COMPLICATIONS of Abdominal Dermolipectomy (“ANCHOR TECHNIQUE”) POST Bariatric SURGERY - Gastroplasty: ANALYSIS of 215 CASES

Goals/Purpose: Patients with massive weight loss after gastroplasty deserve an special attention because of the increase¹ in the number of patients requiring abdominal dermolipectomy for correction of skin excess. In our practice most of the gastroplasty are done by the “open” approach with a median supra-umbilical scar and traditional abdominoplasty often results in poor results in these patients. Weinhold²  in 1907,  Castañares and Goethel³ and Barraya and Dezeuze⁴ in 1967 described abdominoplasty using vertical and horizontal resections. We found only 10 publications at PubMed database with the terms “abdominoplasty”, “fleur-de-lis” and “anchor technique” which reflects the scarcity of data in this topic.

Methods/Technique:

The “anchor” technique consisted of (Figure 1) : 1) marking the superior angle of resection at epigastric region (point A, just above the previous gastroplasty scar) and the inferior border of resection at the pubic projection (point  C – 4 to 7 cm from the vulvar comissure  – is marked raising the skin excess because these patients  usually have pubic skin ptosis), the A-C distance is then measured; both superior anterior iliac spines are marked at this step (D and D’); 2) the vertical resections follow two lines marked under approximation of the skin, not pinching then, but by apposition;  3) the A-C distance is then applied over this vertical line taking care to stretch the skin (points B and B’); 4) the inferior lateral lines are drawn from the pubis (point C) to both anterior superior iliac spines ( D and D’); 5) the superior lateral lines are drawn from the vertical line to the anterior superior iliac spines (B to D and B’ to D’). Points D and D’ can be moved laterally in cases of lateral redundancies. The umbilicus is not reference for any marking point or line. The surgery starts the umbilicus (when not using the neo-umbilicus technique) release,  skin and subcutaneous excess is dissected from the aponeurosis starting at point A, hernias are treated at this time if present. Before resecting the excess skin we mobilize the flaps (not undermining then) to check if they approximate without tension , then we proceed to resection, plicature of rectus diastasis and closure in three layers as described below taking care to approximate strictly all tissues. First the subcutaneous fascia (Camper´s fascia) is sutured to aponeurosis (Baroudi points), this is done to distribute the tensile forces to a deeper level, close dead space and place the scar on position, it was observed that after using these points there was a decrease in the number of complications and drain is no longer used when placing these points. Subdermic and intradermic sutures are then done. Finally umbilicus is exteriorized by a small triangular skin and subcutaneous resection. Anticoagulants are not given but early deambulation is applied for all patients, Foley catheter is not used.

Results/Complications: Software Epi Info™ 3.5.2 was used to analyze the results. 215 patients were submitted to this technique between 2005 and 2008. 170  (79%) were female  and 45 (21%) male, the mean age was 40,67 years (19-67), the average BMI was 27,33 (19,49 - 41,05) , the average weight loss post gastroplasty was 47,91 Kg (13 – 96 Kg). All the patients had their weight stable for at least 3 months. The  average time between gastroplasty and dermolipectomy was 25,75 months (10 months to 16 years). One hundred fifty three patients were submitted to associated procedures (98 hernias,29 breast aesthetic surgery, 2 thigh lift, 3 brachioplasty, 1 colecistectomy). One hundred sixty seven used drain and forty eight did not use it. Average length of hospital stay was 2 days. The mean length of drain was 7 days. Complications: 45 patients (20,9%) developed seroma, 42 (19,6%) suture line extrusion, 39 (18,1%) umbilicus partial necrosis, 32 (14,9%) hypertrophic scar,  25 (11,1%) dehiscence, 15 (7%) hematoma, 10 (4,7%) infection, 7 (3,3%) small skin necrosis, 5 (2,3%) umbilical stenosis and 1 (0,5%) keloidis. Half of the hematomas were immediately submitted to drainage at the operating room. Only one patient with infection required admission to hospital and parenteral antibiotics.

Conclusion:

Abdominal dermolipectomy using the “anchor technique” is a useful procedure especially for patients with supra-umbilical scar, vertical skin excess or in patient who are not concerned about scars.  The rates of complication and are not very different from the traditional abdominoplasty⁸. Seroma was the most seen complication followed by extrusion of suture line, umbilicus partial necrosis, hypertrophic scar and dehiscence. Most of the complications were managed at the office setting and less than 1% required re-hospitalization. There is a high patient satisfaction with this technique.