COSMETIC Aesthetic Evaluation of Lipoabdominoplasty in Overweight Patients Osvaldo R. Saldanha, M.D., Ph.D. Alessandra G. Salles, M.D., Ph.D. Marcus C. Ferreira, M.D., Ph.D. Francis Llaverias, M.D. Luis H. U. Morelli, M.D. Osvaldo R. Saldanha Filho, M.D. Cristianna B. Saldanha, M.D. Santos and São Paulo, Brazil
Background: The aim of this study was to evaluate the aesthetic results of lipoabdominoplasty in overweight patients (body mass index, 25 to 29.9) compared with normal weight patients (body mass index, 18.5 to 24.9). Methods: The authors performed a retrospective and comparative analysis of late follow-up results after lipoabdominoplasty performed from 2000 to 2009 in two groups of 30 patients, one with a body mass index of 25 to 29.9 and one with a body mass index of 18 to 24.9. Aesthetic results were evaluated using a scale with five objective parameters, developed in the Faculty of Medicine, University of São Paulo. There were seven evaluators: three plastic surgeons, three nondoctors, and the surgeon performing the procedure. Results: For all evaluators, the postoperative average grade was significantly higher than before surgery for the entire group of patients (n = 60) and in each subgroup. The average grades for the normal weight group were consistently significantly higher than for the overweight group, both preoperatively and postoperatively, for all evaluators. However, the mean difference between the preoperative and postoperative grades, which measures the aesthetic improvement provided by the operation, was higher in the overweight group. Postoperatively, the average grade of the surgeon was significantly higher than for all other evaluator groups. Conclusions: The normal weight group showed superior grades, both before and after lipoabdominoplasty, for all evaluators. However, the gain between preoperative and postoperative grades was higher in the overweight patient group, indicating that lipoabdominoplasty was beneficial even in these cases. (Plast. Reconstr. Surg. 132: 1103, 2013.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
F
unctional and aesthetic deformities of the abdominal wall, such as sagging skin, lipodystrophy, and diastasis of the rectus abdominis muscles, may contribute to reduced self-esteem and well-being of the patient.1,2 The combination of complete liposuction of the abdomen and abdominoplasty with wide undermining may result in a higher incidence of complications.3–5 Since the 1990s, there has been a trend to limit the undermining of the abdominal flap.6,7 The “lipoabdominoplasty” technique, described in 2001,8,9 combines dissection using liposuction for selective undermining, preserving most of the abdominal perforating vessels.10,11 From the Dr. Ewaldo Bolivar Souza Pinto Plastic Surgery Service, University of Santa Cecília; the Division of Plastic Surgery, Faculty of Medicine, University of São Paulo; and Santa Casa Hospital. Received for publication January 30, 2013; accepted May 9, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182a4c260
At the same time, there has been greater attention given to patient safety, specifically to patient selection, presence of comorbidities, and body mass index. Patients with higher body mass indexes have higher complication rates and less satisfactory subjective final functional and aesthetic results.12 The assessment of the results of aesthetic plastic surgery is a controversial topic, as Disclosure: The authors have no financial interest to declare in relation to the content of this article.
Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www. PRSJournal.com).
www.PRSJournal.com
1103
Plastic and Reconstructive Surgery • November 2013 it is often based on subjective criteria only, making it difficult to achieve adequate standardization and comparison of techniques.13,14 In 2000, Ferreira15 proposed a scale for the aesthetic assessment of mammaplasties based on five objective parameters of the breast (i.e., volume, shape, symmetry, areola, and scar), through analysis of photographic documentation by independent observers, comparing the preoperative and postoperative scores. Simple to reproduce, this scale facilitates comparative studies and statistical analyses. A similar scale was developed and validated by the plastic surgery group of the Faculty of Medicine, University of São Paulo for the aesthetic evaluation of the abdomen, allowing the analysis of results following abdominal plastic surgery, including conventional abdominoplasty and isolated liposuction of the abdomen.16,17 The five aesthetic parameters evaluated were the volume of the abdomen, lateral contour, excess or sagging skin, appearance of the umbilicus, and quality of the abdominal scar. The objective of this study was to evaluate the aesthetic results of lipoabdominoplasty in overweight patients (body mass index, 25 to 29.9) compared with normal weight patients (body mass index, 18.5 to 24.9).
