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28 Panniculectomy: Tips and Tricks to Maximize Outcomes
301
Fig. 28.3 In the panniculectomy patient, an exaggerated
triangle of skin is made on the inferior fl ap to help reduce
the unavoidable tension on the wound closure which may
Patient Markings
Markings include a midline symmetry mark from
the sternal notch to the pubic symphysis. The
inferior incision is marked with excess skin
stretched upwards, as a line from one anterior
superior iliac crest to the other with an exaggerated skin dart at the midpoint, which is a triangle
with a height of 3 cm and a base of 10 cm
(Fig. 28.3 ). With the patient in the diver’s pose,
excess abdominal soft tissue is assessed and the
superior margin is marked, again spanning from
ASIS to ASIS and this marking is reassessed
intraoperatively with the operating table fl exed.
We have previously reported our results in
reducing wound healing complications by employing the use of an expanded skin triangle (i.e., “Skin
Dart”) upon closure of breast reduction sites in
massively obese patients [ 14 ]. We also believe that
similar benefi ts exist when employing the use of
this skin triangle to off-load tension at the time of
closure during panniculectomy. In the panniculectomy patient, an exaggerated triangle of skin is
made on the inferior fl ap to help reduce the unavoidable tension on the wound closure which may otherwise lead to increased ischemia of the skin and
result in skin and fat necrosis, or dehiscence.
Panniculectomy
The operation begins with intraoperative confi rmation of preoperative markings. Next, the operation proceeds with incising the superior mark of
otherwise lead to increased ischemia of the skin and result
in skin and fat necrosis, or dehiscence
the proposed elliptical excision being careful not
to undermine the superior skin fl ap. The inferior
mark of the elliptical excision is then incised and
dissection proceeds to the rectus fascia. Our preference is to leave the subscarpal inguinal fat
down as an attempt to maintain the inguinal lymphatics in that region and potentially reduce
dissection proceeds straight down to the level of
the rectus fascia ensuring that adequate fat
remains attached to the umbilicus to preserve
blood supply. Details of umbilical management
are discussed in a separate section below.
Although classic descriptions of panniculectomy include excision of adipocutaneous tissue
in a “wedge” fashion, with virtually no undermining, when combining panniculectomy with
abdominal wall reconstruction undermining has
advantages. Therefore, we encourage appropriate
skin-fl ap undermining to provide improved exposure to the hernia defect and aid in mesh placement. For instance, if placing the mesh posteriorly,
the use of undermining spares the need for transcutaneous stab incisions to secure the mesh in
place. Conversely, with anteriorly placed mesh,
undermining is a requirement in order to place
the mesh or to perform anterior component separation. If performing upper abdominal skin
undermining during panniculectomy, we strongly
emphasize limited lateral undermining. Extended
skin undermining in the lateral direction increases
the risk of dividing the Huger Zone III blood supply which is the sole blood supply to the entire
panniculectomy skin fl ap. This in turn can dra-
302
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K. Chopra and D. Singh
matically increase the risk of fl ap necrosis and
wound breakdown. This simple modifi cation aids
in reducing the likelihood of hypoperfusion to
the fl ap. This effect can be seen intraoperatively
with perfusion analysis techniques such as indocyanine green (ICG) laser angiography (LA)
which allows quantitative assessment of ischemic areas of the abdominal fl ap.
After the panniculectomy specimen is
resected, the fascial defect is closed based on the
appropriate technique selected for the size and
type of defect. If component separation is
a
selected, the panniculectomy is often advantageous and allows excellent exposure to release
the external oblique muscles.
