COSMETIC

Massive Panniculectomy in the Super Obese

and Super-Super Obese: Retrospective
Comparison of Primary Closure versus Partial
Open Wound Management
Matthew Brown, M.D.
Background: The incidence of obesity is on the rise in the United States and
Paul Adenuga, B.S.
worldwide. Complications following panniculectomy are higher for super
Hooman Soltanian, M.D.
obese patients, often requiring readmission and additional interventions. In
Cleveland, Ohio this study, the authors compare the outcomes of patients who underwent pri-
mary closure of their resection wounds to the outcomes of patients who un-
derwent initial open wound management with a negative-pressure dressing.
Methods: The records of all patients who underwent panniculectomy between
2007 and 2012 were reviewed. Of 14 patients with a body mass index greater
than 50, nine underwent primary closure and five were treated with open
wound management. A retrospective chart review was performed.
Results: There were no statistically significant differences in age or preop-
erative comorbidities, but body mass index was higher for the open wound
management group (66.4 versus 58.9, p = 0.039). There were no statistically sig-
nificant differences in mean operative time, resection weight, estimated blood
loss, or hospital length of stay. The primary closure group had a 44 percent
readmission rate and a 33 percent reoperation rate for wound complications.
The open wound management group had no wound-related readmissions or
secondary procedures for débridement.
Conclusions: Open wound management in the massive panniculectomy pa-
tient reduces hospital readmission and secondary operations. This case series
provides reasons to support the consideration of open wound management
following massive panniculectomy in the super morbidly obese patient popula-
tion.  (Plast. Reconstr. Surg. 133: 32, 2014.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

O
besity across the United States and the patients who undergo panniculectomy while still
world is an epidemic. It is now estimated being significantly obese (Fig. 1). The panniculus
that greater than 66 percent of the United may become a distinct pathologic entity because
States population is considered overweight by of rashes, chronic infection, ulcers, fistulas, severe
body mass index and 34 percent fall into the cat- functional limitation, and immobility. Sometimes,
egory of obese.1 After massive weight loss, pannic- the obese patient who has experienced massive
ulectomy is a common procedure for removing weight loss will require an intermediate pannic-
the excess abdominal skin. A patient with a large ulectomy to aid in mobility.2 In other instances,
panniculus may complain of intertriginous infec- patients are undergoing other abdominal opera-
tions, skin ulcerations, and difficulty with hygiene. tions such as hernia repair or hysterectomy, where
There is an entirely separate population of another surgeon’s operative approach is severely
complicated by the overhanging tissue.3 The pan-
niculus morbidus has been well described before.
From the Department of Plastic Surgery, University Hospi- Various authors have reported their operative
tals and Case Western Reserve University; Case Western Re- experiences.4,5 It has been the experience at our
serve University School of Medicine.
Received for publication May 29, 2013; accepted July 31,
2013. Disclosure: The authors have no financial interest
Copyright © 2013 by the American Society of Plastic Surgeons to declare in relation to the content of this article.
DOI: 10.1097/01.prs.0000436818.34332.34

32 www.PRSJournal.com
Volume 133, Number 1 • Wound Management after Panniculectomy

Fig. 1. (Left) Super obese patient (body mass index >50) treated with primary closure. (Right)
Super-super obese patient (body mass index >60) treated with open wound management.

institution, regardless of the indication for pan- of Plastic Surgery over the past 5 years were
niculectomy, with or without all the manifestations reviewed. Patients with a body mass index greater
of panniculus morbidus, that super obese (body than 50 and panniculus resection weights greater
mass index >50) patients experience a higher rate than 5000 g were included. In the past year, all
of postoperative complications. Many of these patients with a body mass index greater than 50
wound complications may require subsequent were treated with the open wound management.
hospitalization and return to the operating room. There were five consecutive patients in this group.
After débridement, the wounds are typically not This decision was made based on a high level of
closed primarily, allowing them to heal with local complications associated with primary closure.
wound care and negative-pressure therapy. With Hospital and clinic charts were reviewed for
the high rate of wound healing problems present operative times, concomitant procedures, hospital
in these cases, we altered our approach to treat length of stay, complications, hospital readmissions,
some of these patients with open wound care at subsequent procedures or interventions, and docu-
the time of initial surgical resection. mentation of healed wounds. Statistical significance
was tested using chi-square analysis and t test.
PATIENTS AND METHODS Preoperative Assessment and Operative
Retrospective Review Technique
Charts of patients who underwent panniculec- A similar method advocated by previous
tomy performed by surgeons in the Department authors for resection of a large panniculus is