PATIENTS AND METHODS Five hundred eighty-eight patients underwent lipoabdominoplasty performed by the first author (O.R.S.) between 2000 and 2009. Sixty of these patients were selected randomly from the main group and divided into two groups of 30 patients each according to their body mass index. This retrospective study was approved by the Ethics Committee for Research Project Analysis at the Hospital das Clínicas, Faculty of Medicine, University of São Paulo. The inclusion criteria were as follows: female sex; age, 26 to 65 years; body mass index, 18.5 to 24.9 (normal weight group) and 25 to 29.9 (overweight group); indication for abdominal plastic surgery because of dissatisfaction with appearance and abdominal flaccidity with lipodystrophy; and postoperative follow-up of at least 1 year. The average follow-up of the postoperative photographs we included in the study was 14 months (range, 12 to 24 months). We excluded patients who underwent previous aesthetic operations of the abdomen or bariatric surgery, and patients with severe systemic diseases. Smokers were not excluded. Group I consisted of 30 overweight patients and group II (control group) consisted of 30 normal weight patients.
1104
Randomization was performed using the charts of all 588 patients as follows: 30 patients in group I were chosen using a decimal sequence, starting with patient 1, followed by the numbers 11, 21, 31, and so on; 30 patients in group II were selected with the same system, starting with patient 2 and followed by the numbers 12, 22, 32, and so on. Patients who agreed to participate in the study were included in groups according to this decimal randomization in chronologic order if they fit the respective body mass index groups. When there were no medical record data for weight, height, or body mass index, or if the body mass index was not suitable for the group being randomized, we went to the subsequent higher number until we reached 30 patients in each group, which occurred with patient 541. In all patients in both groups, the same lipoabdominoplasty technique was used as described in the literature. (See Video, Supplemental Digital Content 1, which demonstrates safety and improved control of the abdominal contour in lipoabdominoplasty, http://links.lww.com/PRS/A887.) The volumes of adipose aspirates from liposuction of the abdomen extending to the flanks were 1845 ml in group I and 1053 ml in group II, on average. A closed-suction drain was used for 1 to 2 days. We used the scale developed in the Division of Plastic Surgery, Faculty of Medicine, University of São Paulo (Table 1) for the aesthetic evaluation of the abdomen and analyzed standard preoperative and postoperative photographs. Four preoperative images of each patient were grouped into one slide without identifying the patient, including a frontal view, two oblique (three-quarters) views, and one profile view (Fig. 1).
Video. Supplemental Digital Content 1 demonstrates the safety and improved control of the abdominal contour in lipoabdominoplasty, http://links.lww.com/PRS/A887.
Volume 132, Number 5 • Lipoabdominoplasty in Overweight Patients Table 1. Parameters for Aesthetic Evaluation of the Abdomen* Parameter
Description
Volume of the abdomen 0 1 2 Lateral contour 0 1 2 Excess skin/flaccidity 0 1 2 Umbilicus 0 1 2 Scars on the abdominal wall 0 1 2
Large amount of fat in the abdomen, large bulging Moderate amount of fat in the abdomen, regular bulging Adequate amount of fat tissue to the structure of the patient, without bulging On the anterior view, waist at the umbilicus level with bulging Abdomen with straight lateral contour, without definition of the waist Well-defined waist, with concavity Large excess of skin, sagging, and stretch marks Moderate amount of excess skin, with or without stretch marks and sagging No excess of skin and/or sagging Umbilicus with deviation, retraction, hypertrophy, or excess skin adjacent to it Acceptable aspect, with or without scar, discrete deviation, retraction or adjacent excess skin Natural appearing umbilicus Hypertrophic, hyperchromic, depressed, in awkward position scars or keloids Scar on abdomen of regular aspect Absence of abdominal scar or almost imperceptible scar with good appearance
*Data from Salles AG, Ferreira MC, do Nascimento Remigio AF, Gemperli R. Evaluation of aesthetic abdominal surgery using a new clinical scale. Aesthetic Plast Surg. 2012;36:49–53.
