Wound Infections in Body Contouring Mastopexy with Breast Reduction After Laparoscopic Adjustable Gastric Bandings: The Role of Smoking

Background We retrospectively reviewed charts of 42 postbariatric patients who underwent mastopexy and breast reduction for body contouring to determine whether a significant relationship existed between cigarette smoking and postoperative wound infections and to determine the relative risk given by cigarettes and a cut-off value to predict infections. Methods We excluded patients with ongoing clinical infections, recent bariatric surgery (within 1 year), recent antibiotic courses, or systemic diseases such as arteriosclerosis and diabetes mellitus. Results All patients underwent bariatric surgery with the laparoscopic adjustable gastric bending technique and mastopexy with breast reduction for body contouring. Postoperative infections were present in 35.7% (n = 15) of patients, and 60% of these (n = 9) were superficial. Furthermore, 66.7% of them occurred in smoker patients, and 41.7% of smokers vs. 27.8% of nonsmokers developed infections. Significant differences between infected vs. infection-free patients were present for the number of pack years (p < 0.001) and the overall estimated cigarettes smoked (p < 0.001). A cut-off value of approximately 6.85 pack years (50,000 overall estimated cigarettes) distinguished between infections vs. infections-free patients, with 25% of false positives and 8% of false negatives. Relative risk conferred by smoking was 3.8. Conclusions The incidence of infections in our series of postbariatric patients undergoing mastopexy and breast reduction is 35.7%. A cut-off of 6.85 pack years (50,000 estimated overall cigarettes) was determined and, according to this value, the relative risk conferred by smoking was 3.8.     

Pseudomonas aeruginosa Necrotizing Infection of the Abdominal Flap in a Post-Bariatric Patient Undergoing Body Contouring Surgery

Pseudomonas aeruginosa infections may involve any organ or body district and may give serious clinical sequelae. We report the case of an infection of the abdominoplasty flap that compromised wound closure and jeopardized the aesthetic outcome. To the best of our knowledge, this is the first such case reported in the literature for this group of patients. We have presented this case in order to alert plastic and general surgeons who may encounter this complication in future, such that they may be aware of the need to adopt an aggressive approach to manage these patients. This consisted of the accurate monitoring of the patient’s clinical condition, prescribing appropriate antibiotics, and performing serial debridement of necrotic tissue.     

Abdominoplasty after Weight Loss in Morbidly Obese Patients: A 4-Year Clinical Experience

Background Morbid obesity is associated with various co-morbidities. With the significant weight loss, new dysfunctions arise, and prior body contour disorders start to severely affect the patient’s quality of life. The abdominal apron is generally the greater and the first disturbance faced by the post-bariatric patient. Methods The authors retrospectively reviewed their clinical experience in the treatment of those disorders through abdominoplasty. The benefits in terms of relief of said disorders and drawbacks in terms of surgical complications are described. Results 117 abdominoplasties were performed from January 2002 to December 2005 on patients who had lost significant weight.The tissue removed ranged from 400 g to 10,500 g of adipose-cutaneous tissue (mean 2,276.5 g). Mean duration of the procedure was 4 hours and 25 minutes, with a maximum of 7 and a minimum of 2 and 40. Complication rate was 50.43%. Conclusion Abdominoplasty in the post-obese patient is an apparently simple procedure, which in fact causes a high rate of surgical complications. The complication rate is higher than that of cosmetic abdominoplasties. Nevertheless, the improvement in quality of life following such a procedure renders it a fundamental step in the rehabilitation of the formerly obese patient.     

Attitudes of Morbidly Obese Patients to Weight Loss and Body Image following Bariatric Surgery and Body Contouring

Background The authors evaluated body image attitudes in post-obese persons following bariatric surgery who require cosmetic and body contouring operations. Methods We studied 20 morbidly obese women prior to biliopancreatic diversion (BPD) (OB group), 20 post-obese women at >2 years following BPD (POST group), 10 post-obese women following BPD who required cosmetic procedures (POST-A group), 10 post-obese women after BPD and subsequent cosmetic surgery (POST-B group), and 20 healthy lean controls. Attitudes to weight and shape were evaluated by means of the Body Uneasiness Test (BUT). Results In comparison with the obese patients in the POST group, lower BUT scores were observed, while in the POST-A group the values were very similar to those observed in the non-operated obese individuals. In the individuals having received cosmetic surgery, the BUT findings were similar to those recorded in the POST group patients, the values approaching data found in the controls. Conclusion Despite a fully satisfactory weight loss and maintenance, the post-BPD individuals requiring aesthetic surgery showed some disparagement of body image; in these subjects, cosmetic and body contouring procedures may actually improve body weight and shape attitudes towards normality.     

