Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. Body mass index (BMI) is a simple indicator of the relationship between weight and height used for the diagnosis of these conditions. Overweight is defined as BM ≥ 25 and obesity as BMI ≥ 30. Morbid obesity decreases life expectancy and produces disability, feelings of worthlessness and problems associated with social exclusion.

We report the case of a 53-year-old female patient who was referred from the inland of Corrientes with severe abdominal lipodystrophy associated with recurrent soft tissue infections, pressure ulcers on the panniculus morbidus due to contact with the floor, and functional disability over the past 10 years. She had no history of previous surgeries. On admission, the patient was alert and cooperative; her blood pressure was elevated, her weight was 210 kg, her height 1.50 m and the BMI was 93.3. The panniculus morbidus extended to both ankles and presented decubitus ulcers with a diameter of about 20 cm. Most ulcers were located at the distal end of the panniculus and were in contact with the floor. They had signs of inflammation, were painful and had purulent discharge. Laboratory tests were ordered, and the patient underwent multidisciplinary evaluation (hematologist, nephrologist, endocrinologist, intensivist, nutritionist, mental health specialist, pulmonologist and anesthesiologist). A computed tomography scan was performed to rule out abdominal wall defects, with normal results. Once the patient’s status was optimal, surgery was decided to provide treatment and a better quality of life.

Preoperative marking was done with the patient in the supine position, and pictures were taken (Fig. 1). Two surgical teams were established (2 anesthesiologists, 4 surgeons, 2 scrub nurses, and 2 circulating nurses). Under general anesthesia, after antisepsis and placement of surgical drapes, a suprapubic skin incision was made and extended bilaterally towards both anterior superior iliac spines, progressing through layers until reaching the aponeurosis of the abdominal muscles. Large size vessels in the subcutaneous cellular tissue were ligated for hemostasis. Panniculus morbidus dissection extended below the umbilicus and was excised en bloc (Fig. 2). The remaining skin was then pulled downward and medially, and a first stitch was done in the midline with Vicryl 1-0 and on both sides to be in line with the surgical incision. The abdominal wall was closed in anatomic layers with interrupted sutures using Vicryl 1-0, and the skin incision was sutured with Prolene 2-0. Suction drains were inserted and occlusive dressing and compression garment were placed. Operative time was 2 hours. After favorable emergence from anesthesia, the patient was admitted in the intensive care unit for clinical monitoring. She evolved with favorable outcome and was transferred to the general ward on postoperative day 2. Early mobilization and thromboprophylaxis were initiated. The drains were removed some days later, antibiotic therapy was stopped and the patient was discharged on postoperative day 10. Follow-up visits were scheduled once a week.

Figure 1 Initial workup after preoperative marking 

Figure 2 Perioperative sequence 

The patient is currently on the waiting list for bariatric surgery to further reduce her BMI, she is under treatment and is followed-up with a multidisciplinary team made up of nutritionists, psychologists, kinesiologists and psychiatrists. The main positive effect of the surgery is the dramatic change in the patient’s quality of life, since now she can walk, exercise and perform daily activities which were mechanically limited by the panniculus morbidus that was in contact with the floor and was recurrently ulcerated, causing soft tissue infections (Fig. 3).

Figure 3 Late postoperative follow-up (2 years) 

The first dermolipectomies were performed more than a century ago, while the most modern techniques were developed in the sixties. Vertical adbdominoplasty is an important technique that was undoubtedly pioneered by Julián C. Fernández and Miguel Correa-Iturraspe. In 1951, they introduced this technique as part of the fruitful work carried out at the Instituto de Clínica Quirúrgica, Hospital de Clínicas José de San Martín, Buenos Aires².

The first patients underwent this procedure for purely orthopedic purposes, with the intention of relieving them from the excess body weight that altered walking, and the association with lumbar pain, intertrigo under the panniculus and other disorders. As surgeons were mainly general surgeons, the procedure was intended only to solve abdominal wall defects or was associated with concomitant intra-abdominal interventions. At that time, Julian Fernandez and Miguel Correa-Iturraspe were not satisfied with the benefits offered by dermolipectomy via a horizontal incision and developed the vertical incision approach. They were convinced that this technique provided better contouring of the waist through a biological corset or skin corset, which was an innovative concept².

In 1962, Spadafora described the horizontal S-shaped incision, with upper undermining and transposition of the umbilicus. The technique is simple, well-designed, and rapid to perform; therefore, it has become one of the most widely used techniques in clinical practice, although with some modifications and tweaks in line with the natural progression of surgery³. Panniculectomy is presented as the only feasible option, not free from complications, to reduce the panniculus morbidus in serious cases of morbid obesity or after massive weight loss⁶.

Functional dermolipectomy and panniculectomy are the only therapeutic options capable of mitigating this unfavorable course and allow the patient to initiate a weight loss program. Neither diet nor bariatric surgery alone can reduce abdominal lipodystrophy once it has been established¹. Dermolipectomy is described as a surgical procedure involving sutures in the abdominal wall and skin resection. So far, there is no universal classification of abdominal deformities. One can infer that the deforming tetrad of the abdominal wall is constituted by obesity, intestinal bloating, gravity and muscle diastasis. The surgical techniques may be classified in vertical incisions, horizontal incisions and mixed incisions. It is important to mention, from the surgical point of view, that the diameter of the perforating vessels is larger externally to both semilunar lines, so that care must be taken with this anatomical detail during dissection to preserve blood flow and reduce the risk of complications associated with impaired blood perfusion⁵.

Dermolipectomy is a technique that has undergone modifications over time in relation with the demand and standards of each historical moment. This surgical procedure is used worldwide, has a well-defined sequence, is easy to perform, and can be associated with other procedures for abdominal wall repair such as rectus muscle plication and the use of prosthetic meshes, which reduce the number of recurrences of wall defects without modifying the cosmetic results⁴.

It should be noted that consultations for sequelae from previous abdominoplasties are increasing⁷. Treatment of the residual scar from a previous abdominal dermolipectomy will depend on the patient’s expectations and desires, which should be properly evaluated during the first visit to determine if the patient is aware of the results that can be achieved⁷.