Closure of the superior fl ap proceeds with
placement of progressive tension sutures (PTS)
which have two functions (1) obliterate deadspace like quilting sutures and (2) advance the
skin fl aps on the fascia resulting in a decreased
tension at the waistline closure. The PTS are
placed between the Scarpa’s fascia of the skin
fl ap and the fascia of the abdominal wall (see
Fig. 28.4 and Video 28.1). This is a technique
Scarpa’s fasica
Progressive tension
sutures
bc
Fig. 28.4 Closure of the superior fl ap proceeds with
placement of progressive tension sutures (PTS) which
have two functions (1) obliterate deadspace like quilting
sutures and (2) advance the skin fl aps on the fascia result-
ing in a decreased tension at the waistline closure. The
PTS are placed between the Scarpa’s fascia of the skin
fl ap and the fascia of the abdominal wall
28 Panniculectomy: Tips and Tricks to Maximize Outcomes
Fig. 28.5 The technique of umbilicoplasty is surgeon dependent, but we fi nd that the “upside down Pac-man” technique is simple to learn, and has an excellent postoperative appearance. The presence of a small skin triangular dart
inferiorly aids in reducing cicatricial scar contracture similar to a Z-plasty
303
that facilitates closure and assists in obliteration
of deadspace and reduction in seroma formation
[ 17 ]. At this point, the umbilicus is clinically
assessed for viability based on the presence or
absence of dermal bleeding, and with or without
the adjunctive use of ICG-laser angiography. In
our practice we have a low threshold to resect the
umbilicus, but when it is preserved our preferred
method for umbilicoplasty is the “upside down
Pac-man” (Fig. 28.5 ).
Our Preferred Method
of Umbilicoplasty
The technique of umbilicoplasty is surgeon
dependent, but we fi nd that the “upside down
Pac-man” technique is simple to learn, and has an
excellent postoperative appearance. The presence
of a small skin triangular dart inferiorly aids in
reducing cicatricial scar contracture similar to a
Z-plasty. The marking is demonstrated in the
associated video.
Closure of Abdominal Wound
Prior to closure of the wound, closed-suction
drains are placed through the lateral aspects of
the incision. Closed-suction drains are routinely
placed because of the risk seroma from the dissection in various anatomic planes. Our practice
is to maintain drains for at least a week and
remove them based on the amount of output (less
than 30 cc/day for 3 consecutive days). The
abdominal wound closure is a multilayered closure beginning with the Scarpa’s layer. This layer
provides strength to the closure, reduces tension,
reduces the likelihood of an acute postoperative
wound dehiscence, and improves scarring.
Techniques for Optimizing Results
Although it may appear counterintuitive that the
addition of a large transverse incision will
improve would healing, the removal of the hypovascular adipose tissue can paradoxically lead to
improved perfusion to the skin fl aps and consequently improve healing. Obese patients often
suffer from high rates of postoperative complications, such as seroma, surgical site infections,
skin and fat necrosis, dehiscence, and hernia
recurrence [
tions is challenging even for experienced surgeons and therefore achieving an optimal
outcome is technique dependent and can be
improved with the appropriate use of adjuncts
18 ]. Management of these complica-
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K. Chopra and D. Singh
such as PTS, closed-suction drains, and the
DART technique. Below, we will discuss two
additional adjuncts that are also effective at optimizing postoperative outcomes.
Indocyanine Green: Laser
Angiography
Prior to closure, areas concerning for decreased
perfusion are excised to maximize the chances of
achieving wound closure with well-vascularized
tissue. However the clinical criteria (color,
warmth, dermal bleeding, capillary blanching,
and refi ll) can be misleading or underestimate
the true extent of hypovascularity. In high-risk
patients, the authors elect to employ laserassisted near-infrared angiography with intravenous indocyanine green (ICG) dye (SPY
Intraoperative Imaging Systems; Novadaq
Technologies, Inc., Mississauga, Ontario,
Canada). ICG angiography provides real-time
intraoperative information about soft-tissue perfusion through the detection of plasma proteinbound ICG molecules that fl uoresce when
illuminated by a low-energy laser [ 19 ]. The cor-
relation between tissue perfusion and necrosis
has been demonstrated by several animal and
clinical studies [ 20 , 21 ]. Specifi c to hernia repair,
we have previously published on the ability ICG
angiography to reduce postoperative wound
complications after complex ventral hernia
repair using components separation [ 19 ].
Incisional Negative Pressure Wound
Therapy
Another important adjunctive technique to optimize outcomes is the use of closed incisionnegative pressure therapy (ci-NPT). The relatively
novel use of negative pressure wound therapy
(NPWT) over closed incisions to support primary
healing differs from the traditional use of NPWT
which commonly aids healing of open wounds by
secondary intention. The benefi ts of closed incision negative pressure therapy for high-risk incisions is well documented across multiple surgical
disciplines including cardiac surgery, colorectal
surgery, hernia surgery, orthopedics, and vascular
surgery [ 20 ]. These benefi ts include overall
decreased likelihood of surgical site infection and
wound dehiscence. The proposed mechanism is
likely related to increased blood fl ow [ 22 , 23 ],
reduction of edema [ 24 ], and a splinting effect of
the wound [ 25 , 26 ]. This splinting effect is likely
the most important since the negative pressure
reduces tension across high-risk incisions.