Postoperative Wound Infections After Breast Reductions: The Role of Smoking and the Amount of Tissue Removed

Background This prospective study followed patients who underwent breast reductions to determine the influence of smoking and the amount of tissue removed on postoperative wound infections. Methods Patients who had received breast reductions were considered eligible for the study. The study excluded postbariatric patients and those with ongoing clinical infections, a recent antibiotic course, or systemic diseases that could impair tissue oxygenation. Smokers were instructed to quit smoking at least 4 weeks before surgery. Results By March 2004, the study had enrolled 87 patients. Postoperative infections were present in 24 cases (27.9%). Infections included 16 in smokers (37.2%), 8 in nonsmokers (18.2%; p < 0.05), 14 in patients with large resections (>0.85 kg; 70%), and 10 in patients with small resections (14.9%; p < 0.001). Significant differences were found between the patients who experienced infections and those who were infection free in terms of the overall estimated cigarettes smoked (mean, 146,000; range, 29,200–228,125 vs mean, 10,950; range, 9,125–54,750; p < 0.001), the number of pack years (mean, 20; range, 4–31 vs mean, 2; range, 1–8; p < 0.001), and the amount of tissue removed (mean, 0.9 kg; range, 0.5–2 kg vs mean, 0.5 kg; range, 0.2–1.4 kg; p < 0.001). The analysis for all the patients determined an odds ratio of 2.04 for smoking and 4.7 for the amount of tissue removed. Conclusions Smoking and the amount of tissue removed are important issues in aesthetic breast surgery that need to be addressed accurately by the plastic surgeon. If future larger studies confirm these data, surgeons could have a simple and easy method for stratifying patients according to their risk for the development of wound infections and for prescribing specific preventive measures.     

Gender Incongruence: Gender Affirming Body Contouring and Physical Transformation in Transgender Individuals

There is a subset of transgender individuals, who after having undergone gender affirming surgeries want body contouring so that the overall body shape is congruent to the body image. Hormonal therapy can bring about a considerable change in the physical transformation. However, there is an increase in requests for specific body contouring procedures because of increased awareness in the society.There are significant differences between the skeletal as well as soft tissue characteristics of male and female body. Body contouring in transgender individuals can be achieved by altering the skeletal structure or the overlying soft tissues or combining both. In this article, we discuss body contouring as an adjunct to gender affirming surgeries, in both male to female and female to male transgender individuals.     

Quality of Life After Abdominoplasty in Women After Bariatric Surgery

Background Abdominal skin overhang is not unusual after massive weight loss induced by antiobesity interventions, and poor quality of life should be feared in such circumstances, especially in women. However, long-term results of quality of life have not been often documented in this setting. With the purpose of addressing this question, a prospective study was designed. Methods Patients (n = 16, 100% females, age 40.1 ± 8.0 years) submitted to standard or combined circumferential abdominoplasty were recruited for this study. All had undergone open Roux-en-Y gastric bypass between 24 and 48 months earlier with stable weight in the last 12 months. Quality of life was assessed by a trained psychologist employing of a semistructured interview, the Adaptative Operationalized Diagnostic Scale (AODS), covering affectivity/personal relations, productivity, social/cultural performance, and organic/somatic health. Results Circumferential abdominoplasty was followed by few problems (serous fluid collections in 18.8%, anemia because of blood loss in 6.3%). The best overall response to the AODS questionnaire corresponded to the social and cultural domain where 81.3% of the patients had excellent adaptation (level 1). For the other three domains, results were remarkably similar with 62.5% of the tests displaying the highest value of adaptation and rare total failures. Conclusions (1) The current operation corresponded to the expectations of the patients with few complications and favorable body contouring result. (2) Quality of life, quantified by means of adaptation and social adjustment scores, was adequate in most circumstances. (3) Outstanding responses for social/cultural performance were registered with encouraging findings for affectivity/personal relations, productivity, and organic/somatic health as well.     