Fig. 1. Preoperative standard arrangement of the images, including frontal, lateral, and two oblique views.
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Plastic and Reconstructive Surgery • November 2013
Fig. 2. Postoperative (1 year 6 months) standard arrangement of the images, including frontal, lateral, and two oblique views.
The same system was used with the corresponding postoperative images in another slide (Fig. 2). The preoperative and postoperative images were not paired, to avoid comparison by the evaluator. The five aesthetic parameters evaluated were the volume of the abdomen, lateral contour of the abdomen, excess or sagging skin, appearance of the umbilicus, and quality of the abdominal scar. The evaluators were given a table containing guidelines for the evaluation of each item (Table 1). For each slide, the evaluators scored each of the five items as follows: 0, poor; 1, fair; and 2, good. The sum of the individual scores produced a final score, ranging from 0 to 10. Seven evaluators examined the photographs: three plastic surgeons, unrelated to the surgical procedure or to the medical care of the patients; and three independent nondoctors, unrelated to the patients or to the surgeon. The surgeon was the seventh evaluator. Evaluators did not have access to each other’s results.
1106
The average scores of the aesthetic evaluation of the abdomen were compared between the two body mass index groups preoperatively and postoperatively and among the groups of observers (doctors, nondoctors, and the surgeon). According to our statistician, using the central limit theorem, a sample size of more than 20 subjects ensured a normal distribution. The data in this study population were quantitative and continuous, and were analyzed for normality using the Kolmogorov-Smirnov test. The results indicated normality, which enabled the use of parametric tests. A value of p < 0.05 (5 percent) indicated statistical significance with 95 percent confidence intervals. Statistical analysis was performed to: 1. Compare the preoperative and postoperative average grades of the group as a whole for the three evaluator groups (doctors, nondoctors, and the surgeon) using the paired t test. 2. Compare the preoperative and postoperative average grades of the normal and
Volume 132, Number 5 • Lipoabdominoplasty in Overweight Patients
Fig. 3. Comparison of the average preoperative and postoperative grades in the group as a whole for doctors (p < 0.001), nondoctors (p < 0.001), and the surgeon (p < 0.001).
the average preoperative grade for all evaluators (p < 0.001) (Fig. 3).
overweight groups for the three groups of evaluators using the paired t test. 3. Compare the difference in the average grades of the preoperative and postoperative photographs between the two groups for the different evaluators using the analysis of variance test. 4. Compare the scores of the different evaluators to each other in the general sample using the paired t test and the intraclass correlation coefficient to measure the degree of internal reliability of the evaluation method.
Comparison of the Average Preoperative and Postoperative Grades between Groups I and II for the Different Evaluators The average grade for group II was higher than for group I, both preoperatively and postoperatively, for all evaluators. Patients with a normal body mass index had better abdominal aesthetic grades than overweight patients as assessed by all evaluators (doctors, nondoctors, and the surgeon) (Table 2). Comparison of the Difference between the Average Preoperative and Postoperative Grades between the Two Groups for the Different Evaluators The difference between the average preoperative and postoperative grades, which represents the improvement in the aesthetic evaluation of the abdomen provided by the operation, was significantly higher in group I (overweight) for all evaluators (Table 2).