Clinical experience with ci-NPT has demonstrated that it can signifi cantly reduce the rate of
overall wound complications and skin dehiscence
after abdominal wall reconstruction [ 18 ]. In our
practice we employ ci-NPT on most of our
patients presenting with large complex abdominal hernia.
Postoperative Car e
Our standard abdominal binder protocol does not
involve the use of an abdominal binder until postoperative day (POD) #7 because the undermined
skin is at risk from ischemia and tension from
closure. When the ci-NPT dressing is removed
on POD#7 and the incision is intact, we apply a
loose fi tting abdominal binder. Over the next 2
weeks, as the closed-suction drains are removed,
we suggest progressively tightening the binder
especially once the last drain is removed. At this
point, the abdominal binder serves to prevent
seroma formation by applying external pressure
on the skin fl aps to the fascia. We understand that
traditionally an abdominal binder may assist with
pulmonary toilet, but in our experience we have
had excellent patient recovery despite the lack of
abdominal binder in the early postoperative
period.
Early postoperative care involves DVT prophylaxis by sequential compression stockings
and early ambulation at the minimum but can
also involve the use of chemoprophylaxis. It is
our usual practice to administer a dose of prophylactic antibiotics 30–60 min preoperatively and
ensure adequate redosing based upon the pharmacologic half-life of the antibiotic used. It is
discouraged to routinely continue antibiotics
28 Panniculectomy: Tips and Tricks to Maximize Outcomes
305
simply as prophylaxis for the duration that the
drains remain in place. Instead, we use
chlorhexidine- impregnated patches around the
drain site and believe this may offer adequate
prophylaxis against drain-related infection.
Managing Complications
Although careful and deliberate use of the various techniques above such as protection of lateral
(zone III) blood supply, obliteration of deadspace
with closed-suction drains, on-table evaluation of
skin-fl ap vascularity with ICG-LA, and application of incisional NPWT to splint the wound,
complications can still occur.
Wound Breakdown and Flap Necrosis
The medial aspect of the incision is most prone to
ischemia because it is often under the greatest
amount of tension at the time of closure and
because it is furthest away from the remaining,
laterally based zone III blood supply. Although
careful redistribution of tension during closure,
use of the expanded skin dart technique, PTS,
and incisional NPWT can reduce the likelihood
of fl ap necrosis it is still possible and requires
adequate management. Skin breakdown may initially be managed with wet-to-dry gauze dressings or NPWT. Early intervention with these
moist dressings is especially important if there is
exposed biologic matrix at the base of the wound
since desiccation should be avoided. Other cases
of wound breakdown may require operative
debridement of devitalized wound margins, and
reclosure. If cellulitis or frank purulent infection
has developed, then patients should be admitted
to the hospital for management, including possible initiation of appropriate intravenous antibiotics. For full-thickness fl ap necrosis where
biologic mesh is threatened, the authors encourage early operative debridement to healthy
wound edges as dictated clinically, or with the
use of indocyanine green laser angiography. This
also may require mesh removal and placement of
open NPWT.
Seroma
Seroma may be managed with sterile and serial
aspiration or percutaneous drain placement. If
these approaches are unsuccessful then reoperation may be required to excise the pseudobursa
that may have formed. In cases where reoperation is performed, one may elect to employ the
use of quilting sutures or fi brin sealants.
Conclusion
Concomitant panniculectomy can safely be performed during the hernia operation, can optimize
surgical exposure during the hernia repair, and
improve postoperative wound healing. Successful
repair and good outcomes are highly techniquesensitive and require appropriate patient selection, optimization of medical status and nutrition.
Adjunctive techniques presented in this chapter
may assist surgeons in optimizing their patient
outcomes.
