Overview of Panniculectomy
A panniculectomy is a surgical procedure performed to reshape the abdomen. It is done by removing a substantial amount of excess skin and underlying fatty tissue. The procedure is typically done on patients with a large “overhang” of skin and fat, called a panniculus, hanging from the belly below the waistline. Weight gain is usually the cause of this extra skin and fat, which can sometimes cover the thighs, hips, and knees.
A large panniculus can significantly affect a person’s ability to move and perform everyday activities. It is also common for patients with a large panniculus to experience skin infections and rashes, due to constant irritation and sweating.
The extent of a panniculus can vary greatly. It is measured on a scale of 1 to 5, according to how far it hangs. On this scale, grade 1 reaches the area just above the genitals (the mons pubis), while grade 5 extends to or past the knees. A panniculectomy is performed to alleviate these symptoms and restore normal function to the abdomen.
During the procedure, the surgeon removes the excess skin and fat from the abdomen. However, unlike another procedure called abdominoplasty (a cosmetic surgery for toning the belly), the surgeon does not tighten the muscles of the abdominal wall during a panniculectomy.
In the past thirty years, there has been a significant increase in the number of panniculectomies. This increase is partly due to more people opting for liposuction procedures. However, it’s important to know that panniculectomy and abdominoplasty are serious procedures. They need to be performed on the right candidates who are medically prepared for surgery. There have been reports of severe bleeding, and even deaths, following panniculectomy.
Anatomy and Physiology of Panniculectomy
Men and women tend to gather fat in different ways, based on their genes and hormones. Men typically carry their extra weight around the stomach and upper body, while women often store fat around the hips and thighs.
Cellulite, those unwelcome dimples and ridges in the skin, is just ordinary fat under the skin. We have two layers of this kind of fat in our body areas like the abdomen. The top layer is thick and has a bunch of fibrous bands. The deeper layer is loosely arranged and has less of these bands. This deep layer is found most around the belly button, buttocks, lower back, and inner thigh areas. When these areas gain more fat or the skin relaxes with age, it can lead to the uneven, bumpy look we know as cellulite.
Did you know that we produce our fat cells when we’re in the womb, young children, or early teens? After that, the number of fat cells pretty much stays the same. Even when fat cells are removed through things like liposuction, new fat cells don’t form in their place. However, the existing fat cells can get larger, which can result in the same amount of fat or even more in the area. The only exception to this rule is in people who are extremely overweight, where the fat cells can actually multiply.
The main blood supply to the skin on our belly comes from the superior and inferior epigastric vessels. These vessels run within the rectus muscle, which is one of the flat muscles in the abdomen. From there, smaller branches of these vessels take blood through the abdominal fat to reach the skin. If you’re getting a flap surgery on your abdomen, this blood supply is cut off.
There’s a secondary blood supply in the belly, located in the fat layer just above the tissue layer known as the fascia of Scarpa. This blood supply contributes to the central belly skin after a flap is lifted in surgery. Sometimes, due to prior surgeries and scars, the blood supply in this area could be compromised.
The lower part of our torso has three main regions where the tissues are tightly connected with one another. As we age, have a baby, or lose a lot of weight, these connections relax, leading to sagging or drooping of surrounding skin and tissues.
There are different types of surgeries to remove excess skin or adipose tissue (fat). Panniculectomy and abdominoplasty are two such surgeries, and they differ in certain ways. For example, in a Panniculectomy, the amount of skin and fat removed above the tissue nearby is very limited. This is because, after significant weight loss, the large abdominal skin flaps might have reduced blood supply, leading to potential skin loss and collection of serous liquid (seroma). The removal of tissue can almost be thought of as removing a wedge of tissue. Any existing scars need to be carefully considered during these surgeries, as they may also lead to tissue loss.
Why do People Need Panniculectomy
A panniculectomy is a surgical procedure that people usually consider after experiencing significant weight loss. This weight loss often leads to an excess of skin hanging over the lower part of the stomach and covering the area around the private parts. This typically happens to individuals who have had weight loss surgery, notably bariatric surgery. There’s a higher risk of such excess skin, known as a panniculus, forming in older people who had a high Body Mass Index before they had surgery.