RESULTS There was one case of seroma in the overweight group, which was treated by aspiration with syringe (three sessions). There were no cases of hematoma, skin necrosis, suture dehiscence, flap necrosis, deep vein thrombosis, or pulmonary embolism in either group. Comparison of the Preoperative and Postoperative Average Grades in the Group as a Whole for All Evaluators In the overall sample (n = 60), the average postoperative grade was significantly higher than
Comparison of the Scores of the Different Evaluators to Each Other in the General Sample Preoperatively, the average grade of the general sample was 3.47 by the surgeon, significantly
Table 2. Average Preoperative and Postoperative Grades and Difference between Grades in the Two Groups* Preoperatively Doctors Nondoctors Surgeon
Group I 2.04 ± 0.24 3.84 ± 0.34 2.77 ± 0.46
Group II 3.69 ± 0.38 5.26 ± 0.34 4.17 ± 0.42
Postoperative − Preoperative Difference
Postoperatively p
Background: The aim of this study was to evaluate the aesthetic results of lipoabdominoplasty in overweight patients (body mass index, 25 to 29.9) compared with normal weight patients (body mass index, 18.5 to 24.9). Methods: The authors performed a retrospective and comparative analysis of late follow-up results after lipoabdominoplasty performed from 2000 to 2009 in two groups of 30 patients, one with a body mass index of 25 to 29.9 and one with a body mass index of 18 to 24.9. Aesthetic results were evaluated using a scale with five objective parameters, developed in the Faculty of Medicine, University of São Paulo. There were seven evaluators: three plastic surgeons, three nondoctors, and the surgeon performing the procedure. Results: For all evaluators, the postoperative average grade was significantly higher than before surgery for the entire group of patients (n = 60) and in each subgroup. The average grades for the normal weight group were consistently significantly higher than for the overweight group, both preoperatively and postoperatively, for all evaluators. However, the mean difference between the preoperative and postoperative grades, which measures the aesthetic improvement provided by the operation, was higher in the overweight group. Postoperatively, the average grade of the surgeon was significantly higher than for all other evaluator groups. Conclusions: The normal weight group showed superior grades, both before and after lipoabdominoplasty, for all evaluators. However, the gain between preoperative and postoperative grades was higher in the overweight patient group, indicating that lipoabdominoplasty was beneficial even in these cases. (Plast. Reconstr. Surg. 132: 1103, 2013.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
F
unctional and aesthetic deformities of the abdominal wall, such as sagging skin, lipodystrophy, and diastasis of the rectus abdominis muscles, may contribute to reduced self-esteem and well-being of the patient.1,2 The combination of complete liposuction of the abdomen and abdominoplasty with wide undermining may result in a higher incidence of complications.3–5 Since the 1990s, there has been a trend to limit the undermining of the abdominal flap.6,7 The “lipoabdominoplasty” technique, described in 2001,8,9 combines dissection using liposuction for selective undermining, preserving most of the abdominal perforating vessels.10,11 From the Dr. Ewaldo Bolivar Souza Pinto Plastic Surgery Service, University of Santa Cecília; the Division of Plastic Surgery, Faculty of Medicine, University of São Paulo; and Santa Casa Hospital. Received for publication January 30, 2013; accepted May 9, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182a4c260
At the same time, there has been greater attention given to patient safety, specifically to patient selection, presence of comorbidities, and body mass index. Patients with higher body mass indexes have higher complication rates and less satisfactory subjective final functional and aesthetic results.12 The assessment of the results of aesthetic plastic surgery is a controversial topic, as Disclosure: The authors have no financial interest to declare in relation to the content of this article.
Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www. PRSJournal.com).
www.PRSJournal.com
1103
Plastic and Reconstructive Surgery • November 2013 it is often based on subjective criteria only, making it difficult to achieve adequate standardization and comparison of techniques.13,14 In 2000, Ferreira15 proposed a scale for the aesthetic assessment of mammaplasties based on five objective parameters of the breast (i.e., volume, shape, symmetry, areola, and scar), through analysis of photographic documentation by independent observers, comparing the preoperative and postoperative scores. Simple to reproduce, this scale facilitates comparative studies and statistical analyses. A similar scale was developed and validated by the plastic surgery group of the Faculty of Medicine, University of São Paulo for the aesthetic evaluation of the abdomen, allowing the analysis of results following abdominal plastic surgery, including conventional abdominoplasty and isolated liposuction of the abdomen.16,17 The five aesthetic parameters evaluated were the volume of the abdomen, lateral contour, excess or sagging skin, appearance of the umbilicus, and quality of the abdominal scar. The objective of this study was to evaluate the aesthetic results of lipoabdominoplasty in overweight patients (body mass index, 25 to 29.9) compared with normal weight patients (body mass index, 18.5 to 24.9).
