COSMETIC

Abdominal Panniculectomy: Determining the

Impact of Diabetes on Complications and Risk
Factors for Adverse Events
Rami S. Kantar, M.D.
Background: The prevalence of obesity along with bariatric surgery and mas-
William J. Rifkin, B.A.
sive weight loss requiring panniculectomy is increasing in the United States.
Downloaded from https://journals.lww.com/plasreconsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3w7SK+r5dgwMwHo5hr5RCGFpvg+JJ5iyjgmT15sWRevnyiZN12Ab+eQ== on 10/11/2018

Stelios C. Wilson, M.D.

The effect of diabetes mellitus on outcomes following panniculectomy remains
Joshua A. David, B.S. poorly defined despite its prevalence. This study aims to evaluate the impact of
J. Rodrigo Diaz-Siso, M.D. diabetes mellitus on complications following panniculectomy and determine
Jamie P. Levine, M.D. risk factors for adverse events.
Alyssa R. Golas, M.D. Methods: The American College of Surgeons National Surgical Quality Improve-
Daniel J. Ceradini, M.D. ment Program database was used to identify patients undergoing panniculec-
New York, N.Y. tomy between 2010 and 2015. Patients were stratified based on diabetes status.
Results: Review of the database identified 7035 eligible patients who under-
went panniculectomy, of which 770 (10.9 percent) were diabetic. Multivariate
regression showed that diabetes mellitus was a significant risk factor for wound
dehiscence (OR, 1.92; 95 percent CI, 1.41 to 3.15; p = 0.02). Obesity was a
significant risk factor for superficial (OR, 2.78; 95 percent CI, 1.53 to 3.69; p
< 0.001) and deep (OR, 1.52; 95 percent CI, 1.38 to 3.97; p = 0.01) incisional
surgical-site infection. Smokers were also at an increased risk for superficial
(OR, 1.42; 95 percent CI, 1.19 to 1.75; p = 0.03) and deep (OR, 1.63; 95 per-
cent CI, 1.31 to 2.22; p = 0.02) incisional surgical-site infection.
Conclusions: Diabetes mellitus is an independent risk factor for wound dehiscence
following panniculectomy. Obesity and smoking were significant risk factors for
superficial and deep incisional surgical-site infection. These results underscore
the importance of preoperative risk factor evaluation in patients undergoing pan-
niculectomy for safe outcomes.  (Plast. Reconstr. Surg. 142: 462e, 2018.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

T
he rate of obesity in the United States is Diabetes mellitus is considered one the most
increasing, with an estimated prevalence of significant public health challenges of the twenty-
26.2 percent among working-age individu- first century, with a global prevalence that has more
als.1 With the increasing popularity of bariatric than doubled over the past 20 years.5 It is estimated
surgery as a treatment option for obesity, there that more than 400 million individuals have diabetes
are an increasing number of patients that may
benefit from body contouring procedures.2 One Disclosure: The authors have no financial interest
of the most commonly performed body contour- to declare in relation to the content of this article.
ing procedures following massive weight loss is
panniculectomy, or the surgical excision of exces-
sive abdominal skin and subcutaneous tissue of
By reading this article, you are entitled to claim
the lower abdomen.3 Removal of excess lower
one (1) hour of Category 2 Patient Safety Cred-
abdominal tissue can lead to increased mobility,
it. ASPS members can claim this credit by log-
decreased pain, improvements in hygiene, and
ging in to PlasticSurgery.org Dashboard, click-
overall improvements in quality of life.4
ing “Submit CME,” and completing the form.
From the Hansjörg Wyss Department of Plastic Surgery, New
York University Langone Medical Center.
Received for publication November 10, 2017; accepted A Video Discussion by Al Aly, M.D., accompa-
March 16, 2018. nies this article. Go to PRSJournal.com and
The first two authors contributed equally to this article. click on “Video Discussions” in the “Digital
Copyright © 2018 by the American Society of Plastic Surgeons Media” tab to watch.
DOI: 10.1097/PRS.0000000000004732

