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he rate of obesity in the United States is Diabetes mellitus is considered one the most
increasing, with an estimated prevalence of significant public health challenges of the twenty-
26.2 percent among working-age individu- first century, with a global prevalence that has more
als.1 With the increasing popularity of bariatric than doubled over the past 20 years.5 It is estimated
surgery as a treatment option for obesity, there that more than 400 million individuals have diabetes
are an increasing number of patients that may
benefit from body contouring procedures.2 One Disclosure: The authors have no financial interest
of the most commonly performed body contour- to declare in relation to the content of this article.
ing procedures following massive weight loss is
panniculectomy, or the surgical excision of exces-
sive abdominal skin and subcutaneous tissue of
By reading this article, you are entitled to claim
the lower abdomen.3 Removal of excess lower
one (1) hour of Category 2 Patient Safety Cred-
abdominal tissue can lead to increased mobility,
it. ASPS members can claim this credit by log-
decreased pain, improvements in hygiene, and
ging in to PlasticSurgery.org Dashboard, click-
overall improvements in quality of life.4
ing “Submit CME,” and completing the form.
From the Hansjörg Wyss Department of Plastic Surgery, New
York University Langone Medical Center.
Received for publication November 10, 2017; accepted A Video Discussion by Al Aly, M.D., accompa-
March 16, 2018. nies this article. Go to PRSJournal.com and
The first two authors contributed equally to this article. click on “Video Discussions” in the “Digital
Copyright © 2018 by the American Society of Plastic Surgeons Media” tab to watch.
DOI: 10.1097/PRS.0000000000004732
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Volume 142, Number 4 • Abdominal Panniculectomy
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Plastic and Reconstructive Surgery • October 2018
Table 1. Preoperative Patient Characteristics, Clinical Factors, and Medical Comorbidities
Variable Nondiabetic Patients (%) Diabetic Patients (%) p
No. of patients 6265 770
Mean age ± SD, yr 45.4 ± 11.8 54.4 ± 11.0 <0.001*
Mean BMI ± SD, kg/m2 30.8 ± 8.3 40.4 ± 13.7 <0.001*
Obese 2792 (44.6) 611 (79.4) <0.001*
Female 5595 (89.4) 635 (82.6) <0.001*
Smoker 637 (10.2) 82 (10.6) 0.68
ASA class 3 or higher 1145 (18.3) 505 (65.8) <0.001*
Emergency case 18 (0.3) 4 (0.5) 0.07
Prior operation within 30 days 5 (0.1) 4 (0.5) 0.01*
Race
American Indian or Alaska Native 25 (0.5) 13 (1.9) <0.001*
Asian 75 (1.4) 9 (1.3)
Black or African American 688 (12.9) 80 (11.9)
Native Hawaiian or Pacific Islander 18 (0.3) 3 (0.4)
White 4513 (84.8) 569 (84.4)
Wound classification
Clean 5785 (92.3) 621 (80.6) <0.001*
Clean/contaminated 338 (5.4) 54 (7.0)
Contaminated 82 (1.3) 48 (6.2)
Dirty/infected 60 (1.0) 47 (6.1)
Surgical specialty
Plastic surgery 5061 (80.8) 532 (69.1) <0.001*
General surgery 1180 (18.8) 231 (30.0)
Cardiovascular
CHF 6 (0.1) 13 (1.7) <0.001*
Previous PCI 13 (0.2) 7 (0.9) 0.01*
Previous cardiac surgery 15 (0.2) 5 (0.6) 0.06
Hypertension 1359 (21.7) 525 (68.2) <0.001*
PVD requiring surgery 4 (0.1) 3 (0.4) 0.03*
Neurologic
History of TIA 9 (0.2) 3 (0.4) 0.08
Stroke with neurologic deficit 1 (0) 4 (0.5) <0.001*
Genitourinary
Dialysis 16 (0.3) 8 (1.0) <0.001*
Respiratory
Ventilator dependence 2 (0) 1 (0.1) 0.38
Severe COPD 60 (1.0) 53 (6.9) <0.001*
Hematologic
Bleeding disorders 55 (0.9) 28 (3.6) <0.001*
Preoperative transfusion 7 (0.1) 9 (1.2) <0.001*
Infectious
Sepsis 38 (0.6) 27 (3.5) <0.001*
Open/infected wound 98 (1.6) 82 (10.6) <0.001*
Metabolic
Recent significant weight loss 21 (0.3) 5 (0.6) 0.18
Recent steroid use 75 (1.2) 18 (2.3) 0.01*
BMI, body mass index; ASA, American Society of Anesthesiologists; CHF, congestive heart failure; PCI, percutaneous coronary intervention;
PVD, peripheral vascular disease; TIA, transient ischemic attack; COPD, chronic obstructive pulmonary disease.
