title: A multivariate regression analysis of panniculectomy outcomes: does plastic surgery training matter?
abstract: BACKGROUND
  Panniculectomy can improve quality of life in morbidly obese patients, but its functional benefits are counterbalanced by relatively high complication rates. The authors endeavored to determine the impact of plastic surgery training on panniculectomy outcomes.
  
  
  METHODS
  A retrospective review was performed of the prospectively maintained American College of Surgeons National Surgical Quality Improvement Program database for all patients undergoing panniculectomy from 2006 to 2010. Patient demographic details, surgeon specialty training, and 30-day outcomes were assessed.
  
  
  RESULTS
  A total of 954 panniculectomies meeting inclusion criteria were identified. Plastic surgeons performed 694 (72.7 percent) of the procedures, and 260 (27.3 percent) were performed by nonplastic surgeons. Nonplastic surgeons had significantly higher rates of overall complications (23.08 percent versus 8.65 percent; p < 0.001) and wound infections (12.69 percent versus 5.33 percent; p < 0.001) than plastic surgeons. Average operative time for plastic surgeons was significantly longer than that for nonplastic surgeons (3.00 ± 1.48 hours versus 1.88 ± 0.93 hours; p < 0.001). Risk-adjusted multivariate regression showed that undergoing a panniculectomy by a nonplastic surgeon was a significant predictor of overall postoperative complications (odds ratio, 2.09; 95 percent CI, 1.35 to 3.23) and wound infection (odds ratio, 1.73; 95 percent CI, 1.004 to 2.98). Subgroup analysis of propensity-matched samples supported this finding.
  