462e www.PRSJournal.com
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 Volume 142, Number 4 • Abdominal Panniculectomy
mellitus worldwide6 and that almost 10 percent of
the U.S. population is affected.7 Patients with dia-
betes mellitus are known to be at an increased risk
of complications following surgical procedures
because of impairments in wound healing8–11 and
angiogenesis.12 Surgical and medical complications
that occur when caring for this patient popula-
tion contribute to the heavier financial health care
burden observed in patients with diabetes mellitus
compared with nondiabetic patients.7,13
Despite the massive weight loss and improve-
ment in overall health of candidates for pannicu-
lectomy, many of these patients are still obese or
have refractory diabetes mellitus and metabolic
syndrome.14 However, the magnitude of the effect
of diabetes mellitus on postoperative outcomes
has not been specifically defined for this proce-
dure despite being a common comorbidity in this
patient population. Previous studies that have
explored the topic have evaluated the relation-
ship between diabetes mellitus and all aesthetic
procedures,15 focused on the metabolic syndrome
as the exposure of interest instead of diabetes mel-
litus,16 or were limited in sample size.17,18 The aim
of this study was to evaluate the impact of diabetes
mellitus on postoperative complications following
panniculectomy and determine risk factors associ-
ated with adverse postoperative events.
Fig. 1. Study design and CPT codes/description.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
PATIENTS AND METHODS
Database and Patient Population
The American College of Surgeons National
Surgical Quality Improvement Program is a pro-
spective, risk-adjusted, outcomes-based registry
that records demographic, preoperative, peri-
operative, and 30-day postoperative deidenti-
fied patient information.19 For the purpose of
this study, database Participant Use Data Files
from the years 2010 to 2015 were reviewed. The
database is compliant with the Health Insur-
ance Portability and Accountability Act and is
exempt from institutional review board review.
This study was conducted in accordance with
the principles outlined in the Declaration of
Helsinki. A retrospective review of the American
College of Surgeons National Surgical Quality
Improvement Program was performed for CPT
code 15830 (Excision, excessive skin and subcu-
taneous tissue (includes lipectomy); abdomen,
infraumbilical panniculectomy) (Fig. 1). Cases
recorded with a primary abdominoplasty CPT
code were excluded from analysis [CPT code
15847, Excision, excessive skin and subcutane-
ous tissue (includes lipectomy); abdomen (e.g.,
abdominoplasty) (includes umbilical transposi-
tion and fascial plication)].
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 Plastic and Reconstructive Surgery • October 2018

Study Design surgical-site infection, and wound dehiscence.

Database review was performed for the selected
CPT code, and cases with missing age, weight,
height, wound classification, and diabetes mellitus
status were excluded from analysis (Fig. 1). Diabetes
mellitus was the risk factor of interest in this study.
Patient preoperative demographics, clinical factors,
and medical comorbidities at the time of surgery
were analyzed (Table 1). Variables with predomi-
nantly missing data were excluded from the analysis.
Primary outcomes of the study included super-
ficial incisional surgical-site infection, deep inci-
sional surgical-site infection, deep organ/space
Secondary surgical outcomes evaluated included
30-day mortality, reoperation rate, readmission
rate, bleeding/transfusions up to 72 hours post-
operatively, deep venous thrombosis, operative
time in minutes, and postoperative hospital length
of stay in days. Medical complications evaluated
included stroke with neurologic deficit, acute
renal failure, pulmonary embolism, reintubation,
mechanical ventilation greater than 48 hours, car-
diac arrest requiring cardiopulmonary resuscita-
tion, myocardial infarction, pneumonia, urinary
tract infection, sepsis, and septic shock.