*Statistically significant.
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Volume 142, Number 4 • Abdominal Panniculectomy
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Plastic and Reconstructive Surgery • October 2018
45.4 ± 11.8 years; p < 0.001) and had a signifi- sepsis (2.9 percent versus 0.6 percent; p < 0.001),
cantly higher body mass index (40.4 ± 13.7 kg/m2 and septic shock (0.9 percent versus 0.1 percent;
versus 30.8 ± 8.3 kg/m2; p < 0.001), although p < 0.001). Operative time was significantly shorter
the percentage of women was significantly lower (160.7 ± 80.9 minutes versus 177.9 ± 91.4 minutes;
(82.6 percent versus 89.4 percent; p < 0.001). The p < 0.001), whereas the postoperative hospital
diabetic patient group had significantly higher length of stay was significantly longer (3.2 ± 5.2
preoperative rates of obesity (79.4 percent ver- days versus 1.6 ± 7.4 days; p < 0.001) in the diabetic
sus 44.6 percent; p < 0.001), American Society of patient group (Table 2).
Anesthesiologists class 3 or higher classification Multivariate regression for outcomes with sig-
(65.8 percent versus 18.3 percent; p < 0.001), nificant differences between diabetic and nondia-
prior operation within 30 days (0.5 percent ver- betic groups on univariate analysis demonstrated
sus 0.1 percent; p = 0.01), congestive heart fail- that diabetic patients were significantly more
ure (1.7 percent versus 0.1 percent; p < 0.001), likely to develop wound dehiscence (OR, 1.92;
percutaneous coronary intervention (0.9 per- 95 percent CI, 1.41 to 3.15; p = 0.02). Other risk
cent versus 0.2 percent; p = 0.01), hypertension factors for wound dehiscence included obesity
(68.2 percent versus 21.7 percent; p < 0.001), and (OR, 1.61; 95 percent CI, 1.11 to 3.89; p = 0.03),
peripheral vascular disease requiring surgery (0.4 open or infected wound at surgery (OR, 3.13; 95
percent versus 0.1 percent; p = 0.03). Patients with percent CI, 1.79 to 6.34; p = 0.01), recent signifi-
diabetes also had a significantly higher rate of cant weight loss (OR, 9.25; 95 percent CI, 2.43
history of stroke with neurologic deficit (0.5 per- to 41.19; p = 0.004), superficial incisional surgi-
cent versus 0 percent; p < 0.001), dialysis require- cal-site infection (OR, 6.48; 95 percent CI, 1.94
ment (1.0 percent versus 0.3 percent; p < 0.001), to 15.22; p = 0.001), deep incisional surgical-site
chronic obstructive pulmonary disease (6.9 per- infection (OR, 4.53; 95 percent CI, 2.64 to 6.14;
cent versus 1.0 percent; p < 0.001), bleeding dis- p = 0.01), and deep organ/space surgical-site
orders (3.6 percent versus 0.9 percent; p < 0.001), infection (OR, 2.72; 95 percent CI, 1.82 to 4.46;
preoperative transfusion (1.2 percent versus 0.1 p = 0.03). Obesity and smoking were significant
percent; p < 0.001), sepsis (3.5 percent versus 0.6 risk factors for superficial incisional surgical-site
percent; p < 0.001), open or infected wound (10.6 infection (OR, 2.78; 95 percent CI, 1.53 to 3.69;
percent versus 1.6 percent; p < 0.001), and recent p < 0.001; and OR, 1.42; 95 percent CI, 1.19 to
use of steroids (2.3 percent versus 1.2; p = 0.01) 1.75; p = 0.03) and deep incisional surgical-site
(Table 1). infection (OR, 1.52; 95 percent CI, 1.38 to 3.97;
Univariate analysis showed that diabetic p = 0.01; and OR, 1.63; 95 percent CI, 1.31 to
patients presented significantly higher rates of 2.22; p = 0.02). Superficial incisional surgical-site
wound complications, including superficial inci- infection (OR, 1.63; 95 percent CI, 1.25 to 3.18;
sional surgical-site infection (8.1 percent versus p = 0.01), deep incisional surgical-site infection
3.5 percent; p < 0.001), deep incisional surgical- (OR, 38.97; 95 percent CI, 21.43 to 120.67; p <
site infection (3.8 percent versus 1.2 percent; p < 0.001), and deep organ/space surgical-site infec-
0.001), deep organ/space surgical-site infection tion (OR, 6.12; 95 percent CI, 1.31 to 42.08;
(0.6 percent versus 0.2 percent; p = 0.02), and p = 0.001) were significant risk factors for subse-
wound dehiscence (2.6 percent versus 1.1 per- quent reoperation (Table 3).
