, good results
have been achieved. However blood transfusions are
needed in 5% to 80% of these patients. The hospital
length of stay averages 2 to 9 days among reported
series, and morbidity rates range between 15% and
60% in specialized centers [4,6,19].
Abdominoplasty techniques were introduced in the
1960s, but have undergone a continuous process of
evolution to provide better and safer results. One
major advance has been the introduction of total

A. Espinosa-de-los-Monteros

abdominal liposuction before pannus resection [18].

The technique of selective upper ap undermining
with preservation of blood vessels and nerves eliminates the need for total surgical undermining [8,13].
Also, suctioning rather than resection of the deep
abdominal fat, preserves lymphatics while allowing
for resection of the pannus at a more supercial level
[10,11]. Finally, a smoother transition between upper
and lower aps is achieved [12].
The purpose of this study was to evaluate the effects of total abdominal liposuction and subsequent
abdominoplasty for patients with anterior redundancy attributable to massive weight loss after
bariatric surgery.
Material and Methods
We retrospectively reviewed the charts of all the patients who presented to our service with anterior
abdominal wall redundancy resulting from massive
weight loss after bariatric surgery. The patients
treated by means of total abdominal liposuction and
subsequent abdominoplasty during the period between December 2001 and October 2004 were
included in this study.
The surgical technique begins with prepping and
draping of the patient, usually under general anesthesia. Preoperative antibiotics are administered to all
patients. Lidocaine 1% with epinephrine 1:200,000 is
administered along the dermis in the region that will
be excised as part of the panniculectomy. Supercial
skin incisions are made to avoid losing the markings
during liposuction. Wetting solution then is inltrated throughout both the supercial and deep fat
layers of the whole anterior abdomen, and liposuction then is performed. With this technique, we are
able to remove the deep fat beneath the Scarpas
fascia, to undermine the upper ap selectively by
tunneling with the liposuction cannula, to preserve
the upper ap blood supply by eliminating the need
for further surgical undermining, and to liposuction
throughout the whole anterior abdomen, facilitating
a smooth transition between the upper and lower
aps once the pannus is removed.
After liposuction, we excise the redundant skin and
supercial fat layer above the level of the Scarpas
fascia, preserving the lymph vessels below it. A lighted retractor is used to create a narrow tunnel in the
midline from the umbilicus to the epigastrium. A
double-layered rectus muscle plication is performed
from the epigastrium to the pubis using interrupted 0
Prolene suture reinforced with continuous running 0
nylon. Finally, the umbilicus is repositioned; 19Blake drains are exteriorized; and the upper and
lower aps are approximated with the hips exed. A
compression binder is placed, and patients are allowed to ambulate immediately with the hips exed.
The drains are removed when the output is less than
30 ml of serous uid per day.