Table 1.  Preoperative Patient Characteristics, Clinical Factors, and Medical Comorbidities
Variable Nondiabetic Patients (%) Diabetic Patients (%) p
No. of patients 6265 770
Mean age ± SD, yr 45.4 ± 11.8 54.4 ± 11.0 <0.001*
Mean BMI ± SD, kg/m2 30.8 ± 8.3 40.4 ± 13.7 <0.001*
Obese 2792 (44.6) 611 (79.4) <0.001*
Female 5595 (89.4) 635 (82.6) <0.001*
Smoker 637 (10.2) 82 (10.6) 0.68
ASA class 3 or higher 1145 (18.3) 505 (65.8) <0.001*
Emergency case 18 (0.3) 4 (0.5) 0.07
Prior operation within 30 days 5 (0.1) 4 (0.5) 0.01*
Race
 American Indian or Alaska Native 25 (0.5) 13 (1.9) <0.001*
 Asian 75 (1.4) 9 (1.3)
 Black or African American 688 (12.9) 80 (11.9)
 Native Hawaiian or Pacific Islander 18 (0.3) 3 (0.4)
 White 4513 (84.8) 569 (84.4)
Wound classification
 Clean 5785 (92.3) 621 (80.6) <0.001*
 Clean/contaminated 338 (5.4) 54 (7.0)
 Contaminated 82 (1.3) 48 (6.2)
 Dirty/infected 60 (1.0) 47 (6.1)
Surgical specialty
 Plastic surgery 5061 (80.8) 532 (69.1) <0.001*
 General surgery 1180 (18.8) 231 (30.0)
Cardiovascular
 CHF 6 (0.1) 13 (1.7) <0.001*
 Previous PCI 13 (0.2) 7 (0.9) 0.01*
 Previous cardiac surgery 15 (0.2) 5 (0.6) 0.06
 Hypertension 1359 (21.7) 525 (68.2) <0.001*
 PVD requiring surgery 4 (0.1) 3 (0.4) 0.03*
Neurologic
 History of TIA 9 (0.2) 3 (0.4) 0.08
 Stroke with neurologic deficit 1 (0) 4 (0.5) <0.001*
Genitourinary
 Dialysis 16 (0.3) 8 (1.0) <0.001*
Respiratory
 Ventilator dependence 2 (0) 1 (0.1) 0.38
 Severe COPD 60 (1.0) 53 (6.9) <0.001*
Hematologic
 Bleeding disorders 55 (0.9) 28 (3.6) <0.001*
 Preoperative transfusion 7 (0.1) 9 (1.2) <0.001*
Infectious
 Sepsis 38 (0.6) 27 (3.5) <0.001*
 Open/infected wound 98 (1.6) 82 (10.6) <0.001*
Metabolic
 Recent significant weight loss 21 (0.3) 5 (0.6) 0.18
 Recent steroid use 75 (1.2) 18 (2.3) 0.01*
BMI, body mass index; ASA, American Society of Anesthesiologists; CHF, congestive heart failure; PCI, percutaneous coronary intervention;
PVD, peripheral vascular disease; TIA, transient ischemic attack; COPD, chronic obstructive pulmonary disease.
*Statistically significant.

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 Volume 142, Number 4 • Abdominal Panniculectomy

Statistical Analysis bleeding disorder, preoperative transfusion, sep-

Categorical variables are reported as frequen-
cies and percentages within their corresponding
groups, and continuous variables are reported
as mean ± SD. Univariate analysis was performed
using chi-square or Fisher’s exact test (n < 10) for
categorical variables, and t test for continuous vari-
ables. Obesity was defined as a body mass index
greater than 30 kg/m2, and recent significant
weight loss was defined as greater than 10 per-
cent weight loss in the 6 months before surgery.
We controlled for potential confounders using
multivariate logistic and linear regression analy-
ses. Multivariate regression models for wound
outcomes and reoperation included the following
preoperative variables: diabetes, age, body mass
index, obesity, gender, smoking, American Soci-
ety of Anesthesiologists classification, previous
operation within 30 days, race, wound classifica-
tion, surgical specialty, history of congestive heart
failure, percutaneous coronary intervention,
hypertension, peripheral vascular disease requir-
ing surgery, stroke with neurologic deficits, dialy-
sis, severe chronic obstructive pulmonary disease,
sis, open or infected wound, recent significant
weight loss, and recent steroid use. In addition to
the aforementioned variables, all outcomes that
were significant on univariate analysis (Table 2)
were included in the regression models for sepsis,
reintubation, mechanical ventilation longer than
48 hours, readmission, and postoperative hospital
length of stay. Statistical significance was defined
as value of p ≤ 0.05. All data analyses were per-
formed using IBM SPSS Version 23.0 (IBM Corp.,
Armonk, N.Y.).
RESULTS
Review of the database for the mentioned CPT
code identified 7789 patients who underwent
panniculectomy. A total of 7035 patients were eli-
gible for analysis after our exclusion criteria were
applied (Fig. 1). Patients were stratified based on
diabetes status. Of all patients included in the
analysis, 6265 (89.1 percent) were nondiabetic
and 770 (10.9 percent) were diabetic. Univariate
analysis showed that patients in the diabetic group
were significantly older (54.4 ± 11.0 years versus