cent; p = 0.001). Diabetic patients also had higher Septic shock was a risk factor for reintuba-
rates of reoperation (5.8 percent versus 3.3 per- tion (OR, 18.11; 95 percent CI, 3.19 to 110.72;
cent; p = 0.001), readmission (2.1 percent versus p = 0.02) and mechanical ventilation for longer
0.9 percent; p = 0.01), postoperative bleeding/ than 48 hours (OR, 23.52; 95 percent CI, 4.62
transfusions up to 72 hours postoperatively (7.9 to 137.08; p = 0.01). Patients with postoperative
percent versus 4.1 percent; p < 0.001), stroke with wound dehiscence were at increased risk for
deficit (0.3 percent versus 0 percent; p < 0.001), readmission (OR, 14.22; 95 percent CI, 6.09 to
acute renal failure (0.4 percent versus 0 percent; p 45.19; p < 0.001) and reoperation (OR, 6.03; 95
< 0.001), reintubation (1.2 percent versus 0.1 per- percent CI, 2.31 to 11.69; p = 0.001). Reopera-
cent; p < 0.001), mechanical ventilation greater tion (B coefficient, 4.79; 95 percent CI, 2.51 to
than 48 hours (1.6 percent versus 0.1 percent; p 7.03; p < 0.001) was a significant risk factor for
< 0.001), myocardial infarction (0.3 percent ver- reintubation (OR, 18.11; 95 percent CI, 3.19 to
sus 0 percent; p = 0.002), pneumonia (1.0 percent 110.72; p = 0.02) and longer hospital length of
versus 0.2 percent; p < 0.001), urinary tract infec- stay (B coefficient, 4.79; 95 percent CI, 2.51 to
tion (1.3 percent versus 0.6 percent; p = 0.02), 7.03; p < 0.001) (Table 4).
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Table 3. Multivariate Regression Analysis of Wound Complications and Reoperation
Superficial Incisional SSI Deep Incisional SSI Wound Dehiscence Reoperation
Variable OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p
Diabetes 1.05 0.67–1.25 0.44 1.22 0.83–1.85 0.53 1.92 1.41–3.15 0.02* 0.94 0.74–1.89 0.35
Obese 2.78 1.53–3.69 <0.001* 1.52 1.38–3.97 0.01* 1.61 1.11–3.89 0.03* 1.33 0.85–2.87 0.09
Smoker 1.42 1.19–1.75 0.03* 1.63 1.31–2.22 0.02* 1.45 0.88–1.71 0.15 — 0.84
Open/infected wound at surgery 1.12 0.73–2.31 0.62 0.85 0.49–2.13 0.38 3.13 1.79–6.34 0.01* 0.84 0.45–1.67 0.49
Recent significant weight loss 0.85 0.32–5.16 0.72 1.01 0.39–2.08 0.23 9.25 2.43–41.19 0.004* 1.31 0.56–6.52 0.62
Superficial incisional SSI — — 6.48 1.94–15.22 0.001* 1.63 1.25–3.18 0.01*
Deep Incisional SSI — — 4.53 2.64–6.14 0.01* 38.97 21.43–120.67 <0.001*
Deep organ/space SSI — — 2.72 1.82–4.46 0.03* 6.12 1.31–42.08 0.001*
Wound dehiscence — — — 6.03 2.31–11.69 0.001*
SSI, surgical-site infection; OR, odds ratio (categorical variables) or B coefficient (continuous variables).
