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ORIGINAL ARTICLE
Year : 2016  |  Volume : 35  |  Issue : 2  |  Page : 79-82

Histopathological changes in subcutaneous tissue of post bariatric patients, a possible cause of defective healing


Department of General Surgery, Faculty of Medicine, Fayoum University, Al Fayoum, Egypt

Date of Submission26-Sep-2015
Date of Acceptance07-Jan-2016
Date of Web Publication20-May-2016

Correspondence Address:
Ghada Morshed
MD, MRCS, 9 Said Zo El Fokkar, Manial, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1121.182765

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  Abstract 

Background
After bariatric surgery, many patients are contented with the progress in loosing weight; but on the other hand, they become frustrated by the developing fat apron. At this point, patients should perform body contouring and to work out a proper treatment plan. The most common body contouring surgical procedure after massive weight loss is abdominoplasty.
Methods
The study started from January 2014 to January 2015 in Elfayoum University hospital , this study included 25 post bariatric consecutive patients. We presented data on patient demographics, operative procedures, wound complications and revision surgeries.All excised specimen was sent for histopathology. The aim of the study is to detect the histopathological changes in subcutaneous fatty layer and its correlation with post bariatric wound healing complications.
Results
Wound complications occurred in 15 abdominoplasty patients, surgical revision was necessary in 9 of these patients. These problems were associated with microscopic findings, applied on the cutaneous and subcutaneous tissue taken from the horizontal scar during abdominoplasty.
Conclusions
With the increasing number of high weight loss patients, the need for body-contouring surgeries increases. Surgeons operating on post bariatric patients should be concerned that they are not handling healthy structures, therefore, accurate knowledge of microscopic changes in these patients is necessary for a better choice of reconstructive procedure and avoidance of complications.

Keywords: Body contouring, microscopic changes, post bariatric, wound healing


How to cite this article:
Morshed G. Histopathological changes in subcutaneous tissue of post bariatric patients, a possible cause of defective healing. Egypt J Surg 2016;35:79-82

How to cite this URL:
Morshed G. Histopathological changes in subcutaneous tissue of post bariatric patients, a possible cause of defective healing. Egypt J Surg [serial online] 2016 [cited 2020 Apr 1];35:79-82. Available from: http://www.ejs.eg.net/text.asp?2016/35/2/79/182765


  Introduction Top


Obesity is one of the leading health problems in our country. After bariatric surgery, many patients are content with the progress in weight loss, but they become frustrated with the developing fat apron. At this point, patients should undergo body contouring and work out a proper treatment plan. The most common body-contouring surgical procedure after massive weight loss is abdominoplasty [1],[2],[3],[4],[5],[6],[8],[9],[10],[11],[12],[13],[14]. Fraccalvieri et al. [4] found that the complication rate in the postobese patient is higher than the complication rate in cosmetic patients in their 4-year clinical experience with abdominoplasties.

The aim of the study was to detect the histopathological changes in the subcutaneous fatty layer and its correlation with postbariatric wound-healing complications.


  Patients and methods Top


This study was conducted on 25 consecutive post bariatric patients (20 Laparoscopic Sleeve Gastrectomy (LSG) and 5 Laparoscopic Greater Curvature Plication (LGCP)) from January 2014 to January 2015 in El Fayoum University Hospital. Informed consent was taken from all patients. The time interval between bariatric and body-contouring surgeries was 6 months [Figure 1],[Figure 2] and [Figure 3]. The preoperative laboratory tests of three patients revealed only mild anemia, which was treated with iron supplements before surgery, but there was no disturbance of liver and kidney function tests and albumin levels were normal. Five patients had controlled diabetes.
Figure 1: Division of the vascular supply of the greater curvature of the stomach.

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Figure 2: Gastrectomy using a stapler 6cm proximal to the pylorus LSG.

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Figure 3: Plicated stomach.

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All excised specimens were sent for histopathology after abdominoplasty.


  Results Top


Wound complications occurred in 15 abdominoplasty patients, surgical revision was necessary in 9 of these patients [Figure 4]a and b. These problems were associated with microscopic findings, applied on the tissues taken from the horizontal scar during abdominoplasty, we documented anomalies of the dermal elastic (overgrowth, and polyfragmented aspect) and collagen (degenerated and sclerosed) fibers [Figure 5] and [Figure 6] with collapsed adipocytes [Figure 7].
Figure 4: (a and b) Abdominoplasty after bariatric surgery.

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Figure 5: Dermal elastic (overgrowth, and polyfragmented aspect) and collagen (degenerated and sclerosed) fibers.

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Figure 6: Dermal elastic (overgrowth, and polyfragmented aspect) and collagen (degenerated and sclerosed) fibers.

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Figure 7: Collapsed adipocytes.

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All these results were compared by a study which was done with non post bariatric patients undergoing abdominoplasty which included 20 patients. Abdominoplasty was done successfully in all patients [Figure 8]. Complication rate was 20% in the form of seromas, but no major complications were recorded.
Figure 8: Abdominoplasty Post Non bariatric surgery weight loss.

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  Discussion Top


With the increasing rate of morbidly obese patients and the need for bariatric surgery, an increasingly larger number of patients are seeking extensive body-contouring procedures. Nowadays, relatively more lower body lift surgeries are performed instead of classic abdominoplasties alone. In our study wound complications occurred in 15 abdominoplasty patients (3.75%), and surgical revision was necessary in nine of these patients. These problems were associated with microscopic findings from tissues taken from the horizontal scar during abdominoplasty. We documented anomalies in the dermal elastic (overgrowth, serpiginous, and polyfragmented) and collagen (degenerated and sclerosed) fibers.