Plastic and Reconstructive Body Contouring in the Post-vertical Banded Gastroplasty Patient: a retrospective review

Class IV obesity (body mass index > 40) is associated with an increased risk of a variety of health problems, many of them potentially life-threatening or life-shortening. Vertical banded gastroplasty (VBG) is currently the most frequently performed surgical procedure used to restrict food intake and assist with weight loss. After massive weight loss, however, redundant abdominal and breast tissue can result in physiological and psychological problems related to an unusual body habitus. Patients complain of difficulties with daily activities, choice of clothing, social acceptance, etc. Body contouring has proven to be an important part of the rehabilitation of the morbidly obese patient, and we have therefore reviewed the records of 55 patients who experienced massive weight loss following VBG and then underwent abdominoplasty with or without mammoplasty/mastopexy, in order to assess the parameters which will be seen more frequently in the future by plastic surgeons as bariatric surgery becomes more widely accepted and performed.     

Panniculectomy at the time of bariatric surgery: a propensity score-matched analysis of outcomes in the MBSAQIP database

BackgroundBody contouring in the postbariatric surgery patient improves quality of life and daily function.ObjectivesTo determine the risk profile of panniculectomy when performed in select patients at the time of bariatric surgery.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating centers.MethodsWe examined the MBSAQIP database (2016-2017), in which data on 379,544 bariatric surgeries are reported. Concurrent panniculectomy procedures were identified by Current Procedural Technology (CPT) codes. Patient characteristics and in-hospital as well as 30-day complications were compared between the body contouring group and propensity score-matched bariatric surgery controls.ResultsOne hundred twenty-four patients met inclusion criteria and were matched to 248 controls. An infra-umbilical panniculectomy was performed in the majority of patients (n = 94, 75.8%). Most patients received an open rather than laparoscopic bariatric surgery (n = 87, 70.2%). There were no statistically significant differences between 30-day mortality (1.9%), wound complications (11.5%), readmission (12.5%) and reoperation (5.8%) between the 2 groups (P > .05). Wound complications occurred in 11.5% of patients and were associated with prolonged hospital stay (odds ratio 4.65, 95% confidence interval 1.99–10.86, P < .001) and a body mass index (BMI) > 50 (odds ratio 3.19, 95% confidence interval 1.02–9.96, P = .046).ConclusionIn select patients, panniculectomy at the time of bariatric surgery was not associated with increased in-hospital or 30-day adverse outcomes compared with matched bariatric surgery controls. This procedure may be performed in select patients, with awareness that revision surgery may be needed once weight loss stabilizes.     

Analysis of the Incidence and Risk Factors for Wound Infections in Open Bariatric Surgery

Background: Our clinical impression derived from >95% follow-up of patients was that our wound infection rate was higher than the 1-10% reported in the literature. The purpose of this study was to determine the incidence and risk factors for wound infection in open bariatric surgery. Methods: We queried our prospectively acquired bariatric surgery outcomes database, and retrospectively audited the charts of patients operated from April 1 to March 31, 2003. Risk categories were obtained using the National Nosocomial Infection Surveillance (NNIS) definitions and stratification. Expected site-specific rates were adjusted for duration of operation, degree of wound contamination, and underlying disease condition. Results: 269 patients undergoing a standardized open Roux-en-Y gastric bypass were studied. The mean age (SD) was 39.5 (10.5) years and the mean BMI was 54.3 (9.9). Operating time averaged 63 (17) minutes, and length of stay was 4.1 (1.3) days. Based on NNIS categories 10.9 wound infections were expected, but 54 were observed, for a rate of 20%. Bacterial isolates included S. aureus (39%), α-hemolytic strep (26%), Enterococcus (16%), P.mirabilis (9%), and multiple other bacteria at 10%. Epidural analgesia and delayed antibiotic prophylaxis administration (after the incision was made) increased the odds of developing a wound infection, whereas gender, age, BMI, duration of surgery, and incidence of diabetes had no effect.There was a high correlation between wound infection and subsequent incisional hernia formation. Conclusion: The incidence of wound infections following open bariatric surgery is high, and the current recommendations for antibiotic prophylaxis are ineffective. As these infections carry significant morbidity, effective methods to prevent them are needed.     

