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.

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.

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.