What is the difference between a panniculectomy and a tummy tuck?

What is a pannus?

“Pannus” comes from Latin, meaning “cloth.” By definition, a pannus is a condition in which a layer of vascular, fibrous tissue extends over the surface of another organ or specialized anatomical structure. A pannus is a “covering” or “apron” of tissue that covers a neighboring structure. A pannus can occur in the cornea, trachea, and heart. In plastic surgery, the pannus usually refers to the abdominal pannus. The abdominal pannus is the area of excess skin and fat that hangs over the pubic region. The pannus is often described as an apron of lower abdominal skin and fat. Occasionally, the pannus may contain a hernia.

Often with weight gain and weight loss, there is an accumulation of residual fat in the lower abdomen. Because of gravity and weak skin, the lower abdominal fat pulls the abdominal skin. There are attachments of the skin to the pelvis and the top of the pubic bone. These fixation points, reduced skin elasticity, and an extensive collection of fat contribute to the creation of a pannus. Theses factors can create the apron or hammock distribution of skin and fat in the lower abdomen from hip to hip.

What is a panniculectomy?

A panniculectomy is a surgical procedure that removes the abdomen pannus. During a panniculectomy, an incision is made underneath the skin apron, and tissue dissection is carried upwards. Dissection is carried for several inches until the pannus is surrounded. Usually, this is only 3 to 4 inches up the anterior abdominal wall. Then, the skin and fat of the pannus are excised. Drains are placed, and the wound is closed in multiple layers with sutures.

A panniculectomy is performed under general anesthesia with a anesthesiologist. Often, the panniculectomy is covered by your medical insurance. Recovery time for a panniculectomy is approximately 2-3 weeks before you can return to a sitting type job. If your job entails a lot more physical activity, your return to work is about 3-4 weeks after a panniculectomy.

The advantages of a panniculectomy include the eradication of excess skin and fat above the pubic region. Another advantage is the permanent elimination of rashes underneath the abdominal pannus. One disadvantage of a panniculectomy is that the anterior abdominal wall is not repaired. Thus, after a panniculectomy, you may still have a protuberant abdomen from the sternum to the pubic region. However, the excess skin and fat that draped or hung over the pubic area are gone. Another disadvantage of the panniculectomy is that not as much skin and fat are removed, compared to a tummy tuck. Another downside with a panniculectomy is that the belly button is unchanged, and the belly button is left in its original state. Another disadvantage with a panniculectomy (by definition) is that no hernias can be repaired. The hernias would either have to be fixed in a second procedure or during an extension of the panniculectomy.

What is a tummy tuck?

A tummy tuck entails three separate components: muscle plication, removal of lower abdominal skin and fat, and the repositioning of the belly button. During a tummy tuck, an incision is made in the lower abdomen, where the abdominal overhang meets the pubic region. From this incision, tissue dissection is done to the belly button, then to the bottom of your rib cage and then, to the bottom of your sternum. Having undermined these areas, this frees up all the attachments of the skin and fat to the underlying rectus abdominis muscle. With weight gain, weight loss, pregnancy, delivery, the rectus abdominis muscles, and fascia are stretched and weakened. The rectus abdominis muscles and fascia do not have many elastic fibers; often, these muscle fibers do not bounce back after weight loss or after pregnancy. Many patients are left with a distended abdomen after weight loss. This protuberant abdomen can be either due to the weak abdominal fascia or increase in the size of the intra-peritoneal cavity or both. During a tummy tuck after the anterior abdominal wall is exposed, two layers of permanent sutures are placed in the muscle fascia. One layer is positioned as an interrupted fashion from the bottom of the sternum to the bottom of the pubic region. A second layer is placed on top of this to secure the bottom layer. On larger patients, muscle plication may be needed perpendicular to the aforementioned vertical suture line. This creates a cross-like pattern centered around the belly button. This plication is achieved with permanent sutures.

The second stage of the tummy tuck involves the permanent removal of excess skin and fat. Typically, skin from the top of the pubic region or below a C-section scar to the top of the belly button and even higher can be permanently eliminated. By doing the dissection, as mentioned above with muscle plication, the skin and fat are loosened from their underlying attachments. This allows the skin above the belly button to be pulled down and moved to the pubic region. This achieves the permanent removal of excess skin and fat from the lower abdomen. The fascia, fat, and skin are then closed with sutures. Several drains are placed.

The third step of the tummy tuck entails the repositioning of the belly button. This is done by making an incision on the new anterior abdominal wall. The belly button is placed at the intersection of two lines. One line is a vertical line from the bottom of the sternum to the top of the dorsum of the penis or the clitoris. The other line is a horizontal line and is drawn from the top of the iliac crest or hip bones. The intersection of these lines is where the belly button should be repositioned. A small stab incision is made, and the belly button is presented and anchored.

A tummy tuck is performed under general anesthesia with a anesthesiologist. Drains are kept in place for approximately 1-2 weeks. You should be able to return to a sitting type job at approximately 2-3 weeks. If your job is more physical, it may require 3-4 weeks before returning to work after a tummy tuck.

The advantages of a tummy tuck include the permanent plication and flattening of the abdominal wall and more elimination of skin and fat compared to the panniculectomy. Also, other advantages of a tummy tuck include repositioning and recreation of a better belly button and, if present, surgical correction of anterior abdominal wall hernias.

The disadvantages of a tummy tuck are few. However, one drawback of the tummy tuck is that sometimes, the tummy tuck scar may be longer than a panniculectomy scar. Another disadvantage of a tummy tuck is that it is usually not be covered by your medical insurance.

Panniculectomy versus Tummy Tuck

Insurance qualification

To qualify for insurance coverage for a panniculectomy, you need to meet specific criteria. Each insurance company is different; however, there are four standard criteria required for panniculectomy approval.

1) Your pannus must hang below the level of your pubis or pelvic bone. You will need to document that the abdominal apron covers the pubic region. This can be done by taking pictures of the affected area standing in front of a mirror.

2) If you have lost a significant amount of weight (100+ pounds), you must be at a stable weight for six months; if you had weight loss surgery, then, your weight must be stable for 18 months.

3) You must provide objective documented evidence of chronic skin rashes. Documentation should include pictures and medical records from your evaluation and treatment by your internist, dermatologist, or plastic surgeon's office. You should also provide documentation of medications, including topical creams, antibiotics, and antifungal that you have tried over the years to correct these chronic skin infections.

4) You must be able to document difficulty with ambulation or interference with activities of daily living.

CASE #1

CASE #2