The Association of Preoperative Smoking With Postoperative Outcomes in Patients Undergoing Total Hip Arthroplasty

BackgroundPreoperative smoking is an easily modifiable risk factor and has associations with increased postoperative morbidity and mortality. It is important to clarify these risks for specific procedures to provide improved and evidence-based quality of care. The purpose of the present study aims to identify the associations between preoperative smoking and 30-day postoperative outcomes in patients undergoing total hip arthroplasty.MethodsWe used R statistics to conduct a multivariable logistic regression analysis followed by a propensity score matching analysis to explore the association between preoperative smoking and postoperative outcomes.ResultsA final cohort of 67,897 patients who underwent total hip arthroplasty was selected for analysis. After adjusting for potential confounders, the odds of postoperative pulmonary complications (odds ratio [OR], 1.352; 95% confidence interval [95% CI], 1.075-1.700; P = .01), infectious complications (OR, 1.310; 95% CI, 1.094-1.567; P = .003), and extended hospital stay (OR, 1.17; 95% CI, 1.099-1.251; P < .001) were all significantly higher in the smoking population. After propensity matching these cohorts, both infectious complications (P = .017) and extended hospital stays (P = .001) were significantly higher in smoking patients.ConclusionsAfter controlling for potential confounding variables, our multivariable regression analysis revealed a significant increase in pulmonary and infectious complications as well as significantly longer hospital stays in our smoking population. When using a propensity score matching analysis, an increase in infectious complications as well as extended hospital stay was observed. Given the concerning prevalence of smoking in the United States, our data provide updated information toward a growing mass of literature supporting smoking cessation before surgical operations.     

Role of patient-centred outcomes after hospital discharge: a state-of-the-art review

The traditional approach for measuring outcomes after surgery involves ascertaining whether a patient survived surgery while avoiding major complications. This approach does not capture the full spectrum of events that are meaningful to patients, especially because mortality risks after elective surgery are relatively low, and different complication types vary considerably with respect to their impact on postoperative recovery. This review discusses the application, advantages, disadvantages and select examples of patient-centred outcomes in peri-operative medicine. When applied appropriately, these outcomes complement traditional clinical outcomes, identify important changes in postoperative function that impact patients without discernible complications and ensure that the definition of success after surgery is more meaningful to all relevant stakeholders.     

Smoking increases the risk of postoperative wound complications: A propensity score-matched cohort study

Cigarette smoking is associated with surgical complications, including wound healing and surgical site infection. However, the association between smoking status and postoperative wound complications is not completely understood. Our objective was to investigate the effect of smoking on postoperative wound complications for major surgeries. Data were collected from the 2013 to 2018 participant use files of the American College of Surgeons National Surgical Quality Improvement Program database. A propensity score matching procedure was used to create the balanced smoker and nonsmoker groups. Multivariable logistic regression was used to calculate the odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative wound complications, pulmonary complications, and in-hospital mortality associated with smokers. A total of 1 156 002 patients (578 001 smokers and 578 001 nonsmokers) were included in the propensity score matching analysis. Smoking was associated with a significantly increased risk of postoperative wound disruption (OR 1.65, 95% CI 1.56-1.75), surgical site infection (OR 1.31, 95% CI 1.28-1.34), reintubation (OR 1.47, 95% CI 1.40-1.54), and in-hospital mortality (OR 1.13, 95% CI 1.07-1.19) compared with nonsmoking. The length of hospital stay was significantly increased in smokers compared with nonsmokers. Our analysis indicates that smoking is associated with an increased risk of surgical site infection, wound disruption, and postoperative pulmonary complications. The results may drive the clinicians to encourage patients to quit smoking before surgery.     