PATIENTS AND METHODS Five hundred eighty-eight patients underwent lipoabdominoplasty performed by the first author (O.R.S.) between 2000 and 2009. Sixty of these patients were selected randomly from the main group and divided into two groups of 30 patients each according to their body mass index. This retrospective study was approved by the Ethics Committee for Research Project Analysis at the Hospital das Clínicas, Faculty of Medicine, University of São Paulo. The inclusion criteria were as follows: female sex; age, 26 to 65 years; body mass index, 18.5 to 24.9 (normal weight group) and 25 to 29.9 (overweight group); indication for abdominal plastic surgery because of dissatisfaction with appearance and abdominal flaccidity with lipodystrophy; and postoperative follow-up of at least 1 year. The average follow-up of the postoperative photographs we included in the study was 14 months (range, 12 to 24 months). We excluded patients who underwent previous aesthetic operations of the abdomen or bariatric surgery, and patients with severe systemic diseases. Smokers were not excluded. Group I consisted of 30 overweight patients and group II (control group) consisted of 30 normal weight patients.
1104
Randomization was performed using the charts of all 588 patients as follows: 30 patients in group I were chosen using a decimal sequence, starting with patient 1, followed by the numbers 11, 21, 31, and so on; 30 patients in group II were selected with the same system, starting with patient 2 and followed by the numbers 12, 22, 32, and so on. Patients who agreed to participate in the study were included in groups according to this decimal randomization in chronologic order if they fit the respective body mass index groups. When there were no medical record data for weight, height, or body mass index, or if the body mass index was not suitable for the group being randomized, we went to the subsequent higher number until we reached 30 patients in each group, which occurred with patient 541. In all patients in both groups, the same lipoabdominoplasty technique was used as described in the literature. (See Video, Supplemental Digital Content 1, which demonstrates safety and improved control of the abdominal contour in lipoabdominoplasty, http://links.lww.com/PRS/A887.) The volumes of adipose aspirates from liposuction of the abdomen extending to the flanks were 1845 ml in group I and 1053 ml in group II, on average. A closed-suction drain was used for 1 to 2 days. We used the scale developed in the Division of Plastic Surgery, Faculty of Medicine, University of São Paulo (Table 1) for the aesthetic evaluation of the abdomen and analyzed standard preoperative and postoperative photographs. Four preoperative images of each patient were grouped into one slide without identifying the patient, including a frontal view, two oblique (three-quarters) views, and one profile view (Fig. 1).
Video. Supplemental Digital Content 1 demonstrates the safety and improved control of the abdominal contour in lipoabdominoplasty, http://links.lww.com/PRS/A887.
Volume 132, Number 5 • Lipoabdominoplasty in Overweight Patients Table 1. Parameters for Aesthetic Evaluation of the Abdomen* Parameter
Description
Volume of the abdomen 0 1 2 Lateral contour 0 1 2 Excess skin/flaccidity 0 1 2 Umbilicus 0 1 2 Scars on the abdominal wall 0 1 2
Large amount of fat in the abdomen, large bulging Moderate amount of fat in the abdomen, regular bulging Adequate amount of fat tissue to the structure of the patient, without bulging On the anterior view, waist at the umbilicus level with bulging Abdomen with straight lateral contour, without definition of the waist Well-defined waist, with concavity Large excess of skin, sagging, and stretch marks Moderate amount of excess skin, with or without stretch marks and sagging No excess of skin and/or sagging Umbilicus with deviation, retraction, hypertrophy, or excess skin adjacent to it Acceptable aspect, with or without scar, discrete deviation, retraction or adjacent excess skin Natural appearing umbilicus Hypertrophic, hyperchromic, depressed, in awkward position scars or keloids Scar on abdomen of regular aspect Absence of abdominal scar or almost imperceptible scar with good appearance
*Data from Salles AG, Ferreira MC, do Nascimento Remigio AF, Gemperli R. Evaluation of aesthetic abdominal surgery using a new clinical scale. Aesthetic Plast Surg. 2012;36:49–53.
Fig. 1. Preoperative standard arrangement of the images, including frontal, lateral, and two oblique views.