*Statistically significant.
Volume 142, Number 4 • Abdominal Panniculectomy
Table 4. Multivariate Regression Analysis of Medical Complications, Readmission, and Hospital Length of Stay
Mechanical Postoperative
Sepsis Reintubation Ventilation > 48 Hr Readmission Hospital LOS
Variable OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p B 95% CI p
Diabetes 1.43 0.74–3.28 0.21 1.09 0.47–11.02 0.71 0.66 0.21–1.17 0.31 1.24 0.79–1.92 0.28 −0.61 −1.88–1.37 0.24
COPD 2.04 0.69–7.57 0.19 42.47 4.03–594.72 0.004* 3.17 1.78–31.24 0.02* 1.03 0.56–1.37 0.25 1.42 −3.73–2.75 0.32
Deep organ/space SSI 41.12 7.41–371.29 0.001* — 0.99 — 0.99 1.27 0.94–2.09 0.06 4.72 2.53–6.52 0.01*
Wound dehiscence 0.76 0.15–3.27 0.31 — 0.98 4.56 0.79–94.11 0.19 14.22 6.09–45.19 <0.001* 8.42 5.17–11.03 <0.001*
Septic shock — 18.11 3.19–110.72 0.02* 23.52 4.62–137.08 0.01* — 0.99 1.61 1.24–4.70 0.02*
Reoperation 1.30 0.75–2.91 0.28 19.18 2.07–342.13 0.03* 2.48 0.71–5.09 0.31 — 0.99 4.79 2.51–7.03 <0.001*
LOS, length of stay; B, beta coefficient; COPD, chronic obstructive pulmonary disease; SSI, surgical-site infection.
*Statistically significant.
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Plastic and Reconstructive Surgery • October 2018
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Volume 142, Number 4 • Abdominal Panniculectomy
and deep incisional surgical-site infection. These and our study have several limitations. Postopera-
results are consistent with many previous studies tive data are limited to 30 days, which restricts our
showing that obese patients are more prone to ability to define the true effect of diabetes mellitus
wound healing impairment and infection because on long-term outcomes following panniculectomy.
of a chronic inflammatory and immunomodula- The lack of information about patient surgical
tory state.32 Furthermore, obesity has been shown history, including bariatric surgery and surgical
to be strongly associated with wound infections technique, also adds limitations to our study. Our
following abdominoplasty20,21,33,34 and pannicu- study does not exclude patients undergoing con-
lectomy16,17 specifically. The impact of smoking comitant procedures with panniculectomy, which
on wound infections has also been extensively might explain the occurrence of deep organ/
explored in the surgical literature,35–39 with a space infections in some patients. In addition,
strong consensus that smoking is associated with our study and the American College of Surgeons
an increased risk of wound infections. This has National Surgical Quality Improvement Program
also been shown in patients undergoing pannic- database rely on accurate data reporting by par-
ulectomy16 and abdominoplasty.23,40 The adverse ticipating hospitals, and some abdominoplasty
effects of smoking are thought to be multifactorial cases may have been erroneously coded using the
in nature,38 with alterations in wound tissue micro- panniculectomy CPT code. Furthermore, diabetes
environment,41 oxygenation,42 aerobic metabo- mellitus is coded as a categorical variable in the
lism,43 and immune bactericidal functions44 database without data regarding hemoglobin A1c
playing important roles in the pathophysiology. levels or perioperative blood glucose levels, which
An important finding of our study is that would allow us to evaluate the impact of severity
wound complications including superficial inci- of diabetes mellitus on postoperative outcomes.