33
 Plastic and Reconstructive Surgery • January 2014

performed at our institution.2,4,5 All patients were wounds were then either closed with sutures or
seen in our preoperative anesthesia clinic and received occlusive dressing with negative-pressure
underwent a thorough preoperative workup. therapy.
When appropriate, they were referred to a car- In the closure group, the abdominal wound
diologist or internist for further medical opti- was closed in a three-layer fashion with approxi-
mization. Medical optimization was performed, mation of the Scarpa fascia, the deep dermis, and
at times, over a period of several months. The the skin. Two to four 19-French channel drains
patients with a cancer diagnosis were optimized were placed and attached to bulb suction.
more rapidly. For the open wound management group,
The patient’s midline and general outline for the patients had the same resection as described
tissue resection were marked in the preoperative above but did not undergo three-layer closure.
area with the patient in the upright position. Two Instead, they all had their wounds treated with
surgeons operated simultaneously on either side a vacuum-assisted closure (V.A.C.; Kinetic Con-
of the patient for operative efficiency. Patients cepts, Inc., San Antonio, Texas) device in the
were given weight-based antibiotic prophylaxis operating room. In the first two cases, the patients
before incision and in almost all instances received had no closure at all and the entire resection area
a dose of subcutaneous heparin for deep venous was treated with vacuum-assisted closure sponges.
thrombosis prophylaxis in addition to sequential In the remaining three patients, this was modi-
compression devices. The panniculus was pre- fied slightly by closure 10 to 15 cm centrally and
pared and Steinmann pins were placed through 10 cm at each of the lateral edges with heavy
the pendulous part of the abdominal skin. The nylon sutures in single-layer vertical mattress fash-
panniculus was then suspended from above. The ion (partial closure). This helped with wound
abdomen and panniculus were then prepared alignment and ease of vacuum-assisted closure
again and sterilely draped. It is much easier to ­application (Fig. 2).
adequately clean the skin while the panniculus In the cases with simultaneous hernia repair
is suspended. The lower abdominal incision was or gynecologic procedures, the panniculus was
made approximately 3 cm above the inguinal removed before the other operations were per-
crease on either side. It is important to note that formed. The closure and/or negative-pressure
preoperative markings are guidelines and should therapy was performed at the completion of the
not be followed strictly, if overresection is to be combined surgery. If there was any concern about
avoided. In the upright position, the abdominal potential contamination of a synthetic mesh, the
skin is under significant tension by the dependent Scarpa layer was closed and the remaining wound
panniculus. This amount of tension should be was left open.
avoided at the time of closure.
The inferior transverse marking was then
incised. The dissection was carried down to the RESULTS
abdominal wall. A thin layer of adipose and areo- A total of 14 patients met the inclusion criteria
lar tissue was maintained over the deep fascia. The (body mass index >50 and resection volume greater
upper panniculus incision was then made and >5000 g). Nine patients were treated with primary
taken down directly to meet our previous lower closure and five patients were treated with open
dissection, performing a wedge resection of the wound management. Six of nine patients in the
panniculus. Although only anecdotal, the use of primary closure group and three of five patients
LigaSure Impact (Covidien Surgical Solutions in open wound group had significant preoperative
Group, Boulder, Colo.) can be helpful in speed- edema, ulceration, and lymphatic dependency
ing up resection, especially in sealing intermedi- consistent with panniculus morbidus. The mean
ate sized vessels and lymphatics. The LigaSure is ages of the primary closure and open groups were
a bipolar electrosurgical device that delivers high 59 and 63 years, respectively. The mean body mass
voltage and low energy. Most of the dissection indexes of the two groups were 58.9 and 66.4,
was performed using standard electrocautery and respectively (Table 1). The preoperative morbidi-
surgical ties for larger vasculature. There was no ties among the two groups were similar, indicating
undermining of the abdominal skin beyond the very unhealthy patients. These included hyperten-
limits of the resection. The umbilicus was either sion, diabetes, obstructive sleep apnea requiring
removed at the time of surgery or translocated to continuous positive airway pressure, history of
a lower than normal position, if it appeared viable pulmonary embolism, atrial fibrillation, hyper-
and did not impede closure of the wound. The lipidemia, coronary artery disease, asthma, and

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Volume 133, Number 1 • Wound Management after Panniculectomy

Fig. 2. Super obese patient treated with open wound management. (Above) Preoperative
views. (Below, left) Intraoperative view before resection. (Below, right) Intraoperative view
of operative vacuum-assisted closure.