References
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CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–
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8. Saxe A, Schwartz S, Gallardo L, Yassa E, Alghanem
A. Simultaneous panniculectomy and ventral hernia
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repair following weight reduction after gastric bypass
surgery: is it safe? Obes Surg. 2008;18(2):192–5; discussion 196.
9. Finan KR, Vick CC, Kiefe CI, Neumayer L, Hawn MT.
Predictors of wound infection in ventral hernia repair.
Am J Surg. 2005;190(5):676–81.
10. Krupski WC. The peripheral vascular consequences
of smoking. Ann Vasc Surg. 1991;5(3):291–304.
11. Moore KL, Dalley AF, Agur AM. Clinically oriented
anatomy. Philadelphia: Lippincott Williams &
Wilkins; 2013.
12. Huger Jr WE. The anatomic rationale for abdominal
lipectomy. Am Surg. 1979;45(9):612–7.
13. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical
applications. Br J Plast Surg. 1987;40(2):113–41.
14. Chopra K, Tadisina KK, Conde-Green A, Singh DP.
The expanded inframammary fold triangle: improved
results in large volume breast reductions. Indian
J Plast Surg. 2014;47(1):65–9.
15. Le Louarn C, Pascal JF. High superior tension
abdominoplasty. Aesthetic Plast Surg. 2000;24(5):
375–81.
16. Le Louarn C, Pascal J. High superior tension abdominoplasty—a safer technique. Aesthet Surg J. 2007;
27(1):80–9.
17. Pollock H, Pollock T. Progressive tension sutures: a
technique to reduce local complications in abdominoplasty. Plast Reconstr Surg. 2000;105(7):2583–6.
18. Conde-Green A, Chung TL, Holton 3rd LH, et al.
Incisional negative-pressure wound therapy versus
conventional dressings following abdominal wall
reconstruction: a comparative study. Ann Plast Surg.
2013;71(4):394–7.
19. Wang H, Singh D. The use of indocyanine green
angiography to prevent wound complications in ventral hernia repair with open components separation
technique. Hernia. 2013;17(3):397–402.
20. Gurtner GC, Jones GE, Neligan PC, et al.
Intraoperative laser angiography using the SPY system: Review of the literature and recommendations
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21. Holm C, Mayr M, Höfter E, Becker A, Pfeiffer U,
Mühlbauer W. Intraoperative evaluation of skin-fl ap
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22. Erba P, Ogawa R, Ackermann M, et al. Angiogenesis
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23. Atkins BZ, Tetterton JK, Petersen RP, Hurley K,
Wolfe WG. Laser doppler fl owmetry assessment of
peristernal perfusion after cardiac surgery: benefi cial
effect of negative pressure therapy. Int Wound
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Stannard J, Martin R. Negative pressure wound therapy for management of the surgical incision in orthopaedic surgery: a review of evidence and mechanisms
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2009;123(2):589–98; discussion 599–600.
Tissue Expansion During
Abdominal Wall Reconstruction
Lauren Chmielewski , Michelle Lee ,
and Hooman Soltanian
Background
Abdominal wall defects are some of the most
commonly encountered reconstructive challenges.
Goals of abdominal wall reconstruction include
providing stable soft-tissue coverage, restoring
fascial integrity, preventing hernia, protecting
abdominal viscera, and restoring function [ 1 ].
The fascia and the soft-tissue envelope of the
abdominal wall should be considered as two
separate units. Each unit should be reconstructed
using the “like with like” principle of reconstructive surgery. In general, dead space should be