Table 2.  Univariate Analysis of Surgical Outcomes and Medical Complications

Nondiabetic Diabetic
Variable Patients (%) Patients (%) p
No. of patients 6265 770
Wound outcomes
 Superficial incisional SSI 218 (3.5) 62 (8.1) <0.001*
 Deep incisional SSI 78 (1.2) 29 (3.8) <0.001*
 Deep organ/space SSI 12 (0.2) 5 (0.6) 0.02*
 Wound dehiscence 72 (1.1) 20 (2.6) 0.001*
Other surgical outcomes
 30-day mortality 1 (0) 1 (0.1) 0.08
 Reoperation 166 (3.3) 35 (5.8) 0.001*
 Readmission 35 (0.9) 11 (2.1) 0.01*
 Bleeding/transfusions up to 72 hr postoperatively 259 (4.1) 61 (7.9) <0.001*
 DVT 28 (0.4) 6 (0.8) 0.21
 Mean operative time ± SD, min 177.9 ± 91.4 160.73 ± 80.9 <0.001*
 Mean postoperative hospital LOS ± SD, days 1.6 ± 7.4 3.2 ± 5.2 <0.001*
Neurologic outcomes
 Stroke with deficit 0 (0) 2 (0.3) <0.001*
Genitourinary outcomes
 Acute renal failure 2 (0) 3 (0.4) <0.001*
Respiratory outcomes
 Pulmonary embolism 22 (0.4) 1 (0.1) 0.31
 Reintubation 5 (0.1) 9 (1.2) <0.001*
 Mechanical ventilation >48 hr 9 (0.1) 12 (1.6) <0.001*
Cardiovascular outcomes
 Cardiac arrest requiring CPR 1 (0) 0 (0) 0.73
 MI 1 (0) 2 (0.3) 0.002*
Infectious outcomes
 Pneumonia 11 (0.2) 8 (1.0) <0.001*
 UTI 36 (0.6) 10 (1.3) 0.02*
 Sepsis 37 (0.6) 22 (2.9) <0.001*
 Septic shock 5 (0.1) 7 (0.9) <0.001*
SSI, surgical-site infection; DVT, deep vein thrombosis; LOS, length of stay; CPR, cardiopulmonary resuscitation; MI, myocardial infarction;
UTI, urinary tract infection.
*Statistically significant.