43

The variables studied included gender, age, height,

weight, body mass index (BMI) (both at the time of
bariatric surgery and at the time of abdominoplasty),
time elapsed between procedures, comorbidities,
pannus dimension, amount of wetting solution inltered and total aspirate, pannus weight, other procedures performed, transfusions, hospital length of
stay, pre- and postoperative hemoglobin and hematocrit, complications, their treatment, and total follow-up evaluation. Also we examined patient
satisfaction labeled as regretful, disappointed, satised, or very satised. Dierences in complications
were studied by unpaired Students t-test, and statistical signicance was set to a p value less than 0.05.
Factors aecting pannus weight were analyzed with
the correlation coecient, and signicance was set at
an r2 value greater than 0.25.
Results
The study enrolled 60 patients with an average age of
43 years (range, 25 61 years). The average BMI at
the time of the bariatric procedure was 54 kg/m2
(range, 42 72 kg/m2). Gastric bypass had been performed for 97% of the patients, whereas verticalbanded gastroplasty had been performed for 3%. The
average time from the bariatric surgery to the abdominoplasty was 26 months (range, 11 216
months). The BMI at the time of abdominoplasty
was 31 kg/m2 (range, 21 47 kg/m2), with 8% of the
patients rated as morbidly obese (BMI > 35 kg/m2).
The mean weight loss after bariatric surgery was 40%
(range, 28 54%). The average amount of wetting
solution used was 3.1 l (1 5l), and the average total
aspirate was 2.5 l (range, 0.5 6.4 l). The inltrationto-aspiration ratio was 1.3:1. The mean pannus
weight was 3,649 g (range, 690 8575 g), and the
average dimensions were 48 25 6 cm (range, 15
15 2 to 99 55 20 cm).
At the time of the abdominoplasty, 25% of the
patients underwent hernia repair, and 33% underwent
other procedures including mastopexy for 11 patients, reduction mammaplasty for 5 patients, brachioplasty for 3 patients, and thighplasty for 1 patient.
No patient required a blood transfusion. The median
in-hospital stay was 1 day (range, 0 5 days), with 25
patients (42%) treated as outpatients. The mean
hemoglobin levels were 12.8 g/dl preoperatively and
10.5 g/dl postoperatively, and the average decrease
was 15%. A total of 14 complications occurred in 13
patients (22%), including 13 local complications (6
partial dehiscences, 3 skin edge necrosis, 2 seromas, 1
abscess, and 1 wound infection) and 1 case of acute
renal failure requiring intravenous uid resuscitation.
None of the local complications required further
hospital admission or treatment in the operating
room. The median follow-up period was 3 months
(range, 1 15 months). The factors associated with
the development of complications were weight of the

44

Abdominoplasty with Total Abdominal Liposuction

pannus (5,433 vs 2848 g; p < 0.0001), transverse

dimension of the pannus (61 vs 42 cm; p < 0.01), and
BMI (35 vs 28 kg/m2; p < 0.05). The factors aecting
pannus weight were BMI (r2 = 0.89) and transverse
dimension of the pannus (r2 = 0.38). Neither the
dierence in the amount of wetting solution injected
nor the dierence in the total fat aspirated had an
eect on the dierences in the pannus weight (r2 =
0.05 and 0.04, respectively). The patients treated as
outpatients did not have any dened comorbidity and
were not obese (BMI < 30 kg/m2). According to a
separate analysis, their pannus transverse dimension
was shorter than 60 cm, and their pannus weighed
less than 4,000 g. The associated postoperative morbidity rate was 12% (partial wound dehiscences).
Whereas 88% of the patients were very satised with
their results, 12% graded their results as satisfactory.
No patients were disappointed or regretful.
Discussion
Obesity is dened as a BMI of 30 kg/m2 or more.
Approximately 20% of obese people are morbidly obese, dened as a BMI of at least 40 kg/m2 or a BMI of at
least 35 kg/m2 in the presence of high-risk comorbid
conditions such as hypertension, coronary artery disease, cerebral ischemia, peripheral venous insuciency, thrombophlebitis, obstructive sleep apnea,
obesity hypoventilation syndrome, diabetes mellitus,
hyperlipidemia, and back disc herniation or osteoarthritis of weightbearing areas, among others [2,16].
Although lifestyle changes, use of herbal therapies,
and some pharmacologic agents may improve weight
loss, the results often are disappointing and temporary. For these reasons, bariatric surgery has become
the method of choice for the management of morbid
obesity [9].
After surgery, patients lose 80% of their excess
weight, on the average, by 1 year [17]. As this massive
weight loss occurs, patients experience changes in
their morphology. The skin that drapes their excess
volume becomes lax and redundant, particularly at
the abdomen. As a result, mechanical and postural
deciencies along with dermatosis on the skin folds
interfere with their ability to perform routine tasks,
worsen their self-esteem, and facilitate the development of secondary conditions. Also, the trunk,
thighs, arms, and breasts may be aected, creating a
challenging dilemma that usually requires several
surgical procedures for proper correction.
In the most severe cases, the abdominal deformity
occurs circumferentially, and is better managed with
a circumferential procedure such as belt lipectomy or
high-lateral-tension abdominoplasty. Nevertheless,
some patients are better served by an anterior-only
procedure, either because they have a dermatoliposis
that is more prominent on the abdomen itself and not
on the anks and on the back, or because their desire
is to undergo an anterior-only procedure (Figs. 1, 2,

Fig. 1. A 39-year-old patient with 79 kg of weight loss who

underwent total abdominal liposuction and full abdominoplasty through a low transverse incision. Above left:
preoperative anterior view. Above right: postoperative
anterior view. Below left: preoperative lateral view. Below
right: postoperative lateral view.