hypothyroidism (Table 2). Two patients in the pri- three in the open wound management group) had
mary closure group reported a history of smoking simultaneous procedures. Mean operative time in
but had not smoked for several years before the the primary closure group was 310 minutes, with a
operation. Body mass index was the only preop- mean estimated blood loss of 672 cc. In the open
erative factor statistically different between the two wound management group, mean operative time
groups (higher in the open wound group). was 233 minutes, with a mean estimated blood loss
Operative data revealed that a total of 10
patients (seven in the primary closure group and
Table 2.  Preoperative Comorbidities
Table 1.  Patient Characteristics Primary Open
(%) (%) p
Primary (%) Open (%) p
No. 9 5
No. 9 5 Hypertension 5 (56) 5 (100) 0.36
Sex 0.2 Diabetes mellitus 5 (56) 3 (60) 0.87
 Male 1 (11) 2 (40) Obstructive sleep apnea
 Female 8 (89) 3 (60) plus CPAP 3 (33) 4 (80) 0.09
Age 0.262 Atrial fibrillation 2 (22) 1 (20) 0.9
 Mean 59.1 63.7 Prior pulmonary embolism 1 (11) 1 (20) 0.64
 Range 47.1–68.1 55.3–68.7 Coronary artery disease 1 (11) 1 (20) 0.64
BMI 0.039 Hyperlipidemia 2 (22) 2 (40) 0.2
 Mean 58.9 66.4 Hypothyroidism 1 (11) 1 (20) 0.64
 Range 49.1–67.7 52.7–67.7 Asthma 1 (11) 1 (20) 0.64
BMI, body mass index. CPAP, continuous positive airway pressure.

35
 Plastic and Reconstructive Surgery • January 2014

Table 3.  Operative Data Table 4.  Postoperative Course and Interventions
Primary Open Primary Open
(%) (%) p (%) (%) p
No. 9 5 Significant wound breakdown 6 (66) *
Concomitant procedures Superficial skin dehiscence 2 (22) 1 (20) 0.92
  Hernia repair 3 (33) 1 (20) 0.59 Readmission 4 (44) 1 (20) 0.36
 Hysterectomy 4 (44) 3 (60) 0.57 Operative débridements 3 (33) 0 0.14
 Other 1 (11) 0 0.43 Positive wound culture 3 (33) 0 0.14
Operative time, min 0.13 Use of intravenous antibiotics 3 (33) 1 (20) 0.59
 Mean 310 233 Stay in skilled nursing facility 5 (55) 4 (80) 0.36
 Range 134–444 181–328 Total readmission time, days 59 5 0.27
Resection weight, kg 0.77 Readmission time for wound-
 Mean 11.6 10.3 related complication, days 43 0 0.12
 Range 5.2–35 6.1–18.2 Mean total hospital days
Estimated blood loss, ml 0.22 (primary plus readmission
 Mean 672 250 for wound), days 9.1 6.5 0.23
 Range 100–2500 100–550 Mean time to healed wounds,
Length of stay, days* 0.39 days 122 83 0.16
 Mean 5.6 6.5 *Open wound management group.
 Range 5–7 3–9
*With outliers removed.
other patients had superficial skin dehiscence
that resolved with local wound care not requiring
of 250 cc. The difference here was not statistically
deep packing. Only one patient in the primary
significant (Table 3).
closure group (11 percent) had totally uncompli-
The mean hospital stay for the primary closure
cated healing. Other postoperative complications
group was 7 days, with a range of 3 to 19 days. The
in this group included a pelvic hematoma, atrial
patient with the 19-day hospital stay had a compli- fibrillation with rapid ventricular rate, acute kid-
cated postoperative course with acute new-onset ney injury, and thrombocytopenia.
atrial fibrillation, acute kidney injury, and a stay In the open wound management group,
in the intensive care unit for respiratory concerns. no patient required a secondary operation for
With this outlier patient excluded, the mean hos- débridement. One patient was readmitted during
pital stay was 6.5 days. the postoperative period for a supratherapeutic
For the open wound management group, the anticoagulation level while on Coumadin (Bristol-
mean length of hospital stay was 18 days, with a Myers Squibb, Princeton, N.J.). The patient was
range of 5 to 60 days. The patient hospitalized not readmitted for a wound-related complication.
for 60 days had a prolonged stay because of an One patient who had partial closure of the mons
incarcerated ventral hernia and its surgical man- area experienced breakdown at this site that was
agement. The stay was unrelated to her pannicu- treated with local wound care along with nega-
lectomy wound, which was healing throughout tive-pressure care for the rest of the wound. This
her hospitalization. The mean hospital length same patient had cellulitic changes in the scrotum
of stay was 5.6 days if this patient is excluded noted in the clinic and was treated with a course
(Table 3). There were no statistically significant of oral antibiotics, which resulted in resolution of
differences in the operative data and immediate the symptoms.
hospitalization.
In the primary closure group, four patients
(44 percent) had readmissions and three patients DISCUSSION
(33 percent) required secondary operations for The World Health Organization classifies
débridement (Table 4). The total hospital read- obesity into class I, II, and III. Class I is defined
mission days related to the wound complications as a body mass index greater than 30, class II as
in the primary closure group was 45 days for the a body mass index greater than 35, and class III
entire group. Two of these patients had repeated as a body mass index greater than 40. Literature
readmissions when they presented to outside hos- has referred to patients with a body mass index
pitals with new draining sites and were ultimately greater than 50 as the super obese and those with
transferred to our institution. Three patients had a body mass index greater than 60 as the super-
positive wound cultures for multi–drug-resistant super obese.6,7 All of the patients in this study were
organisms. Six patients in the primary closure super obese or super-super obese. In addition to
group had large open wounds treated with dress- the technical issues with handling their size in
ing changes and negative-pressure therapy. Two the operating room, they often suffer from poor