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 Plastic and Reconstructive Surgery • October 2018
45.4 ± 11.8 years; p < 0.001) and had a signifi-
cantly higher body mass index (40.4 ± 13.7 kg/m2
versus 30.8 ± 8.3 kg/m2; p < 0.001), although
the percentage of women was significantly lower
(82.6 percent versus 89.4 percent; p < 0.001). The
diabetic patient group had significantly higher
preoperative rates of obesity (79.4 percent ver-
sus 44.6 percent; p < 0.001), American Society of
Anesthesiologists class 3 or higher classification
(65.8 percent versus 18.3 percent; p < 0.001),
prior operation within 30 days (0.5 percent ver-
sus 0.1 percent; p = 0.01), congestive heart fail-
ure (1.7 percent versus 0.1 percent; p < 0.001),
percutaneous coronary intervention (0.9 per-
cent versus 0.2 percent; p = 0.01), hypertension
(68.2 percent versus 21.7 percent; p < 0.001), and
peripheral vascular disease requiring surgery (0.4
percent versus 0.1 percent; p = 0.03). Patients with
diabetes also had a significantly higher rate of
history of stroke with neurologic deficit (0.5 per-
cent versus 0 percent; p < 0.001), dialysis require-
ment (1.0 percent versus 0.3 percent; p < 0.001),
chronic obstructive pulmonary disease (6.9 per-
cent versus 1.0 percent; p < 0.001), bleeding dis-
orders (3.6 percent versus 0.9 percent; p < 0.001),
preoperative transfusion (1.2 percent versus 0.1
percent; p < 0.001), sepsis (3.5 percent versus 0.6
percent; p < 0.001), open or infected wound (10.6
percent versus 1.6 percent; p < 0.001), and recent
use of steroids (2.3 percent versus 1.2; p = 0.01)
(Table 1).
Univariate analysis showed that diabetic
patients presented significantly higher rates of
wound complications, including superficial inci-
sional surgical-site infection (8.1 percent versus
3.5 percent; p < 0.001), deep incisional surgical-
site infection (3.8 percent versus 1.2 percent; p <
0.001), deep organ/space surgical-site infection
(0.6 percent versus 0.2 percent; p = 0.02), and
wound dehiscence (2.6 percent versus 1.1 per-
cent; p = 0.001). Diabetic patients also had higher
rates of reoperation (5.8 percent versus 3.3 per-
cent; p = 0.001), readmission (2.1 percent versus
0.9 percent; p = 0.01), postoperative bleeding/
transfusions up to 72 hours postoperatively (7.9
percent versus 4.1 percent; p < 0.001), stroke with
deficit (0.3 percent versus 0 percent; p < 0.001),
acute renal failure (0.4 percent versus 0 percent; p
< 0.001), reintubation (1.2 percent versus 0.1 per-
cent; p < 0.001), mechanical ventilation greater
than 48 hours (1.6 percent versus 0.1 percent; p
< 0.001), myocardial infarction (0.3 percent ver-
sus 0 percent; p = 0.002), pneumonia (1.0 percent
versus 0.2 percent; p < 0.001), urinary tract infec-
tion (1.3 percent versus 0.6 percent; p = 0.02),
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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
sepsis (2.9 percent versus 0.6 percent; p < 0.001),
and septic shock (0.9 percent versus 0.1 percent;
p < 0.001). Operative time was significantly shorter
(160.7 ± 80.9 minutes versus 177.9 ± 91.4 minutes;
p < 0.001), whereas the postoperative hospital
length of stay was significantly longer (3.2 ± 5.2
days versus 1.6 ± 7.4 days; p < 0.001) in the diabetic
patient group (Table 2).
Multivariate regression for outcomes with sig-
nificant differences between diabetic and nondia-
betic groups on univariate analysis demonstrated
that diabetic patients were significantly more
likely to develop wound dehiscence (OR, 1.92;
95 percent CI, 1.41 to 3.15; p = 0.02). Other risk
factors for wound dehiscence included obesity
(OR, 1.61; 95 percent CI, 1.11 to 3.89; p = 0.03),
open or infected wound at surgery (OR, 3.13; 95
percent CI, 1.79 to 6.34; p = 0.01), recent signifi-
cant weight loss (OR, 9.25; 95 percent CI, 2.43
to 41.19; p = 0.004), superficial incisional surgi-
cal-site infection (OR, 6.48; 95 percent CI, 1.94
to 15.22; p = 0.001), deep incisional surgical-site
infection (OR, 4.53; 95 percent CI, 2.64 to 6.14;
p = 0.01), and deep organ/space surgical-site
infection (OR, 2.72; 95 percent CI, 1.82 to 4.46;
p = 0.03). Obesity and smoking were significant
risk factors for superficial incisional surgical-site
infection (OR, 2.78; 95 percent CI, 1.53 to 3.69;
p < 0.001; and OR, 1.42; 95 percent CI, 1.19 to
1.75; p = 0.03) and deep incisional surgical-site
infection (OR, 1.52; 95 percent CI, 1.38 to 3.97;
p = 0.01; and OR, 1.63; 95 percent CI, 1.31 to
2.22; p = 0.02). Superficial incisional surgical-site
infection (OR, 1.63; 95 percent CI, 1.25 to 3.18;
p = 0.01), deep incisional surgical-site infection
(OR, 38.97; 95 percent CI, 21.43 to 120.67; p <
0.001), and deep organ/space surgical-site infec-
tion (OR, 6.12; 95 percent CI, 1.31 to 42.08;
p = 0.001) were significant risk factors for subse-
quent reoperation (Table 3).
Septic shock was a risk factor for reintuba-
tion (OR, 18.11; 95 percent CI, 3.19 to 110.72;
p = 0.02) and mechanical ventilation for longer
than 48 hours (OR, 23.52; 95 percent CI, 4.62
to 137.08; p = 0.01). Patients with postoperative
wound dehiscence were at increased risk for
readmission (OR, 14.22; 95 percent CI, 6.09 to
45.19; p < 0.001) and reoperation (OR, 6.03; 95
percent CI, 2.31 to 11.69; p = 0.001). Reopera-
tion (B coefficient, 4.79; 95 percent CI, 2.51 to
7.03; p < 0.001) was a significant risk factor for
reintubation (OR, 18.11; 95 percent CI, 3.19 to
110.72; p = 0.02) and longer hospital length of
stay (B coefficient, 4.79; 95 percent CI, 2.51 to
7.03; p < 0.001) (Table 4).
 Table 3.  Multivariate Regression Analysis of Wound Complications and Reoperation
Superficial Incisional SSI Deep Incisional SSI Wound Dehiscence Reoperation
Variable OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p
Diabetes 1.05 0.67–1.25 0.44 1.22 0.83–1.85 0.53 1.92 1.41–3.15 0.02* 0.94 0.74–1.89 0.35
Obese 2.78 1.53–3.69 <0.001* 1.52 1.38–3.97 0.01* 1.61 1.11–3.89 0.03* 1.33 0.85–2.87 0.09
Smoker 1.42 1.19–1.75 0.03* 1.63 1.31–2.22 0.02* 1.45 0.88–1.71 0.15 — 0.84
Open/infected wound at surgery 1.12 0.73–2.31 0.62 0.85 0.49–2.13 0.38 3.13 1.79–6.34 0.01* 0.84 0.45–1.67 0.49
Recent significant weight loss 0.85 0.32–5.16 0.72 1.01 0.39–2.08 0.23 9.25 2.43–41.19 0.004* 1.31 0.56–6.52 0.62
Superficial incisional SSI — — 6.48 1.94–15.22 0.001* 1.63 1.25–3.18 0.01*
Deep Incisional SSI — — 4.53 2.64–6.14 0.01* 38.97 21.43–120.67 <0.001*
Deep organ/space SSI — — 2.72 1.82–4.46 0.03* 6.12 1.31–42.08 0.001*
Wound dehiscence — — — 6.03 2.31–11.69 0.001*
SSI, surgical-site infection; OR, odds ratio (categorical variables) or B coefficient (continuous variables).
*Statistically significant.
Volume 142, Number 4 • Abdominal Panniculectomy