eliminated, skin undermining should be minimized,
and the reconstructive choice should reduce
potential for bowel adhesions, fi stulization, and
perforation [
whether the defect in the abdominal wall is due to
skin, subcutaneous tissue, or musculofascial
insuffi ciency. Musculofascial defect s are often
L. Chmielewski , M.D.
Plastic Surgery , University Hospitals Case Medical
Center , Cleveland , OH , USA
M. Lee , M.D.
Plastic and Reconstructive Surgery , Beth Israel
Deaconess Medical Center, Harvard Medical School ,
Boston , MA , USA
H. Soltanian , M.D., F.A.C.S. (
Department of Plastic Surgery , Case Medical Center ,
Cleveland , OH , USA
e-mail:
1 ]. It is important to distinguish
*)
Hooman.Soltanian@UHHospitals.org
2 9
repaired by reconstruction techniques such as
component separation and mesh repair [
cases of abdominal skin/subcutaneous tissue
defi ciency, primary closure of the skin fl aps
under tension will result in tissue ischemia,
wound dehiscence, and possible exposure/
contamination of biomaterials used to reconstruct
the musculofascial defects. Defi ciency in the
skin/subcutaneous tissue can be repaired by a
variety of methods: (1) primary closure, if there
is minimal tension between the wound edges, (2)
rearrangement of existing tissue such as skin
grafts, local fl aps, regional fl aps, and free fl aps
and (3) expanding the existing tissue with tissue
expansion.
One of the earliest reports of the use of
abdominal wall tissue expansion was described
by Byrd et al. in 1989 for congenital defects of
the lower abdominal wall [ 3 ]. For skin and
subcutaneous tissue deficits, tissue expansion
remains a powerful tool to increase the amount
of abdominal skin/subcutaneous tissue with
subsequent skin flaps closure without tension.
It involves insertion of a silicone balloon
under the skin and subcutaneous tissue. The
balloon is serially inflated by gradual injection of sterile saline via a remote or integrated
port to inflate the skin and subcutaneous
tissues over the expander. This can provide
well- vascularized, autologous skin, subcutaneous tissue, and abdominal fascia for the
repair of large defects [ 1 ].
2 ]. In
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_29
307© Springer International Publishing Switzerland 2016
308
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L. Chmielewski et al.
Physiology of Expansion
The physiology of tissue expansion is based on
the dynamic response of tissues to mechanical
stresses placed on them [ 4 ]. The intrinsic visco-
elastic properties of skin on which the principle
of tissue expansion is based are stress relaxation
and creep. Stress relaxation is defi ned as the
decrease in the amount of force necessary to
maintain a fi xed amount of skin stretch over time.
Creep is the gain in skin surface area that results
when a constant load is applied [ 5 ]. The physio-
logic basis for these properties lies in the fact that
as force is applied to a leading skin edge, tissue
thickness decreases because of extrusion of fl uid
and mucopolysaccharides, dermal collagen bundles realign, elastic fi bers undergo microfragmentation, and skin stretches mechanically [ 5 ].
Tissue expansion can be achieved by the
placement of internal or external expanders.
Internal expanders are prosthetic devices placed
in the subcutaneous plane that enlarge by volume
expansion. This technique is generally performed
over 3–6 months with infl ation performed at
weekly intervals [ 6 ]. Expansion should be
continued until the expanded fl ap is approximately 20% larger than the size of the defect in
order to account for tissue recoil after removal of
the expander [ 5 ]. External tissue expansion
involves placing continuous tension at the wound
edge. The skin and the subcutaneous planes are
expanded until the wound edges are close enough
for primary closure. External expansion should
also undergo a period of consolidation to account
for tissue recoil.
Expanded tissues demonstrate predictable
changes. An increase in epidermal thickness is
noted during expansion, which tends to return to
initial levels within 4–6 weeks, although some
thickness persists for many months. Melanocyte
activity is also increased during expansion, but
returns to normal within several months after
completion of reconstruction. Thinning of the
dermis occurs within the fi rst several weeks of
expansion and persists throughout the expansion
process. This dermal thinning persists for at least
9 months after completion of expansion [ 4 ].
Signifi cant muscle atrophy occurs during the
expansion process, regardless of whether the
expander is placed above or below a specifi c
muscle. Expanded tissue demonstrates increased
vascularity with a signifi cant number of new
vessels formed adjacent to the expander capsule.
It is thought that the observed angiogenesis
occurs secondary to the ischemia produced during the expansion process [ 4 ] [Table 29.1 ].
Tissue expansion can contribute to a variety of
treatment options: full thickness skin grafts, local
fl aps adjacent to the lesion, or expansion of a free
fl ap. Advantages of tissue expansion include the
ability to create and recruit tissue having similar
esthetics of color, texture, thickness, and hair
production [ 6 ]. Expansion can be associated with
the risks of infection, fl ap ischemia, extrusion,
implant failure, patient intolerance/pain, and scar
widening. Each of these complications may
necessitate prosthesis removal [ 6 ]. A representa-
tive defect that best suits repair by insertion of a
tissue expander is one that is well-defi ned, healed,
and stable. Areas that have undergone irradiation,
burns, previous excision and skin grafting, scar
contracture, or areas with open or chronically
draining wounds are not appropriate for tissue
expansion.
