PANNICULECTOMY
Panniculectomy is a surgical procedure in which a large, redundant apron of subcutaneous fat and abdominal skin (the panniculus) is removed from the lower abdomen. This redundant apron of skin and fat is caused by a lack of underlying supportive tissue that does not respond to weight loss or exercise, and can occur in people of normal weight and in morbidly obese individuals. Skin chafing may be present under the apron, which may create an environment favorable to bacterial or fungal infections (intertrigo).
It has been proposed that for certain abdominal or gynecologic surgical procedures, including but not limited to incisional/ventral hernia repair or hysterectomy, the presence of a large overhanging panniculus may interfere with the surgery or may compromise postoperative recovery. However, adjuvant panniculectomy in most instances is not essential to improving clinical outcomes of the abdominal or gynecologic surgical procedures. In addition, available published peer-reviewed literature does not indicate that a panniculus contributes to formation of a hernia (a small sac containing tissue that protrudes through an opening in the muscles of the abdominal wall). The main cause of hernia formation is an abdominal wall weakness or defect, not a pulling effect from a redundant or large panniculus.
There are circumstances in which a panniculectomy may be indicated in conjunction with other medically necessary surgical procedures. For individuals undergoing hysterectomy who concurrently have a large, overhanging, abdominal pannus, a panniculectomy will improve exposure of the operative field and decrease postoperative wound infections. In a person with multiple, recurrent ventral hernias with multiple surgical scars when mesh has been used in the repair, if mesh use is planned in the repair, or when a components separation procedure* is planned, a panniculectomy will remove many of the pre-existing scars, which will reduce ischemic skin edges and decrease the risk of skin necrosis, mesh exposure, and infection while also decreasing the amount of postoperative tension on the surgical closure. Additionally, in an individual who has a prior ostomy, an open wound(s), or exposed draining fistula(ae) from infected mesh, a panniculectomy will remove infected soft tissues, prior scars, and infected foreign body mesh that may contaminate the new abdominal wall construction.
Panniculectomy may be performed to correct the redundant tissue that occurs in obese individuals after massive weight loss resulting from various regimens such as bariatric surgery. After these individuals experience massive weight loss, many are left with a redundant panniculus that poses a risk for a panniculus bacterial or fungal infection. Weight stability is required before panniculectomy because there is potential for development of another panniculus if additional weight loss occurs, thus increasing the risk of postoperative complications.
ABDOMINOPLASTY
Abdominoplasty is a surgical procedure that is performed to tighten a lax abdominal wall. It involves the removal of excess skin and fat from the middle and lower abdomen: the skin is pulled downward, and the underlying fascia (dense connective tissue that surrounds the muscles) is tightened. This procedure may also include reimplantation of the umbilicus. During an abdominoplasty procedure, a large incision is made across the lower abdomen, and the skin is separated from the abdominal wall up to the ribs. According to the American Society of Plastic Surgeons (ASPS), abdominoplasty is typically performed for cosmetic purposes.
An abdominal wall weakness or defect is also evident in diastasis recti. The main musculature of the abdomen is held together at the anterior midline by a long, triangular structure called the linea alba. The linea alba's insertion is at the xiphoid process of the sternum and extends downward to the pubis. According to medical literature, the condition of diastasis recti presents as a weakness or laxity of the abdominal wall, including the linea alba, but does not constitute a true hernia and is of no clinical significance.
EXCISIONS OF REDUNDANT SKIN OTHER THAN ABDOMEN/PANNUS
Extensive redundancy of skin and fat folds can also appear in areas such as the medial aspect of the upper arms, breasts, buttocks, and thighs, and may create environments that are susceptible to skin infection. Fungal dermatitis, bacterial or monilial infection, and/or panniculitis, collectively called "intertrigo," can occur. Medical management by the application of skin barriers, moisture-absorbing agents, and/or the use of supportive garments is indicated as the first line of treatment. However, if the condition is persistent and remains refractory to medical treatment, improvement may be achieved by surgical intervention. Excessive skin and fat are excised using appropriate incisions and techniques that allow for the direct removal of the redundant skin, with the subsequent approximation and suturing of the remaining skin.
In recent years, the surgical correction of morbid obesity and/or stringent diet regimens have assisted many individuals in achieving and sustaining weight loss. Although the benefits of weight loss are obvious, problems that are secondary to weight loss may appear, including skin redundancy with folds of skin and/or fat that are prone to infection. In addition, the aging process itself causes the underlying supportive structures of the skin to sag, which often creates skin redundancy.
COSMETIC
There may be times when panniculectomy and other excisions of redundant skin are performed for cosmetic purposes. Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.
* The Component Separation Technique (CST) is a type of rectus abdominis muscle advancement flap. It was first used to reconstitute the linea alba, reduce abdominal wall tension, and provide a dynamic abdominal wall in persons with large abdominal wall defects. This technique allows reconstruction of a large defect without requiring a free distant transposition flap. The advantages of CST are that it restores structural support of the abdominal wall, provides stable soft tissue coverage, and optimizes aesthetic appearance of complex abdominal wall defects and giant midline abdominal wall hernias.