Furthermore, Fraccalvieri and other authors found seroma as the most frequent complication of abdominoplasties [2],[4],[5],[12],[15]. Walgenbach et al. [16] found a new approach to decrease seroma formation using TissueGlu (Cohera Medical, Inc., USA) Surgical Adhesive, which is used in the management of wound drainage following abdominoplasty.

Fang et al. [17] found that flap elevation in a plane superficial to the standard suprafascial approach during abdominoplasty may decrease seroma formation. In my own surgical practice in a previous paper for abdominoplasty after bariatric surgeries, I preserved the costomarginal branch of the deep superior epigastric artery during undermining to ensure adequate vascular supply to the superior flap, and limited lateral undermining not extending past the anterior axillary line as well as limited the excision or suction in order to reduce the risk for flap necrosis; I also undermined the skin and subcutaneous tissue superficial to the suprafascial plane, thus decreasing the rate of seroma [18].

In contrast, several publications show higher rates for wound-healing deficits than seromas, which correspond with my personal findings. In their review of body contouring in super obese patients Mericli and Drake [1] found wound-healing deficits in 32% and seromas in 13%. Also, Taylor and Shermak [9] reported in their work on body contouring following massive weight loss a higher rate of wound breakdowns (20%) than seromas (16%). Vico et al. [10] showed in the study on circumferential body contouring in bariatric and nonbariatric patients similar low rates of 3.5-5% as ours for seromas.


  Conclusion Top


With the increasing number of high weight loss patients, the need for body-contouring surgeries has increased. Surgeons operating on postbariatric patients should take into consideration the fact that they are not handling healthy body structures, and therefore accurate knowledge of microscopic changes in these patients is necessary for a better choice of reconstructive procedures and for avoidance of complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mericli AF, Drake DB. Abdominal contouring in super obese patients: a single-surgeon review of 22 cases. Ann Plast Surg 2011; 66(5): 523-527.  Back to cited text no. 1
    
2.
Stewart KJ, Stewart DA, Coghlan B, Harrison DH, Jones BM, Waterhouse N. Complications of 278 consecutive abdominoplasties. J Plast Reconstr Aesthet Surg 2006; 59(11): 1152-1155.  Back to cited text no. 2
    
3.
Zuelzer HB, Ratliff CR, Drake DB. Complications of abdominal contouring surgery in obese patients: current status. Ann Plast Surg 2010; 64(5): 598-604.  Back to cited text no. 3
    
4.
Fraccalvieri M, Datta G, Bogetti P, Verna G, Pedrale R, Bocchiotti MA, et al. Abdominoplasty after weight loss in morbidly obese atients: a 4-year clinical experience. Obes Surg 2007; 17:1319-1324.  Back to cited text no. 4
    
5.
Neaman KC, Hansen JE. Analysis of complications from abdominoplasty: a review of 206 cases at a university hospital. Ann Plast Surg 2007; 58(3): 292-298.  Back to cited text no. 5
    
6.
Shermak MA. Body contouring. Plast Reconstr Surg 2012;129:963e-968e.  Back to cited text no. 6
    
7.
Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development following body contouring surgery for massive weight loss: patient risk factors and treatment strategies. Plast Reconstr Surg 2008; 122(1): 280-288.  Back to cited text no. 7
    
8.
Shermak MA, Chang D, Magnuson TH, Schweitzer MA. An outcomes analysis of patients undergoing body contouring surgery after massive weight loss. Plast Reconstr Surg 2006;118(4): 1026-1031.  Back to cited text no. 8
    
9.
Taylor J, Shermak M. Body contouring following massive weight loss. Obes Surg 2004; 14(8): 1080-1085.  Back to cited text no. 9
    
10.
Vico PG, De Vooght A, Nokerman B. Circumferential body contouring in bariatric and non-bariatric patient. J Plast Reconstr Aesthet Surg 2010; 63(5): 814-819.  Back to cited text no. 10
    
11.
Colwell AS. Current concepts in post-bariatric body contouring. Obes Surg 2010; 20(8): 1178-1182.  Back to cited text no. 11
    
12.
Greco JA 3 rd , Castaldo ET, Nanney LB, Wendel JJ, Summitt JB, Kelly KJ, et al. The effect of weight loss surgery and body mass index on wound complications after abdominal contouring operations. Ann Plast Surg 2008; 61(3): 235-242.  Back to cited text no. 12
    
13.
Agha-Mohammadi S, Hurwitz DJ. Enhanced recovery after body-contouring surgery: reducing surgical complication rates by optimizing nutrition. Aesthetic Plast Surg 2010; 34(5): 617-625.  Back to cited text no. 13
    
14.
Richter DF, Stoff A. Lower body contouring procedures. Chirurg. 2011; 82(9): 797-800.  Back to cited text no. 14
    
15.
Spiegelman JI, Levine RH. Abdominoplasty: a comparison of outpatient and inpatient procedures shows that it is a safe and effective procedure for outpatients in an office-based surgery clinic. Plast Reconstr Surg 2006; 118(2): 517-522. (discussion 523-534).  Back to cited text no. 15
    
16.
Walgenbach KJ, Bannasch H, Kalthoff S, Rubin JP. Randomized, prospective study of TissuGlu® surgical adhesive in the management of wound drainage following abdominoplasty. Aesthetic Plast Surg 2012; 36(3): 491-496.  Back to cited text no. 16
    
17.
Fang RC, Lin SJ, Mustoe TA. Abdominoplasty flap elevation in a more superficial plane: decreasing the need for drains. Plast Reconstr Surg 2010; 125(2): 677-682.  Back to cited text no. 17
    
18.
Morshed G. Abdominoplasty following weight loss: what is new? Kasr El-Aini Med J 2012; 18:57-61.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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