Table 4.  Multivariate Regression Analysis of Medical Complications, Readmission, and Hospital Length of Stay
Mechanical Postoperative
Sepsis Reintubation Ventilation > 48 Hr Readmission Hospital LOS
Variable OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p B 95% CI p
Diabetes 1.43 0.74–3.28 0.21 1.09 0.47–11.02 0.71 0.66 0.21–1.17 0.31 1.24 0.79–1.92 0.28 −0.61 −1.88–1.37 0.24
COPD 2.04 0.69–7.57 0.19 42.47 4.03–594.72 0.004* 3.17 1.78–31.24 0.02* 1.03 0.56–1.37 0.25 1.42 −3.73–2.75 0.32
Deep organ/space SSI 41.12 7.41–371.29 0.001* — 0.99 — 0.99 1.27 0.94–2.09 0.06 4.72 2.53–6.52 0.01*
Wound dehiscence 0.76 0.15–3.27 0.31 — 0.98 4.56 0.79–94.11 0.19 14.22 6.09–45.19 <0.001* 8.42 5.17–11.03 <0.001*
Septic shock — 18.11 3.19–110.72 0.02* 23.52 4.62–137.08 0.01* — 0.99 1.61 1.24–4.70 0.02*
Reoperation 1.30 0.75–2.91 0.28 19.18 2.07–342.13 0.03* 2.48 0.71–5.09 0.31 — 0.99 4.79 2.51–7.03 <0.001*
LOS, length of stay; B, beta coefficient; COPD, chronic obstructive pulmonary disease; SSI, surgical-site infection.
*Statistically significant.