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Volume 133, Number 1 • Wound Management after Panniculectomy

mobility status and multiple comorbidities. These super obese patients. After our experience with
factors likely lead to a high rate of complications. primary closure, we moved to an open wound
It is not uncommon at our institution to preop- management, which involved primary negative-
eratively advise these patients to expect some type pressure dressing placement to the entire wound
of wound complication during the postopera- bed. The thought was to allow these patients
tive period. Resection through lymphedematous to heal secondarily, permitting for more open
skin and subcutaneous tissue is prone to result in drainage and reducing any chance for seroma
breakdown and recurrence because the lymphatic and abscess formation. In addition, any postop-
vessels remain compromised. In addition to erative fat necrosis could be treated with dressing
wound healing complications, these patients carry changes or bedside débridement. We theorized
a high risk for airway compromise, deep venous that open wound treatment may simply speed up
thrombosis, and perioperative cardiac morbidity. the timeline in their healing process, eliminating
If presented with the option to live with the pan- the process of treating a closed wound that ulti-
niculus or possibly die in surgery, it has been our mately breaks down and is converted to an open
experience that these patients quite often would wound. The process of wound breakdown and
rather assume the risk of surgery. This mindset treatment is more likely to involve hospital read-
emphasizes the importance of quality of life over mission, infection, and subsequent operations,
the “quantity” of life for many of these patients. although the differences were not statistically
We hope to quantify this fact in a prospective man- different secondary to the small patient popula-
ner in the future. Efforts were made to reduce tion. Total operative times were also less in open
operative risk with appropriate optimization of wound management group, although these were
medically treated illnesses. Recently, Koulaxou- not statistically significant. We would argue that
zidis et al. described the effectiveness of preop- the closure times were shorter in the open wound
erative decongestive therapy before resection of management group, but these specific data were
panniculus morbidus.8 The decongestive therapy not available retrospectively. A decrease in total
included manual lymph drainage, compression operative time is not reflective of the decreased
bandaging, lymphatic exercise, skin care, and closure time because of the number patients who
education in lymphedema self-management. The had simultaneous procedures.
patients receiving therapy had decreased rates of In our open wound management group, we
complications related to blood transfusion and altered our practice slightly after the first two
wound healing. Every patient who did not receive patients because of some difficulty in the home
therapy had some type of complication. care nursing staff applying and sealing the nega-
We report a high rate of complications in our tive-pressure wound therapy. We found that par-
patient population with use of techniques simi- tial closure of the lateral edge and central mons
lar to those described in the literature.2–5 Matory area aided in negative-pressure dressing changes
et al., in a review of 42 abdominal operations in on the floor and by home health nurses. The aver-
the morbidly obese, reported 27 minor wound age length of initial hospital stay is not altered sig-
and three major wound complications.3 Manahan nificantly by open wound management, although
and Shermak2 reported uncomplicated wound most patients did require home care to be set up
healing in 44 percent of their population of mas- or opted to stay at a skilled nursing facility for a
sive panniculectomy after massive weight loss, short period. The negative-pressure therapy was
implying a 56 percent wound complication rate. continued until wounds could not be packed and
Hughes et al. reported a greater than 49 percent typically were less than 2 cm in width or depth.
wound complication rate in patients weighing Residual open areas were treated with topical
more than 200 lb who had simultaneous hernia wound therapy and nonadherant dressings until
repair and panniculectomy. Most of the patients everything was fully healed.
in our study weighed twice as much. Friedrich et It is our belief that the super obese and super-
al.,5 in their review of panniculus morbidus treat- super obese populations likely have greater risk
ment, reported significant problems with achiev- factors than even the morbidly obese. This was
ing primary healing. Petty et al. commented that demonstrated by Zannis et al. in a review of 562
“the extent of fat necrosis always exceeds the vis- panniculectomies. They reported that patients
ible extent skin necrosis. Necrosis leads to wound with a body mass index greater than 50 are 12.1
dehiscence.”4 times more likely to have a wound complica-
Similar to the experience of Friedrich et al., tion than those with a body mass index less than
we altered our approach in the treatment of these 30. Those with a body mass index greater than

