Increasing age impairs outcomes in breast reduction surgery.

BACKGROUND: Although multiple breast reduction outcomes studies have been performed, none has specifically identified the impact of advanced age. The authors aimed to study the impact of age on breast reduction outcome. METHODS: Medical records for all patients billed for Current Procedural Terminology code 19318 over the past 10 years (1999 to 2009) at a large academic institution were analyzed under an institutional review board-approved protocol. A total of 1192 consecutive patients underwent 2156 reduction mammaplasties performed by 17 plastic surgeons over a 10-year period. Breast reduction techniques included inferior pedicle/Wise pattern in 1250 patients (58.9 percent), medial pedicle/Wise pattern in 360 (16.9 percent), superior pedicle/nipple graft in 305 (14.4 percent), superior pedicle/vertical pattern in 206 (9.7 percent), and liposuction in three (0.14 percent). The average patient age was 36 years. Age groups were divided into younger than 40 years, 40 to 50 years, and older than 50 years. Multiple logistic regression analysis was performed to identify significant relationships. RESULTS: Women older than 50 years more likely experienced infection (odds ratio, 2.7; p = 0.003), with trends toward wound healing problems (odds ratio, 1.6; p = 0.09) and reoperative wound débridement (odds ratio, 5.1; p = 0.07). There was a trend toward infection in women aged 40 to 50 years (odds ratio, 1.7; p = 0.08). Advanced age did not exacerbate fat necrosis or seroma development. CONCLUSIONS: Age older than 50 years impairs breast reduction outcomes, particularly infection, and may negatively impact wound healing. Hormonal deficiency may partially account for this finding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Barbed suture impact on wound closure in body contouring surgery.

BACKGROUND: As artistry has been refined in body contouring surgery, streamlining wound closure is the next advance on the horizon. Absorbable barbed suture is one potential solution. The authors present their experience with this suture in wound closure for different body regions. METHODS: A review of operative and clinic notes of 496 patients who had body contouring procedures from March of 1998 to September of 2008 was performed. Variables studied included age, gender, body mass index, medical history, and operative data. Use of barbed suture was noted, and complications were tabulated. Multilevel analysis was performed using generalized estimate equation method. RESULTS: The records of 910 operations in 496 patients were analyzed. Procedures were performed on multiple body regions: abdomen (n=493), chest (n=124), back (n=104), thigh (n=104), and arm (n=88). Barbed suture was used in 114 cases. There were 115 wound-healing problems, with barbed suture present in 17 cases. On unadjusted analysis, the wound complication rate with barbed suture was 17.5 percent, compared with 12.0 percent when barbed suture was not used (p=0.093). On multilevel multivariable analysis, age (odds ratio, 1.04) and body mass index at contour (odds ratio, 1.05) were significant in impairing wound healing (p<0.01), and barbed suture was not associated with the wound complication rate. In subset analysis, barbed suture was associated with significantly higher wound complication rate in the arm (odds ratio, 8.4; p=0.046). CONCLUSIONS: Barbed suture presents problems with wound healing, particularly in the arm. The authors look forward to seeing the evolution in technologies designed to improve the speed and outcome of wound closure for lengthy body contouring procedures.

Biomechanical properties of skin in massive weight loss patients.

BACKGROUND: The aim of this study is to assess skin strength in MWL patients relative to control cosmetic abdominoplasty patients biophysically, biochemically, and histologically. Growing success of weight loss programs has brought about an increase in the MWL population. Skin quality is thought to be impaired by MWL, but there are no compelling studies that have fully addressed the structural mechanisms involved. METHODS: Skin from the medial and lateral abdomen was harvested fresh from patients undergoing cosmetic abdominoplasty (n = 6) or abdominal panniculectomy for MWL (n = 35), and burst strength was tested in the horizontal and vertical directions. Collagen content was measured, and histological studies were performed to assess epidermal and dermal thickness, vascularity as well as the morphology and density of the collagen fibers. RESULTS: In all groups, skin stretched horizontally was stronger than skin stretched vertically (p < 0.001). The skin of MWL patients was stronger medially compared to the skin of cosmetic patients. (p = 0.047) Newly formed collagen was diminished in MWL than that in the control group, but the results were not statistically significant. Epidermal thickness was significantly higher medially in MWL (p = 0.049). Elastin fibers were decreased in the MWL group, while dermal vascularity was higher in the MWL group. CONCLUSIONS: The skin of MWL patients demonstrated stronger mechanical parameters than that of cosmetic patients in the medial part of the abdomen; however, the decrease in elastic fibers associated with a decrease in newly formed collagen seemingly provides a contradiction. Skin changes with MWL merits further study to understand it more completely.

Do preexisting abdominal scars threaten wound healing in abdominoplasty?