  
  CONCLUSIONS
  Multivariate regression analysis of National Surgical Quality Improvement Program data showed that panniculectomy performed by plastic surgeons results in lower rates of overall postoperative complications compared with that performed by nonplastic surgeons.
authors.affiliation: Nashville, Tenn.; and Chicago, Ill. From the Vanderbilt School of Medicine and the Division of Plastic and Reconstructive Surgery, the Department of Surgery, and the Biostatistics Core, Northwestern University, Feinberg School of Medicine.
authors.forename: Lauren M
authors.initials: LM
authors.lastname: Mioton
authors.forename: Donald W
authors.initials: DW
authors.lastname: Buck
authors.forename: Michael S
authors.initials: MS
authors.lastname: Gart
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Hanwright
authors.forename: Edward
authors.initials: E
authors.lastname: Wang
authors.forename: John Y S
authors.initials: JYS
authors.lastname: Kim
mesh_terms: D061645:Abdominoplasty / Q000592:standards*; D002983:Clinical Competence; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012044:Regression Analysis; D012189:Retrospective Studies; D013518:Surgery, Plastic / Q000193:education*; D016896:Treatment Outcome
references.citation: Kelly H. Case 3, excessive growth of fat. Bull Johns Hopkins Hosp. 1899;10:197.
references.citation: Acarturk TO, Wachtman G, Heil B, Landecker A, Courcoulas AP, Manders EK. Panniculectomy as an adjuvant to bariatric surgery. Ann Plast Surg. 2004;53:360–366.
references.citation: Davis MM, Slish K, Chao C, Cabana MD. National trends in bariatric surgery, 1996–2002. Arch Surg. 2006;141:71–74.
references.citation: Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005;294:1909–1917.
references.citation: Pope GD, Birkmeyer JD, Finlayson SR. National trends in utilization and in-hospital outcomes of bariatric surgery. J Gastrointest Surg. 2002;6:855–860.
references.citation: Borud LJ, Warren AG. Body contouring in the postbariatric surgery patient. J Am Coll Surg. 2005;203:82–93.
references.citation: Mitchell JE, Crosby RD, Ertelt TW, et al.. The desire for body contouring surgery after bariatric surgery. Obes Surg. 2008;18:1308–1312.
references.citation: Blackburn GL. The 2008 Edward E. Mason Founders Lecture: Interdisciplinary teams in the development of "best practice" obesity surgery. Surg Obes Relat Dis. 2008;4:679–684.
references.citation: Iglesias M, Butron P, Abarca L, Perez-Monzo MF, de Rienzo-Madero B. An anthropometric classification of body contour deformities after massive weight loss. Ann Plast Surg. 2010;65:129–134.
references.citation: Petty P, Manson PN, Black R, Romano JJ, Sitzman J, Vogel J. Panniculus morbidus. Ann Plast Surg. 1992;28:442–452.
references.citation: Gurunluoglu R. Insurance coverage criteria for panniculectomy and redundant skin surgery after bariatric surgery: Why and when to discuss. Obes Surg. 2009;19:517–520.
references.citation: Leahy PJ, Shorten SM, Lawrence WT. Maximizing the aesthetic result in panniculectomy after massive weight loss. Plast Reconstr Surg. 2008;122:1214–1224.
references.citation: Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH. Body image and quality of life in post massive weight loss body contouring patients. Obesity 2006;14:1626–1636.
references.citation: Coriddi MR, Koltz PF, Chen R, Gusenoff JA. Changes in quality of life and functional status following abdominal contouring in the massive weight loss population. Plast Reconstr Surg. 2011;128:520–526.
references.citation: Cooper JM, Paige KT, Beshlian KM, Downey DL, Thirlby RC. Abdominal panniculectomies: High patient satisfaction despite significant complication rates. Ann Plast Surg. 2008;61:188–196.
references.citation: 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;118:1026–1031.
references.citation: Arthurs ZM, Cuadrado D, Sohn V, et al.. Post-bariatric panniculectomy: Pre-panniculectomy body mass index impacts the complication profile. Am J Surg. 2007;193:567–570.
references.citation: Zannis J, Wood BC, Griffin LP, Knipper E, Marks MW, David LR. Outcome study of the surgical management of panniculitis. Ann Plast Surg. 2011;68:194–197.
references.citation: Zemlyak AY, Colavita PD, El Djouzi S, et al.. Comparative study of wound complications: Isolated panniculectomy versus panniculectomy combined with ventral hernia repair. J Surg Res. 2012;177:387–391.
references.citation: Zuelzer HB, Ratliff CR, Drake DB. Complications of abdominal contouring surgery in obese patients: Current status. Ann Plast Surg. 2010;64:598–604.
references.citation: Manahan MA, Shermak MA. Massive panniculectomy after massive weight loss. J Plast Reconstr Aesthet Surg. 2006;117:2191–2197.
references.citation: Ferraris VA, Saha SP, Davenport DL, Zwischenberger JB. Thoracic surgery in the real world: Does surgical specialty affect outcomes in patients having general thoracic operations? Ann Thorac Surg. 2012;93:1041–1048.
references.citation: Coon D, Gusenoff JA, Kannan N, El Khoudary SR, Naghshineh N, Rubin JP. Body mass and surgical complications in the postbariatric reconstructive patient: Analysis of 511 cases. Ann Surg. 2009;249:397–401.
references.citation: 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;122:280–288.
references.citation: Chong T, Coon D, Toy J, Purnell C, Michaels J, Rubin JP. Body contouring in the male weight loss population: Assessing gender as a factor in outcomes. Plast Reconstr Surg. 2012;130:325e–330e.
references.citation: Khuri SF, Daley J, Henderson W, et al.. The Department of Veterans Affairs' NSQIP: The first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg. 1998;228:491–507.
references.citation: Khuri SF, Daley J, Henderson W, et al.. The National Veterans Administration Surgical Risk Study: Risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg. 1995;180:519–531.
references.citation: D'Agostino R. Tutorial in biostatistic propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med. 1998;17:2265–2281.
references.citation: Ingraham AM, Cohen ME, Bilimoria KY, Pritts TA, Ko CY, Esposito TJ. Comparison of outcomes after laparoscopic versus open appendectomy for acute appendicitis at 222 ACS NSQIP hospitals. Surgery 2010;148:625–637.
references.citation: Leichtle SW, Mouawad NJ, Welch K, Lampman R, Whitehouse WM Jr, Heidenreich M. Outcomes of carotid endarterectomy under general and regional anesthesia from the American College of Surgeons' National Surgical Quality Improvement Program. J Vasc Surg. 2012;56: 81–88.
references.citation: Greenblatt DY, Rajamanickam V, Pugely AJ, Heise CP, Eugene Foley, Kennedy GD. Short-term outcomes after laparoscopic-assisted proctectomy for rectal cancer: Results from the ACS NSQIP. J Am Coll Surg. 2011;212:844–854.
references.citation: Austin P. Some methods of propensity-score matching had superior performance to others: Results of an empirical investigation and Monte Carlo simulations. Biom J. 2009;51:171–184.
references.citation: Wang R, Lagakos SW, Ware JH, Hunter DJ, Drazen JM. Statistics in medicine: Reporting of subgroup analyses in clinical trials. N Engl J Med. 2007;357:2189–2194.
references.citation: Dijkman B, Kooistra B, Bhandari M. How to work with subgroup analysis. Can J Surg. 2009;52:515–522.
references.citation: Adamson PA, Strecker HD. Patient selection. Aesthetic Plast Surg. 2002;26(Suppl 1):S11.