In some severe cases, this excess skin hits against the thighs when walking. This not only causes discomfort and irritation but can also restrict movement and potentially lead to additional weight gain. On average, people who get weight loss surgery usually stabilize their weight loss around the 12- to 18-month mark, but some may request a panniculectomy as early as six months because the hanging skin is too bothersome.
When a Person Should Avoid Panniculectomy
A panniculectomy is a voluntary type of surgery. In other words, it’s not a life-or-death procedure. That means doctors usually want to ensure that a person’s health is well managed before they go ahead with the operation. For example, if a person smokes cigarettes, this can affect how well blood flows and how wounds heal after surgery. Therefore, the surgery is not advisable for people who are active smokers or those who have uncontrolled heart disease, lung disease, or diabetes. The surgery can also be more risky for those who have a weakened immune system, as this could impact wound healing.
People who are significantly overweight and have had weight-loss surgery may face additional challenges. This group tends to have more severe physical changes, like excess skin, loose skin, and poor muscle tone. This can put them at a higher risk for complications during and after surgery. Things like other medical issues, previous surgical scars, and nutritional deficiencies can add to these risks.
Equipment used for Panniculectomy
For plastic surgery operations, such as a large-volume panniculectomy (a surgical procedure that removes excess skin and fat from the lower abdomen), a standard set of tools for plastic surgery or soft-tissue surgery is usually prepared. Sometimes, a body-contouring retractor system is used. This is a system with a rigid tubular frame that attaches to the surgical bed. It has a bar or ring that juts out over the patient and can hold up the large flap of skin and fat (known as the panniculus), using specially designed retractors or hooks. This helps to clearly expose the area to be operated on and allows the surgeon to create flaps and cut lines without any tension.
In the surgery, the surgeon uses a tool called a monopolar diathermy, which is crucial for the process. This tool uses heat produced by electric current to cut tissue or seal bleeding vessels. A bipolar cautery, another form of this tool, could also be helpful. It is often used to cauterize (seal off through burning) smaller perforator vessels, which are small blood vessels that tunnel vertically through tissue.
Who is needed to perform Panniculectomy?
This surgery is usually done while you’re under general anesthesia, which means you’ll be asleep and won’t feel anything. This is done by a medical professional known as an anesthetist, who has the right qualifications to safely put you to sleep and keep an eye on you throughout the operation.
The main doctor performing the surgery, also known as a surgeon, is aided by an assistant. This assistant could be another surgeon or someone who’s specifically trained to help in surgeries. There are also nurses present during the operation. One nurse, called a scrub nurse or tech, helps with the surgical equipment, while another nurse, known as a circulator or scout nurse, helps manage the operation room.
Preparing for Panniculectomy
When planning an operation, it is important that the doctor and the patient have a conversation about what the patient is hoping to achieve. They should talk about any trouble the patient may have had with going to the bathroom, what kind of clothes they prefer, their eating, exercise and activity habits.
The length of the patient’s abdomen and the area between the lower rib edges (costal margins) and the top of the hip bone (iliac crest) also need to be looked at. This area is key in determining the shape of the waist and how much it can be shaped during the operation. People with a distance of 5 to 6 cm between these areas are considered to have a short waist, and people with a distance of 10 to 11 cm are considered to have a long waist.
The flexibility and tightness of the skin on the tummy should be checked. Photos should be taken before surgery, and a specialist (internist) should give clearance for the operation. It is crucial to tell the patient about any risks related to the surgery. This includes both physical risks and emotional risks, like how the patient’s expectations might change if any problems arise during surgery. The patient should know what’s realistically possible with the operation. If there’s any doubt, it may be best to talk with a mental health professional before the surgery.
How is Panniculectomy performed
In this procedure, the doctor starts by making a cut in the natural crease above the pubic area of the patient. This cut is extended sideways towards the point where your hip bone meets your spine but stops at the edges of your pubic hair. The doctor then goes deeper with the cut, through a layer of fibrous tissue (Scarpa fascia), until they reach the muscle.