Comparative analysis on the effect of low‐thermal plasma dissection device (PEAK PlasmaBlade) vs conventional electrosurgery in post‐bariatric abdominoplasty: A retrospective randomised clinical study

Post‐bariatric patients undergoing abdominoplasty have a relatively high risk of complications due to residual obesity and major comorbidities. Also, conventional electrosurgery and the associated thermal tissue damage may compromise outcomes. This retrospective randomised clinical study evaluated the effect of low‐thermal plasma dissection device (PEAK [pulsed electron avalanche knife] PlasmaBlade) in comparison with conventional electrosurgery. A total of 52 post‐bariatric patients undergoing abdominoplasty were randomised to PEAK PlasmaBlade (n = 26) and to monopolar electrosurgery (n = 26). Wounds of 20 patients per group were examined histologically for acute thermal injury depth. In PEAK PlasmaBlade incisions, acute thermal damage was significantly reduced compared with standard of care (40% vs 75%; P = .035). Also, acute thermal injury depth from PEAK PlasmaBlade was less than that from electrosurgery (2780 μm vs 4090 μm). Significantly less total complication rate (30.8% vs 69.2%; P = .012) was found by PEAK PlasmaBlade compared with electrosurgery. Moreover, the PEAK PlasmaBlade showed less than half as many wound healing problems (19.2% vs 46.2%; P = .075), far fewer secondary bleeding (7.7% vs 30.8%; P = .075), and no seroma compared with four seroma with the standard of care (0% vs 15.4%; P = .11). PEAK PlasmaBlade appears to be superior to traditional monopolar electrosurgery for post‐bariatric abdominoplasty, because it demonstrated significantly less tissue damage, less total complication rate, and fewer postoperative seroma resulting in faster wound healing.     

Smoking increases the risk of postoperative wound complications: A propensity score‐matched cohort study

Cigarette smoking is associated with surgical complications, including wound healing and surgical site infection. However, the association between smoking status and postoperative wound complications is not completely understood. Our objective was to investigate the effect of smoking on postoperative wound complications for major surgeries. Data were collected from the 2013 to 2018 participant use files of the American College of Surgeons National Surgical Quality Improvement Program database. A propensity score matching procedure was used to create the balanced smoker and nonsmoker groups. Multivariable logistic regression was used to calculate the odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative wound complications, pulmonary complications, and in‐hospital mortality associated with smokers. A total of 1 156 002 patients (578 001 smokers and 578 001 nonsmokers) were included in the propensity score matching analysis. Smoking was associated with a significantly increased risk of postoperative wound disruption (OR 1.65, 95% CI 1.56‐1.75), surgical site infection (OR 1.31, 95% CI 1.28‐1.34), reintubation (OR 1.47, 95% CI 1.40‐1.54), and in‐hospital mortality (OR 1.13, 95% CI 1.07‐1.19) compared with nonsmoking. The length of hospital stay was significantly increased in smokers compared with nonsmokers. Our analysis indicates that smoking is associated with an increased risk of surgical site infection, wound disruption, and postoperative pulmonary complications. The results may drive the clinicians to encourage patients to quit smoking before surgery.     

Wound Complications Following Vertical Banded Gastroplasty: report of experience and review of the literature

This prospective study was undertaken to evaluate wound management and outcome in 76 morbidly obese patients undergoing vertical banded gastroplasty through a detailed protocol to determine the nature and incidence of wound complications and to evaluate these results relative to the surgical literature. Early wound complications can be infrequent. Late wound failures often occur in patients not experiencing early wound complications. Mechanical factors, such as size-related tension across the incision, undoubtedly play a major role in late wound failure. A long suture length to wound length ratio mitigates mechanical factors involved in late wound failure. With attention to technical factors and detail, wound complications can be minimized, though not eliminated.     

Devastating Methicillin Resistant <Emphasis Type="Italic">Staphylococcus Aureus</Emphasis> Wound Infection following Abdominoplasty in a Prior Bariatric Surgery Patient

A 46-year-old female smoker presented 12 months after laparoscopic adjustable gastric banding, with massive weight loss and skin excess of the abdomen and flanks. She underwent abdominoplasty with muscle plication and flanks liposuction, but on the 14th postoperative day this was complicated by a methicillin-resistant Staph. aureus wound infection. Multiple surgical debridements and high doses of intravenous antibiotics were necessary for cure and to avoid further septic complications. Complete wound closure was achieved after 3 months of therapy. Concomitant risk factors for wound infection (obesity, smoking, flap construction) contributed to a rare but potentially fatal wound complication following abdominoplasty.We alert the surgeon to such postoperative infections and the necessity for a non-conservative approach.