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 Plastic and Reconstructive Surgery • October 2018
DISCUSSION
Our study examined early postoperative out-
comes following panniculectomy, with an empha-
sis on the impact of diabetes mellitus. The rate
of diabetes mellitus in patients in our study (10.9
percent) was comparable to the reported national
prevalence of the disease in the United States.7
The impact of diabetes mellitus on outcomes fol-
lowing panniculectomy remains controversial.
Previously published studies evaluating outcomes
following abdominal dermal lipectomy have
focused on panniculectomy, abdominoplasty, or
both. In an analysis of outcomes following 25,478
abdominoplasties, Winocour et al. concluded
that diabetes mellitus was not a significant risk
factor for major complications.20 Similarly, Greco
et al. did not find diabetes mellitus alone to be
a significant predictor of complications following
abdominoplasty and panniculectomy.21 Moreover,
Rollins et al. did not find compelling evidence
for an association between hemoglobin A1c lev-
els and adverse postoperative outcomes or com-
plications.22 Interestingly, Zavlin et al. showed
that although patients with metabolic syndrome
undergoing panniculectomy were at a significantly
higher risk of developing postoperative complica-
tions, diabetes mellitus by itself was not a signifi-
cant risk factor.16 In contrast, other studies have
demonstrated that diabetes mellitus significantly
increased the risk of postoperative wound compli-
cations in patients undergoing abdominoplasty.23
In a large retrospective review of the CosmetAs-
sure database, Bamba et al. demonstrated that dia-
betes mellitus was an independent risk factor for
major complications following all aesthetic pro-
cedures, and abdominoplasty specifically.15 The
primary outcome, however, was a composite and
included hematoma, infection, venous thrombo-
embolism, fluid overload, hypotension, and pul-
monary and cardiac complications. Interestingly,
the effect of diabetes mellitus on various wound
complications was not evaluated.
In our study, univariate analysis showed that
rates of wound complications including super-
ficial and deep incisional surgical-site infection,
deep organ/space surgical-site infection, and
wound dehiscence—in addition to other adverse
outcomes—were significantly higher in the dia-
betic patient group. However, after adjusting for
confounders through regression analysis, diabetes
mellitus was found to be a significant independent
risk factor for only wound dehiscence but not
for any other wound complications. The associa-
tion between diabetes mellitus and postoperative
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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
wound dehiscence is poorly defined, but preclini-
cal data from animal models suggests that diabe-
tes mellitus is associated with decreased wound
healing, collagen density, and tensile strength,
leading to increased rates of wound dehiscence.24
These impairments are further compounded by
the microvasculopathy inherent in diabetes mel-
litus and its effects on wound healing and regen-
eration.12 In addition, wound healing has been
shown to be impaired in diabetic phenotypes
even after normalization of blood glucose levels,
because of accumulation of advanced glycated
end-products leading to increased reactive oxy-
gen species.25 Overall, our clinical data are in line
with these physiologic observations of impaired
diabetic wound healing.
In addition to associating diabetes mellitus
with complications, our data showed that wound
dehiscence was associated with postoperative
wound infections. This is consistent with previous
studies, which demonstrated that wound infec-
tion is a strong predictor of wound dehiscence.26
Similarly, significant preoperative weight loss was
associated with an increased risk of postoperative
wound dehiscence in our study. Unfortunately, we
are unable to determine how many patients in our
cohort underwent previous weight reduction sur-
gery, but bariatric patients are well known to have
significant nutritional impairments that might
affect wound healing,27 highlighting the impor-
tance of patient nutritional status before surgery.
Wound healing is known to be nutrition-depen-
dent, with protein playing a fundamental role in
achieving maximal wound tensile strength.28,29 In
a study exploring protein supplementation in bar-
iatric patients undergoing abdominoplasty, Austin
et al. show that preoperative protein nutritional
supplementation significantly decreases post-
operative wound healing complication rates.30
Furthermore, Agha-Mohammadi and Hurwitz
demonstrate that nutritional supplementation
in both obese post–bariatric surgery patients and
obese non–bariatric surgery patients can lead to
enhanced recovery and decreased wound com-
plications after abdominal dermal lipectomy.31
Recent significant weight loss should therefore be
a consideration in the workup of potential pannic-
ulectomy patients; future research may help delin-
eate the precise relationship between amount of
weight loss, period of time of weight loss, and
proximity to surgery with postoperative compli-
cations, which may help guide management and
improve outcomes.
Our analysis also confirmed that obesity and
smoking were significant risk factors for superficial
 Volume 142, Number 4 • Abdominal Panniculectomy
and deep incisional surgical-site infection. These
results are consistent with many previous studies
showing that obese patients are more prone to
wound healing impairment and infection because