sional, deep incisional, and deep organ/space Although our study shows significant associations
surgical-site infection and wound dehiscence were between diabetes and certain postoperative out-
associated with a significantly increased rate of comes, it is important to note that no associations
reoperation. Wound dehiscence was also a signifi- can be made between diabetes mellitus severity
cant risk factor for readmission and longer post- and outcomes. The increased rate of complica-
operative hospital length of stay, whereas deep tions might be attributable to patients with the
organ/space surgical-site infection significantly severe spectrum of the disease rather than those
increased the risk of sepsis. These findings high- with well-controlled diabetes mellitus. Future pro-
light the critical need to implement all available spective studies are needed to analyze the effect of
surgical-site infection prevention resources and diabetes mellitus and disease severity on long-term
guidelines45 to minimize the risk of wound com- outcomes in patients undergoing panniculectomy
plications, subsequent reoperations, and resul- while accounting for these more specific details.
tant patient adverse events. The higher risks of
readmission and longer postoperative hospital
length of stay associated with wound complica- CONCLUSIONS
tions are consistent with published data demon- Evaluation of the association between diabetes
strating that patients with surgical-site infection mellitus and panniculectomy in a large nationwide
had an almost 6-fold increase in rate of readmis- cohort of patients shows that diabetic patients are
sion and a hospital length of stay that was twice as at a significantly higher risk of developing post-
long as that in patients without surgical-site infec- operative wound dehiscence independent of
tion.46 The financial burden on annual hospital many of the comorbidities often associated with
revenue associated with these surgical-site infec- diabetes mellitus and obesity. Surgical-site infec-
tions was estimated to be $3,255,034,46 underlin- tions, obesity, presence of open/infected wounds,
ing the financial incentive to wound complication and recent significant weight loss were also sig-
prevention as well. It is also important to note nificant risk factors for wound dehiscence in all
that although wound dehiscence increased the patients. Furthermore, obesity and smoking sig-
risk of reoperation and longer hospital length of nificantly increased the risk of superficial and
stay, diabetes mellitus did not. This may be partly deep incisional surgical-site infections. Along with
explained by the association between wound the increased hospital length of stay, consequent
dehiscence and wound infections, which were in comorbidities, and financial implications, these
turn associated with reoperation. results underscore the importance of preopera-
The American College of Surgeons National tive risk factor evaluation in patients undergoing
Surgical Quality Improvement Program database panniculectomy for safe outcomes.
469e
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Plastic and Reconstructive Surgery • October 2018
Daniel J. Ceradini, M.D. 15. Bamba R, Gupta V, Shack RB, Grotting JC, Higdon KK.
Hansjörg Wyss Department of Plastic Surgery Evaluation of diabetes mellitus as a risk factor for major com-
plications in patients undergoing aesthetic surgery. Aesthet
New York University Langone Medical Center
Surg J. 2016;36:598–608.
305 East 33rd Street
16. Zavlin D, Jubbal KT, Balinger CL, et al. Impact of metabolic
New York, N.Y. 10016
syndrome on the morbidity and mortality of patients undergo-
daniel.ceradini@nyumc.org
ing panniculectomy. Aesthetic Plast Surg. 2017;41:1400–1407.
17. Cooper JM, Paige KT, Beshlian KM, Downey DL, Thirlby
RC. Abdominal panniculectomies: High patient satisfac-
DISCLAIMER tion despite significant complication rates. Ann Plast Surg.
The American College of Surgeons National Surgi- 2008;61:188–196.
cal Quality Improvement Program and participating 18. Zuelzer HB, Ratliff CR, Drake DB. Complications of abdomi-
hospitals are the source of the data used herein; they have nal contouring surgery in obese patients: Current status. Ann
Plast Surg. 2010;64:598–604.
not verified and are not responsible for the statistical 19. American College of Surgeons. ACS National Surgical Quality
validity of the data analysis or the conclusions derived Improvement Program. Available at: https://www.facs.org/
by the authors. quality-programs/acs-nsqip. Accessed October 1, 2017.
20. Winocour J, Gupta V, Ramirez JR, Shack RB, Grotting JC,
Higdon KK. Abdominoplasty: Risk factors, complication
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