Proceeding in the direction of this fibrous tissue layer, the doctor removes some of the belly skin and tissue just beneath the skin. The cut is then closed layer by layer. Special attention is given in closing the fibrous layer (Scarpa fascica), deep skin layer and the layer just under the skin surface. The doctors will use stitches that will stay for a long time or dissolve on their own in these important layers.
The doctor will also take care to prevent a ripple or fold (dog ear) from forming on the side of the wound when it is closed. Before the cut is closed, small tubes that remove fluid (suction drains) are placed under the flap of skin and taken out through a small cut in the pubic region. To prevent a pocket of serous fluid (seroma) from forming while the drains are in place, the patient must wear tightly fitted clothes (compression garments).
Once the fluid coming out of the drain is less than 30 mL/day, the doctors can remove them, and the patient can continue wearing compression garments for comfort. [13][15]
Possible Complications of Panniculectomy
After having a panniculectomy (surgery that removes overhanging skin and tissue from the belly), there could be some complications. Problems could be more common if you have other illnesses, a high pre-surgery body mass index, or if you’ve had weight loss surgery before.
The most common types of problems after a panniculectomy affect wound healing. These include skin infection (cellulitis), wound openings (dehiscences), and dead tissue (necrosis). This happens because the blood flow in the belly area isn’t great to begin with, and the surgery can make it worse. Normally, these issues can be managed with careful wound care, but sometimes another surgery is needed to clean out the wound or fix the opening.
Another common complication is called a seroma, which is a pocket of fluid that forms under the skin after surgery. Your body tries to fill in the empty space that was created during the surgery, which is why suction drains are used to get rid of this fluid. Using minimal procedures and preserving certain tissue can help prevent seromas. After surgery, wearing a compression garment and reducing physical activity can also help prevent seromas, especially in patients who had less tissue removed and have a lower body mass index. If a seroma does occur, it needs to be watched closely, and the fluid might need to be drained multiple times. Sometimes a drain or medication is needed to help close it.
If there is a simple skin infection (cellulitis), antibiotics can be used to treat it. In some cases, an abscess can form, making the treatment more complicated, possibly requiring surgery to drain the infected fluid.
A hematoma is another potential complication, which is a pocket of blood that collects under the skin after surgery. The drains that are placed during surgery help doctors monitor any bleeding after surgery and hopefully catch a hematoma early before bigger issues develop. If the bleeding doesn’t stop or the hematoma keeps growing, surgery could be necessary to stop the bleeding.
A wound can sometimes open prematurely (dehiscence), and steps are taken right after surgery to try and prevent this. After surgery, patients are instructed to stay in a certain position to help the wound heal. They may also wear belly binders or dressings to help support the healing process.
The blood supply to a healing wound is crucial. There might be challenges with less blood flow due to the nature of the surgery and your inherent tissue characteristics. Additional risk factors could be an intense surgical approach, excessive fat removal, very thin flaps, and high tension. If dead tissue (necrosis) does occur, specialized wound care can generally promote healing. In the presence of bad scarring, there are options to revise the scar.
What Else Should I Know About Panniculectomy?
A panniculectomy is a surgical procedure where the extra skin and fat that hangs over the thigh, which can interfere with personal cleanliness, walking, and other physical activities, is removed. It’s important to know that this isn’t done for cosmetic reasons.
To qualify for this surgery, certain conditions must be met, though these can vary from place to place. The three main requirements are usually as follows:
1. The extra skin and fat, also known as the pannus, must hang below the level of the pubic bone. This has to be proven with photographs.
2. The patient must have tried and failed to control skin inflammation or intertrigo with medical treatments for three months. These treatments could include maintaining good hygiene, using topical antifungals, corticosteroids, and antibiotics.
3. The aim of the surgery is to restore normal functioning capacity. Therefore, it is necessary that patients maintain a stable weight for a minimum of six months prior to surgery.
If the surgery is done following bariatric surgery, which is a type of surgery to help lose weight, the patient must have maintained a stable weight for at least the last 18 months, including the six months directly before the panniculectomy.