37
 Plastic and Reconstructive Surgery • January 2014

60 were 15.5 times more likely to have a wound negative-pressure wound therapy, but also to the
complication.9 Panniculectomy combined with absence of trauma to the subcutaneous tissue
other operations has shown increased complica- resulting from suture closure. Every time these
tion rates, similar to those reported in various patients were seen in follow-up, they showed
­studies.10–13 The wound complications in our progress and improvement of their wounds. The
patients presented in various forms, including opposite was often experienced in the primary
seroma, fat necrosis, and primary dehiscence, closure group, as we experienced progression of
and some of these had an associated infection the breakdown of their wounds in the initial office
or bacterial growth. These wound complications follow-up.
typically presented 2 to 3 weeks after surgery, with This study indicates that there is a benefit in
the patient’s initial postoperative course proceed- open wound management. As a small case series,
ing well. Initial signs of a wound problem mani- the findings of the current study have to be veri-
fested with drainage from the incision. The skin fied in a prospective study. There are numerous
opening was often small, but the underlying fat variables among the individual patients that could
necrosis or seroma tracked for a much larger account for their postoperative course. In addi-
subcutaneous area. Local wound care often was tion, this was a retrospective review and does not
not adequate, prompting a need for operative have the power of a prospective randomized trial.
débridement. This entailed opening a larger por- The decision to treat the more recent super obese
tion of the incision and following various sinus patients with open wound management was at the
tracts that may have formed through the thick discretion of the surgeon and therefore has inher-
subcutaneous tissue. Sixty-seven percent of our ent selection bias. In most instances, the operative
primary closure group were ultimately treated for surgeons believed they were selecting patients at
large open wounds with packing and negative- higher risk rather than lower risk for wound com-
pressure wound therapy. In review of the three plications. The two different methods show more
patients who did not incur significant wound of an evolution in the treatment of this high-risk
problems, only one suffered from obstructive group of patients rather than a conscious patient
sleep apnea and hypertension. In addition, only selection. Tables 1 and 2 show that the open wound
one patient had the diagnosis of diabetes melli- management group showed a greater mean body
tus, which was controlled with diet and oral medi- mass index; greater mean age; and higher rates
cations. This indicates that large body habitus in of diabetes, hypertension, and obstructive sleep
conjunction with other medical comorbidities apnea adds, which credence to this argument. The
may lead to wound complications (Table 5). open wound management group experienced less
No patient in the open wound management blood loss and shorter operative times, although
group needed operative débridement. The these changes were not statistically significant.
areas of fat necrosis were almost negligible, and Reduced blood loss and shorter operative times
no beside or office débridement was required. are thought to reduce perioperative complica-
This could be attributed to theorized benefits of tions. Although these factors could explain the

Table 5.  Individual Patient Data

Significant No. of Initial Hospital
No. of Resection Wound Operative Hospital Stay Readmission
Patient Group BMI Comorbidities Mass Breakdown Débridements (days) (days)
1 PC 55.6 1 9072 3
2 PC 57.4 3 6800 X 3 7 16
3 PC 50.1 3 6078 X 2 9 8
4 PC 67.7 1 35,000 X 5
5 PC 58.4 5 7500 X 19
6 PC 65.9 3 11,800 5
7 PC 59.4 4 16,500 X 3 4
8 PC 64 2 5020 X 1 7 14
9 PC 52.7 1 6720 5
10 OWM 59.3 2 6601 * 7
11 OWM 65 4 18,180 * 7
12 OWM 66 5 11,000 * 5
13 OWM 67.7 3 6045 * 7
14 OWM 74.2 4 9474 * 60
BMI, body mass index; PC, primary closure; OWM, open wound management.
*Patient treated with open wound management.

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Volume 133, Number 1 • Wound Management after Panniculectomy

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39