PURPOSE: Abdominal scars may impair healing after abdominoplasty. We aimed to determine whether right subcostal or upper midline scars led to increased wound healing problems. METHODS AND MATERIALS: Review of all patients who had abdominoplasty from March 1998 to February 2008 was performed. Variables studied included age, gender, body mass index (BMI), medical history, and postoperative complications. Statistical analysis was performed in Stata SE, version 10. RESULTS: Of 420 abdominoplasty procedures, 62.2% had open gastric bypass surgery (GBS) and 19% had laparoscopic GBS. Seven percent (n = 29) of the series had a right subcostal scar. Overall risk of any complication was 32.9%, with 18.3% risk of wound healing problem (18.3%) and seroma (14.9%). chi(2)analysis revealed a significant relationship between any abdominal scar and any complication (P = .001), and wound healing problem specifically (P = .009). The subcostal scar was significantly associated with wound healing problems (P = .003). The upper midline scar was not associated with wound healing or seroma complication. While multivariate analysis erased any significant relationship between abdominal scars and complications, elevated BMI presented a significant threat to wound healing. With every unit increase in BMI, a 5% increase in the risk of any complication and a 6% increased risk in wound healing was calculated (P = .001). There was no difference in complications between the open and laparoscopic GBS groups, indicating that the upper midline incision did not pose a threat to wound healing. CONCLUSIONS: Elevated BMI poses a greater threat to healing than does abdominal scar. Caution is recommended in undermining when the right subcostal scar exists.

Does thighplasty for upper thigh laxity after massive weight loss require a vertical incision?

BACKGROUND: After massive weight loss (MWL), many patients present with concerns about skin excess and laxity. The thigh is one of the more complex regions to address in MWL patients because of the differing degree, location, and quality of skin excess and fatty tissue, as well as surgical risk factors. OBJECTIVE: The authors describe a technique called the anterior proximal extended (APEX) thighlift to effectively treat upper thigh skin excess with a hidden scar while also enhancing adjacent body regions. METHODS: A review was performed of 97 MWL patients who underwent thighlift surgery between March 1998 and October 2007. Eighty-six women and 11 men, with average weight loss of 146 lb and average body mass index (BMI) at contouring of 29.8, were included in the study. The risk factors that were assessed included age, gender, medical conditions, tobacco use, BMI, weight of skin excised, and surgery performed. The outcomes that were assessed included wound healing and lymphedema. Extended vertical thighlift was performed in 11 patients and anterior superior thighlift in 86 patients. RESULTS: Complications of thighlift included wound healing problems (n = 18; 18.6%); lymphedema (n = 8; 8.3%); cellulitis (n = 7; 7.2%); seroma (n = 3; 3.1%); and bleeding (n = 1; 1%). On multivariate statistical analysis, age and BMI were found to impair healing in the entire thighlift group. For patients with a BMI greater than or equal to 35, the odds ratio (OR) for a wound healing complication was 13.7 (P = .03). Hypothyroidism was strongly associated with lymphedema, with an OR of 23 (P = .06). Extended thighlift trended toward lymphedema (OR = 16.7; P = .08). CONCLUSIONS: Thighlift can be a satisfying procedure for both the patient and surgeon because it provides aesthetic improvement in terms of skin excess and laxity. The APEX thighlift is a new technique that expands upon those previously described in the literature to effectively treat upper thigh laxity with a hidden scar after MWL.

Financial analysis of factors impacting reimbursement for abdominoplasty.

BACKGROUND: With growth in numbers of abdominoplasty procedures performed, we studied our experience with reimbursement and factors that impacted reimbursement and indirectly access to care. METHODS: From July 2004 to June 2007, 245 patients had abdominoplasty. Demographic and financial variables were noted. Twenty different insurance plans were categorized as a single "commercial insurance" group in our analysis, and the other two study groups were "self-pay" and "Medicare" patients. RESULTS: Of the 245 patients studied, 87 paid for surgery ("self pay"), while 134 had commercial insurance, and 24 had Medicare. One hundred sixty patients (65%) had gastric bypass surgery (gbs). Medicare paid 28% less than insurance, and insurance paid 48% less than patients who prepaid. Of the 24 Medicare patients, 16 (67%) resulted in zero payment. On multiple logistic regression analysis, BMI, gbs history, and coincident hernia repair significantly impacted payment. BMI negatively impacted reimbursement, with every unit increase in BMI leading to a 0.77 percentage point reduction in reimbursement. Coincident hernia repair was associated with 17.5 percentage points reduction in reimbursement (p = 0.002). History of gbs improved reimbursement by a factor of 11 (p = 0.01). Neither age, gender, race, nor weight of tissue removed impacted reimbursement. CONCLUSIONS: Higher BMI and coincident hernia repair impaired reimbursement for abdominoplasty, while massive weight loss after gbs improved compensation. While having patients pay for their surgery guarantees the best reimbursement, strategies such as assuring authorization prior to surgery, which Medicare will not do, will secure better reimbursement.