Continuing Education Activity
The management of abdominal panniculus should not be thought solely as a cosmetic procedure. To achieve good outcomes, the goals and objectives of a panniculectomy must be defined. This activity reviews preoperative optimization, indications, techniques, and complications associated with a panniculectomy.
- Identify indications for panniculectomy.
- Describe potential complications of a panniculectomy.
- Describe the standard the technique of a panniculectomy.
- Explain why careful planning and interprofessional evaluation, treatment, and patient education will lower the associated morbidity and improve patient outcomes.
A panniculectomy is an operative procedure used for abdominal wall contouring, changing the shape and form of the abdomen. This procedure is performed on patients with a large overhanging abdominal panniculus. A panniculus is an apron of excess skin and fat that hangs down from the abdomen. This excess skin and fat are secondary to weight gain and can sometimes cover the anterior thighs, hips, and knees. A major issue is that a large panniculus can lead to a severe impact on activities of daily life. Skin infections and rashes are common complaints of patients with a substantially large panniculus due to constant irritation and sweating.
The size of a panniculus varies and can be graded on a scale of 1 to 5, which correlates with how far it extends. Grade 1 reaches the mons pubis, while a grade 5 extends to or reaches past the knees. A panniculectomy is performed to relieve these symptoms and restore formal function. During a panniculectomy, the excess skin and fat are removed. Tightening or plication of the abdominal wall muscle is not performed, which differentiates this procedure from an abdominoplasty - a cosmetic procedure, usually involving fascial plication .
Over the past 3 decades, there has been a significant increase in panniculectomies, partly promoted by the development of liposuction techniques. However, the reader should be aware that panniculectomy or abdominoplasty are not benign procedures. Patients must be thoroughly worked up and cleared for surgery. There are ample reports of severe bleeding and deaths following panniculectomy.
Anatomy and Physiology
Men and women accumulate fat in distinct and predictable patterns. These patterns are genetically and hormonally related. The fat distribution in men is primarily around the abdomen and torso, which is an android pattern. Women accumulate fat around the hips and thighs in a gynoid pattern.
The fat present in cellulite is no different from ordinary subcutaneous fat. The subcutaneous fat in the trunk area is composed of a superficial and deep layer. The superficial layer is dense, compact, and contains multiple fibrous septa. The deep layer is loose, areolar, and contains few septa. The deep layers are located around the umbilical, gluteal, paralumbar, and medial thigh regions. One patient concern is the appearance of cellulite. This is due to the presence of dense vertical septa separating the fat into pockets. As the fat hypertrophies or the skin relaxes with age, the septa cause an accordion appearance of cellulite.
Fat cells are produced in utero, early childhood, and early adolescence. Once maturity is reached, the number of fat cells remains the same. When fat cells are removed through liposuction or other techniques, new fat cells do not form to replace them; however, the remaining fat cells may hypertrophy, causing the total fat mass in the area to increase. One exception is for patients who are morbidly obese, in these cases the fat cells become hyperplastic and multiply.
The primary blood supply to the abdominal skin is from the superior and inferior epigastric vessels. These vessels run within the rectus muscle and branch off perforating the rectus fascia and abdominal fat, finally reaching the skin. When performing an abdominal flap, the blood supply is interrupted.
A second blood supply to the abdominal skin is located in the fat superficial to the fascia of Scarpa. The lateral intercostal, subcostal and lumbar vessels are the only blood supply of the central abdominal skin after flap elevation. Previous surgeries put the blood supply to the skin at risk because of interruptions of these vessels by scars.
The lower trunk has three horizontal zones of adherence in the inguinal region, suprapubic, and hip/lateral thighs. The tissue adherence becomes relaxed secondary to aging, pregnancy, and massive weight loss. Due to the laxity of these attachments, the tissues descend around the pelvis and migrate centrally. 
Most often, the patient experiences a dramatic weight loss, and the excess lower abdominal skin overhangs the groin and pubic regions. This is often seen in patients following bariatric surgery. The risk of the formation of a large panniculus post-bariatric surgery is higher in older patients and patients with a higher pre-operative Body Mass Index.  It is possible that the panniculus strikes against the thighs as the patient walks, causing significant discomfort and irritation. Bariatric surgery patients typically achieve stable weight loss in 12 to 18 months, but some patients present in as few as 6 months for panniculectomy due to interference from the overhanging skin.
Panniculectomy differs from standard abdominoplasty by the amount of skin and adipose tissue undermining superior to the tissue being excised, which is extremely limited for this procedure. The abdominal flaps with massive weight loss often demonstrate a compromised vascular status, and undermining is associated with a high rate of skin loss and seroma formation. The excision can almost be thought of as a wedge excision of the tissue to be removed. Previous scars must be carefully noted because these also predispose to tissue loss. If the tissue needed to be removed extends above the umbilicus, an umbilectomy is discussed with the patient as well .
Panniculectomy is an elective procedure where medical problems must be under control before the operation. Cigarette smoking affects blood supply and wound healing, and surgery should be avoided in active smokers and any patient with uncontrolled cardiac disease, lung disease, or diabetes.
Patients with morbid obesity who are postbariatric have more severe deformities, excess skin, laxity, and poor tone. These patients are at greater risk of complications with medical comorbidities, surgical scars, and nutritional deficiencies .