Fig. 2. A 40-year-old patient with 50 kg of weight loss who

underwent total abdominal liposuction and full abdominoplasty through a eur-de-lis incision. Above left: preoperative anterior view. Above right: postoperative anterior
view. Below left: preoperative lateral view. Below right:
postoperative lateral view.

and 3). Either anterior dermolipectomy or full abdominoplasty may be considered for this subset of
patients. Directed liposuction also has been used for
contour-specic areas such as the anks and the
pubis. With these techniques, the reported morbidity
rates have ranged from 15% to 60%, with 5% to 80%

A. Espinosa-de-los-Monteros

Fig. 3. A 32-year-old patient with 82 kg of weight loss who

underwent total abdominal liposuction and full abdominoplasty through a eur-de-lis incision. Above left: preoperative anterior view. Above right: postoperative anterior
view. Below left: preoperative lateral view. Below right:
postoperative lateral view.

of patients requiring a blood transfusion, and the

reported length of hospitalization has ranged from 2
to 9 days [4,6,19].
In 1987, Ohana et al. [18] described some advantages of using liposuction as an adjunct to abdominoplasty, including easier upper ap advancement.
In 1992, Le Louarn [11] proposed liposuctioning the
abdominal pannus to remove the deep abdominal fat,
and then performing the abdominoplasty resection at
a more supercial level to preserve the blood vessels
and lymphatics, thus decreasing the risk for seroma
formation. In the same year, Illouz [8] reinforced his
previous ndings, noting that an eective, discontinuous undermining is achieved by liposuction of the
upper ap. This method avoids the need for surgical
undermining, thus preserving the vessels and nerves
to the ap and to the area that denes the wound
edge. It also decreases the amount of blood loss
during and after the surgery [8]. Lockwood [13] also
recognized the utility of liposuction undermining
during abdominoplasty, and its ability to preserve
perforators to the surface of the abdominal wall.
One year later, in 1996, Le Louarn [10] updated his
experience with his technique, reporting no seroma
formation and shorter hospitalizations by removal of
fat with liposuction and preservation of the abdominal layers that include lymphatic vessels. Le Louarn
and Pascal [12] detailed several steps for an attempt to
avoid local complications during abdominoplasty by
the use of liposuction. In 1999, Shestak [22] introduced the term marriage abdominoplasty because it
involves the use of abdominoplasty and extended
liposuction, and reported a morbidity rate of 7%, with

45

60% of cases managed on an outpatient basis.

Saldanha et al. [20] further demonstrated the safety of
this technique with a published morbidity of 3%.
In the current series, we applied these concepts to
patients with anterior abdominal skin excess resulting
from massive weight loss who were candidates for an
anterior-only procedure. In our series, the morbidity
rate of 22% resulted from local wound complications
requiring standard ambulatory care and one case of
transient renal insuciency. None of the patients
required intraoperative or postoperative transfusions,
and the median hospital stay was 1 day. The patients
with less severe abdominal dermatoliposis and without comorbidities (including current obesity) were
treated successfully in the outpatient setting.
The factor most commonly associated with postoperative complications was the weight of the pannus, a factor that cannot be accurately known before
surgery. Pannus dimension and BMI (factors that can
be determined before surgery) also were associated
with postoperative complications, and correlated
positively with pannus weight. Dierences in the
amount of wetting solution administered or in the
amount of fat aspirated did not aect the weight of
the pannus among patients. All the patients were
satised with the results and willing to undergo further contouring procedures. Further technical developments are needed to guarantee safer results for this
subset of patients, and for those with a more severe
form of the disease.
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