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Plastic and Reconstructive Surgery • November 2013
Fig. 2. Postoperative (1 year 6 months) standard arrangement of the images, including frontal, lateral, and two oblique views.
The same system was used with the corresponding postoperative images in another slide (Fig. 2). The preoperative and postoperative images were not paired, to avoid comparison by the evaluator. The five aesthetic parameters evaluated were the volume of the abdomen, lateral contour of the abdomen, excess or sagging skin, appearance of the umbilicus, and quality of the abdominal scar. The evaluators were given a table containing guidelines for the evaluation of each item (Table 1). For each slide, the evaluators scored each of the five items as follows: 0, poor; 1, fair; and 2, good. The sum of the individual scores produced a final score, ranging from 0 to 10. Seven evaluators examined the photographs: three plastic surgeons, unrelated to the surgical procedure or to the medical care of the patients; and three independent nondoctors, unrelated to the patients or to the surgeon. The surgeon was the seventh evaluator. Evaluators did not have access to each other’s results.
1106
The average scores of the aesthetic evaluation of the abdomen were compared between the two body mass index groups preoperatively and postoperatively and among the groups of observers (doctors, nondoctors, and the surgeon). According to our statistician, using the central limit theorem, a sample size of more than 20 subjects ensured a normal distribution. The data in this study population were quantitative and continuous, and were analyzed for normality using the Kolmogorov-Smirnov test. The results indicated normality, which enabled the use of parametric tests. A value of p < 0.05 (5 percent) indicated statistical significance with 95 percent confidence intervals. Statistical analysis was performed to: 1. Compare the preoperative and postoperative average grades of the group as a whole for the three evaluator groups (doctors, nondoctors, and the surgeon) using the paired t test. 2. Compare the preoperative and postoperative average grades of the normal and
Volume 132, Number 5 • Lipoabdominoplasty in Overweight Patients
Fig. 3. Comparison of the average preoperative and postoperative grades in the group as a whole for doctors (p < 0.001), nondoctors (p < 0.001), and the surgeon (p < 0.001).
the average preoperative grade for all evaluators (p < 0.001) (Fig. 3).
overweight groups for the three groups of evaluators using the paired t test. 3. Compare the difference in the average grades of the preoperative and postoperative photographs between the two groups for the different evaluators using the analysis of variance test. 4. Compare the scores of the different evaluators to each other in the general sample using the paired t test and the intraclass correlation coefficient to measure the degree of internal reliability of the evaluation method.
Comparison of the Average Preoperative and Postoperative Grades between Groups I and II for the Different Evaluators The average grade for group II was higher than for group I, both preoperatively and postoperatively, for all evaluators. Patients with a normal body mass index had better abdominal aesthetic grades than overweight patients as assessed by all evaluators (doctors, nondoctors, and the surgeon) (Table 2). Comparison of the Difference between the Average Preoperative and Postoperative Grades between the Two Groups for the Different Evaluators The difference between the average preoperative and postoperative grades, which represents the improvement in the aesthetic evaluation of the abdomen provided by the operation, was significantly higher in group I (overweight) for all evaluators (Table 2).
RESULTS There was one case of seroma in the overweight group, which was treated by aspiration with syringe (three sessions). There were no cases of hematoma, skin necrosis, suture dehiscence, flap necrosis, deep vein thrombosis, or pulmonary embolism in either group. Comparison of the Preoperative and Postoperative Average Grades in the Group as a Whole for All Evaluators In the overall sample (n = 60), the average postoperative grade was significantly higher than
Comparison of the Scores of the Different Evaluators to Each Other in the General Sample Preoperatively, the average grade of the general sample was 3.47 by the surgeon, significantly
Table 2. Average Preoperative and Postoperative Grades and Difference between Grades in the Two Groups* Preoperatively Doctors Nondoctors Surgeon
Group I 2.04 ± 0.24 3.84 ± 0.34 2.77 ± 0.46
Group II 3.69 ± 0.38 5.26 ± 0.34 4.17 ± 0.42
Postoperative − Preoperative Difference
Postoperatively p