Listening to the patient's chief complaint is essential. Important questions to discuss are any history of constipation or difficulty in passing urine, clothing preference, dietary habits, exercise, and general level of activity.
Focus special attention on the general length of the abdomen and the relationship of the costal margins to the iliac crest region. The lowest point of the costal margin to the iliac crests determines the waist configuration and potential for increasing definition at the waist. Patients with 5 to 6 cm waist configurations are considered short-waisted, while those with 10 to 11 cm configurations are long-waisted. 
The elasticity of the abdominal wall skin should be assessed. Photos should be obtained and the patient should be cleared for surgery by the internist. It is vital to inform the patient about the risks of surgery, which are not minuscule. The patient should have realistic expectations about the procedure.
An incision is made in the patient's natural suprapubic crease. The incision is extended laterally towards the anterior superior iliac spine, stopping at the lateral edges of the pubic hair. The incision is deepened, and dissection is continued through the Scarpa fascia and down to the muscle. Following the musculoaponeurotic fascial plan superiorly, the abdominal skin and subcutaneous tissue are excised. The wound is closed in multiple layers with attention paid to the Scarpa fascia, deep dermis, and intradermal layers. Permanent or long-lasting absorbable sutures are used in these strength layers. When closing the wound, avoiding dog-ears on the lateral aspects is very important. Before the wound is closed, suction drains are placed under the flap and brought out through a small incision in the pubic region. To prevent seroma formation, compression garments should be worn while drains are present. Once the output of the drain is less than 30 mL/day, they can be removed, and compression garments can be continued for patient comfort. 
Post-operative complications are associated with comorbidities, higher pre-operative Body Mass Index and previous bariatric surgery. 
Wound healing is the most common complication after a panniculectomy including cellulitis, seromas, hematomas, wound dehiscences, and tissue necrosis. Conservative management and wound care are usually the treatment of choice, but some patients require surgical intervention.
Seromas are the most common complication, especially after a larger dissection. Once a flap is created, the body tries to fill the empty space with fluid which is why suction drains are placed during the procedure. The best preventative management is the preservation of the Scarpa fascia with minimal dissection. Postoperatively, compression garments and reduction of activity can reduce seroma occurrence. Once a seroma occurs, management involves close observation and serial aspirations. Some patients require catheter insertions and sclerosing agents.
Simple cellulitis is a skin infection that will respond to antibiotics and follow-up. Complicated cellulitis with abscess formation will require surgical drainage and washout. When performing serial aspirations of seromas, there is a risk of introducing bacteria with each needle puncture, and the practitioner must weigh the risks versus the benefits. The patient will have a seroma and overlying cellulitis, fever, and drainage. Infected seromas require intravenous antibiotics and surgical drainage.
A hematoma is the accumulation of blood under the abdominal flap. Surgical drains placed during the operation do not prevent hematomas but allow the surgeon to track the amount and rate of postoperative bleeding. The drains evacuate the hematoma, and management is conservative. If the bleeding does not spontaneously stop or the hematoma is expanding, surgical drainage and obtaining hemostasis is required.
Wound dehiscence is the separation of a wound which can occur at any level down to the fascia. Postoperatively, patients are instructed to remain bent at the waist 30 degrees in a semi-fowler position for a week and slowly return to the full upright position. The slow return to standing position allows the wound to form scar tissue and prevents the sutures that are holding the wound together from breaking. Patients should be instructed about careful ambulation during the first few weeks postoperatively.
Blood supply to the wound is key to wound healing. Vascular compromise can lead to tissue necrosis and wound breakdown. Risk factors include extensive lateral dissection, excessive liposuction, thin flap, and extreme tension. Once skin necrosis occurs, local wound care is the treatment to allow the wound to heal by secondary intention. After a scar forms, discussion about scar revision is an option. 
Panniculectomy is not a cosmetic procedure. The intention of the procedure is to remove the excess skin and fat that hangs over the thigh and causes difficulty in personal hygiene, walking, and other physical activities. A panniculectomy must meet specific criteria to be medically necessary.
The pannus must hang below the level of the pubis and be confirmed with photography. Patients must fail medical treatment of intertrigo for three months. Medical treatment includes good hygiene, topical antifungals, corticosteroids, and antibiotics. The role of panniculectomy is to restore normal function. Patients must maintain a stable weight for at least 6 months. After bariatric surgery, patients must maintain a stable weight for at least 18 months, including the most recent six months. 
Enhancing Healthcare Team Outcomes
Pannus treatment, whether surgical or medical, requires an interprofessional team involving a specialty-trained nurse and specialist surgeon. The primary care clinicians including the nurse should educate the patient about the procedure and encourage the patient to stop smoking. Since the surgery is elective, the patient should try and attain the desired body weight prior to surgery. All medical health problems should be assessed and minimized. The patient should be encouraged to remain physically active and have completed childbearing.
Patients require vigilant monitoring for extended periods which means close follow up of both the clinician and nurse with constant supervision and ongoing education of the patient. There should be close communication between the team members if one wants to achieve good outcomes. [Level V]
Nursing, Allied Health, and Interprofessional Team Interventions
- Educate the patient about the procedure
- Obtain the consent
- Set up the surgery instruments
- Prep the patient
- Assist the surgeon
Nursing, Allied Health, and Interprofessional Team Monitoring
- Monitor the patient during surgery
- Monitor the patient after surgery
- Speak to the family and relatives after surgery
- Follow up after surgery