of a chronic inflammatory and immunomodula-
tory state.32 Furthermore, obesity has been shown
to be strongly associated with wound infections
following abdominoplasty20,21,33,34 and pannicu-
lectomy16,17 specifically. The impact of smoking
on wound infections has also been extensively
explored in the surgical literature,35–39 with a
strong consensus that smoking is associated with
an increased risk of wound infections. This has
also been shown in patients undergoing pannic-
ulectomy16 and abdominoplasty.23,40 The adverse
effects of smoking are thought to be multifactorial
in nature,38 with alterations in wound tissue micro-
environment,41 oxygenation,42 aerobic metabo-
lism,43 and immune bactericidal functions44
playing important roles in the pathophysiology.
An important finding of our study is that
wound complications including superficial inci-
sional, deep incisional, and deep organ/space
surgical-site infection and wound dehiscence were
associated with a significantly increased rate of
reoperation. Wound dehiscence was also a signifi-
cant risk factor for readmission and longer post-
operative hospital length of stay, whereas deep
organ/space surgical-site infection significantly
increased the risk of sepsis. These findings high-
light the critical need to implement all available
surgical-site infection prevention resources and
guidelines45 to minimize the risk of wound com-
plications, subsequent reoperations, and resul-
tant patient adverse events. The higher risks of
readmission and longer postoperative hospital
length of stay associated with wound complica-
tions are consistent with published data demon-
strating that patients with surgical-site infection
had an almost 6-fold increase in rate of readmis-
sion and a hospital length of stay that was twice as
long as that in patients without surgical-site infec-
tion.46 The financial burden on annual hospital
revenue associated with these surgical-site infec-
tions was estimated to be $3,255,034,46 underlin-
ing the financial incentive to wound complication
prevention as well. It is also important to note
that although wound dehiscence increased the
risk of reoperation and longer hospital length of
stay, diabetes mellitus did not. This may be partly
explained by the association between wound
dehiscence and wound infections, which were in
turn associated with reoperation.
The American College of Surgeons National
Surgical Quality Improvement Program database
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
and our study have several limitations. Postopera-
tive data are limited to 30 days, which restricts our
ability to define the true effect of diabetes mellitus
on long-term outcomes following panniculectomy.
The lack of information about patient surgical
history, including bariatric surgery and surgical
technique, also adds limitations to our study. Our
study does not exclude patients undergoing con-
comitant procedures with panniculectomy, which
might explain the occurrence of deep organ/
space infections in some patients. In addition,
our study and the American College of Surgeons
National Surgical Quality Improvement Program
database rely on accurate data reporting by par-
ticipating hospitals, and some abdominoplasty
cases may have been erroneously coded using the
panniculectomy CPT code. Furthermore, diabetes
mellitus is coded as a categorical variable in the
database without data regarding hemoglobin A1c
levels or perioperative blood glucose levels, which
would allow us to evaluate the impact of severity
of diabetes mellitus on postoperative outcomes.
Although our study shows significant associations
between diabetes and certain postoperative out-
comes, it is important to note that no associations
can be made between diabetes mellitus severity
and outcomes. The increased rate of complica-
tions might be attributable to patients with the
severe spectrum of the disease rather than those
with well-controlled diabetes mellitus. Future pro-
spective studies are needed to analyze the effect of
diabetes mellitus and disease severity on long-term
outcomes in patients undergoing panniculectomy
while accounting for these more specific details.
CONCLUSIONS
Evaluation of the association between diabetes
mellitus and panniculectomy in a large nationwide
cohort of patients shows that diabetic patients are
at a significantly higher risk of developing post-
operative wound dehiscence independent of
many of the comorbidities often associated with
diabetes mellitus and obesity. Surgical-site infec-
tions, obesity, presence of open/infected wounds,
and recent significant weight loss were also sig-
nificant risk factors for wound dehiscence in all
patients. Furthermore, obesity and smoking sig-
nificantly increased the risk of superficial and
deep incisional surgical-site infections. Along with
the increased hospital length of stay, consequent
comorbidities, and financial implications, these
results underscore the importance of preopera-
tive risk factor evaluation in patients undergoing
panniculectomy for safe outcomes.
469e
 Plastic and Reconstructive Surgery • October 2018
Daniel J. Ceradini, M.D.
Hansjörg Wyss Department of Plastic Surgery
New York University Langone Medical Center
305 East 33rd Street
New York, N.Y. 10016
daniel.ceradini@nyumc.org
DISCLAIMER
The American College of Surgeons National Surgi-
cal Quality Improvement Program and participating
hospitals are the source of the data used herein; they have
not verified and are not responsible for the statistical
validity of the data analysis or the conclusions derived
by the authors.
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