Technical points critical for successful expansion include:
1. Adequate preoperative planning to permit
ideal incision to facilitate suffi cient safe tissue
expansion
2. Proper choice of size and shape of the expander
3. Correct positioning of the expander
Incisions are incorporated into tissue that will
become one margin of the fl ap. They should be
Table 29.1 Effects of tissue expansion
Tissue expansion
Epidermal
thickening
Increased
vascularity
Increased
melanocytic activity
Thinning of
dermis
Muscle atrophy
29 Tissue Expansion During Abdominal Wall Reconstruction
Fig. 29.1 Various shapes and
sizes of the implants are
available with both external
and internal fi ll ports.
Accuspan
Expanders (PMT Corporation:
http://www.pmtcorp.com/
tissue_expanders.html
accessed 12/2014)
®
& Integra ® Tissue
,
planned to minimize tension on the suture line
and thus decrease the risk of extrusion. Tension
from infl ation will be less when incisions are
perpendicular to the suture line, rather than parallel
[ 7 ]. Expanders are available in a variety of shapes
and sizes (rectangular, circular, or elliptical) and
can even be custom fabricated to any dimension
(Fig. 29.1 ). They include remote or integrated
ports. Integrated ports are composed of selfsealing silicone rubber backed by stainless steel
and can be located through the skin by magnetic
sensing devices. Ideally, the length of the expander
should match the length of the wound and the
height of the expander should match the width.
Specifi c fi ll volume is not vital because expanders
are designed to tolerate overfi lling. Placement of
the expander is usually situated adjacent to the
long access of the defect. They are usually placed
beneath the skin and subcutaneous tissue above
the fascia (Fig. 29.2 ). However, when the subcuta-
neous tissue is thin or the risk of extrusion is high,
expanders may be placed below the muscle
29.3 ). They should be placed away from sen-
(Fig.
sitive areas, bony prominences, and areas subjected to pressure to minimize patient discomfort.
In certain cases, the use of multiple small expanders is better than the use of one large expander.
Multiple expanders infl ate and expand the tissue
more rapidly and complications are fewer [ 7 ].
309
Indications for Using TE
for Abdominal Wall Reconstruction
Tissue expansion should be considered in abdominal wall reconstruction when there is a defi ciency in abdominal skin and subcutaneous t issue
and a clean wound. An inability to primarily
close the abdominal wall skin and subcutaneous
tissue can be due to a wide range of etiologies,
such as large skin resection, serial debridements
for infections (such as necrotizing fasciitis),
congenital absence of abdominal wall (such as
omphalocele), massive distention of the bowels
and/or retroperitoneal structures secondary to
resuscitation, or may be a result of fl orid sepsis or
active infection [ 8 ]. In order to replace the missing
abdominal wall skin and subcutaneous tissue, the
surgeon needs to either rearrange surrounding
skin and subcutaneous tissue with local, regional,
and free fl aps or increase the area of the remaining abdominal wall skin and subcutaneous tissue
with tissue expansion.
Tissue expanders are most commonly placed
above the abdominal wall fascia and serially
infl ated to increase the amount of abdominal skin
available for primary closure. Tissue expanders
can also be placed between the internal and external oblique and used to expand the abdominal
310
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Fig. 29.2 Top panel :
Placement of the tissue
expander in the
subcutaneous layer about
the fascia and muscle layers.
Lower panel : Infl ated
subcutaneous expander.
Both the superfi cial skin and
fat and the deep muscular
layers are affected
L. Chmielewski et al.
Injection port
Fill tube
Expander
Skin
Muscle tissue
Deflated expander placed subcutaneously
Fig. 29.3 Submuscular
placement of the tissue
expander deep to the external
oblique layer and superfi cial to
the internal oblique layer
Inflated expander demonstrating expanded skin
Expanded
skin
Saline-inflated
expander
Muscle tissue
Rectus
abdominis
Hernia
Expander
External
oblique
Internal
oblique
Transversus
abdominis
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