The Fleur-De-Lys Abdominoplasty: Not Simply for the Massive Weight Loss Patient

Goals/Purpose:

 

1. To clearly define the characteristics of the patients needing the Fleur-de-Lys (FDL) design.
2. To isolate parameters associated with complications.
3. To identify factors positively influencing safety.
4. To demonstrate visually the power of this technique in shaping bodies across all BMI spectra.

Methods/Technique:

1.      July 1, 2003 – June 30, 2010: Retrospective chart review of four hundred and four (404) abdominoplasty procedures performed by a single surgeon on an outpatient basis (certified office facility: AAAASF Class C).

2.      Isolation of the seventy seven FDL designs (77/404 = 19%) for comparison with the remainder of the cohort.

3.      Collection of the five parameters thought to influence complications: Age; BMI (Body/Mass Index); Co-morbid conditions; Presence and Depth (1 to 5) of the stretch marks; and Average pre-surgical weight loss.

4.      Adoption of the Null Hypothesis for all parameters: None was thought à priori to be of relevance unless rigid statistical analysis dictated the consideration of an alternate explanation.

5.      Analysis of the data by an outside body using an online statistical tool (Winstat for Excel): Degrees of confidence; Standard error; Standard deviation; F and t-tests (pooled and separated) were obtained.

6.      Survey of patient satisfaction randomized by pre-surgical BMI.

7.      Surgeon’s post-operative photographic analysis based on given criteria:

·         Universal: Scar placement – Scar symmetry – Scar length – Position of the umbilicus – Position and Inclination of the Mons pubis – Waistline definition.

·         Specific (BMI influenced): Shape of the umbilicus – Abdominal muscle definition – Abdominal profile – Sexual attractiveness.

Results/ Complications:

 

1. No difference in Mortality between FDL (0%) and traditional (0%) designs.
2. No significant difference in DVT incidence (FDL: 0% - Traditional: 1.5%).
3. No significant difference in incidence of suspected infection (FDL: 3.8% - Traditional: 4%).
4. Significant difference in incidence of seroma formation (FDL: 0% - Traditional: 7%).
5. Distribution of BMI for FDL: 20.1 to25: 24%; 25.1 to 30: 32%; 30.1 to 35: 33%; and 35.1 to 40: 11%.
6. Changing incidence of wound problems with BMI in FDL: 20.1 to 25: 44%; 25.1 to 30: 21%; 30.1 to 35: 40%; and 35.1 to 40: 62.5% (note: any opening in the suture line regardless of size was included as wound complication).
7. Both separate and pooled t-tests showed a very significant correlation between extreme BMI’s and incidence of wound problems (p = 0.007).
8. Depth of stretch marks (level 3 to 5) showed significant correlation with wound problems (p = 0.05).
9. No statistical correlation with the presence of co-morbid conditions except for smoking.
10. Incidence of Gastric Bypass/Banding in this FDL series: 36%.
11. 29% of patients in this series did not lose any weight prior to their surgery.
12. Average BMI for patients without any weight loss prior to FDL surgery: 30.1 (range: 22.1 to 38.7).
13. Patient esthetic satisfaction: 79% (responders: n = 51).
14. Surgeon’s esthetic satisfaction based on mentioned criteria: 70% (n = 77).

Conclusion:

The Fleur-de-Lys abdominoplasty is a powerful tool that should be offered to any patient presenting with excessive dermatochalasia along both the horizontal and vertical axes regardless of their history of weight loss. The importance of this series of 77 patients is that if offers a true look into the FDL procedure without pre-selection and is thus able to offer meaningful conclusions as to the selection criteria thought to influence both the esthetic outcome and rate of complications. For example and contrary to the established wisdom, the incidence of wound problems did not fall precipitously with a falling BMI but was least seen in patients with intermediate BMI’s (25.1 to 35) and was independent of both weight loss and history of gastric bypass/banding surgery. Technical factors that were identified as positively improving safety and esthetic outcome include:

 

1. Pre-surgical accurate designing through its reduction of intra-operative decisions.
2. Emphasis on the height of the vertical limb.
3. Limited lateral dissection beyond the costal margins.
4. Decreased surgical time (Average: 128 minutes for this series).
5. The adoption of anti-thrombotic measures (this element cannot be scientifically validated from this study for reasons of randomization).

Esthetic surgery remains a visual field. An abundance of examples across all BMI landscapes will be presented to demonstrate the validity of offering the FDL technique to patients who could have been turned away under more sentimental argumentations.

 

FDL Surgical Planning

FDL - BMI: 25.1
FDL - BMI: 27.8
FDL - BMI: 32.9
FDL - BMI: 38.7

Back to: Tuesday Session A

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