The Potential Impact of Plastic Surgery Expertise on Body Contouring Procedure Outcomes

Abstract

Background

With the increasing demand for body contouring procedures in the United States over the past 2 decades, more surgeons with diverse specialty training are performing these procedures. However, little is known regarding the comparative outcomes of these patients.

Objectives

The purpose of this study was to compare outcomes of body contouring procedures based on the specialty training of the surgeon.

Methods

Data from the American College of Surgeons National Surgical Quality Improvement Program (2005-2015) were reviewed for all body contouring procedures. Patients were stratified by surgeon training (plastic surgery [PS] vs general surgery [GS]). Descriptive statistics and regression analyses were used to evaluate differences in outcomes.

Results

A total of 11,658 patients were included; 9502 PS cases and 2156 GS cases. Most were women (90.4%), aged 40 to 59 (52.7%) and white (79.5%). Compared with PS patients, GS patients were more likely to be obese (61.4% vs 40.6%), smokers (13.6% vs 9.8%), and with ASA classification ≥3 (35.3% vs 18.6%) (all P < 0.001). Abdominal contouring procedures were the most common (76%) cases. Multivariate regression revealed that compared with PS cases, those performed by GS practitioners were associated with increased wound and infectious complications (adjusted odds ratio [aOR], 1.81; 95% confidence interval [CI], 1.44-2.27), reoperation (aOR, 1.85; 95% CI, 1.31-2.62), and predicted mean length of stay (1.12 days; 95% CI, 0.64-1.60 days).

Conclusions

The variable outcomes in body contouring procedures performed by PS compared with GS practitioners may imply procedural-algorithmic differences between the subspecialties, leading to the noted outcome differential.

Level of Evidence: 2

Over the past 2 decades, social media has played a significant role in promoting body contouring procedures and the public’s impressions thereof.^1,2 In addition, readily accessible public displays of success stories related to weight loss and bariatric procedures have increased as well.³ In addition to vigorously influencing “normative” perceptions of the “ideal physique,” social media has become a vehicle for developing aspirations and promotion of overall well-being, both physically and mentally. More than 1,000,000 body contouring procedures were performed in the United States in 2018.⁴ With the increasing demand for body contouring, there is a growing need for surgeons to perform these procedures. This rising market has led surgeons from surgical specialties other than plastic surgery to perform these procedures as well.^5,6

Abdominal contouring procedures are among the most frequent that are performed by both plastic surgeons and surgeons of other surgical specialties.⁶ Some might argue these procedures should be limited to the purview of plastic surgery, whereas others feel it is reasonable for alternatively trained surgeons to perform these procedures. Mioton et al⁶ suggested, however, that panniculectomies performed by plastic surgeons result in lower rates of overall postoperative complications than those performed by surgeons from other specialties. Just as surgeons from other specialties must undergo vigorous training to master the clinical and surgical skills of that particular specialty, plastic surgeons are required to do the same. They must accomplish milestones and achieve competency in procedures within the realm of plastic surgery.⁷ Thus, formally trained plastic surgeons performing body contouring procedures should theoretically be well equipped to handle the complexities of weight-loss-related body contouring.

Although it is plausible that outcomes of body contouring procedures performed by plastic surgeons vs non–plastic surgeons might show variability, there are limited outcomes data comparing these provider groups. Therefore, the purpose of this study was to evaluate the outcomes of body contouring according to a national database and assess if surgical specialty was independently associated with these outcomes.

METHODS

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was conducted from 2005 to 2015 for all body contouring procedures. Patients were identified according to Current Procedural Terminology (CPT) codes for body contouring procedures including: panniculectomy (15830), abdominoplasty (15847), truncal lipectomy (15877), mastectomy for gynecomastia (19140, 19300), mastopexy (19316), and reduction mammaplasty (19318).

Demographic data extracted included age, sex, race/ethnicity, body mass index (BMI), and American Society of Anesthesiologists (ASA) classification. Comorbid conditions of interest included smoking status, diabetes, chronic obstructive pulmonary disease (COPD), dyspnea, hypertension, chronic steroid use, congestive heart failure, renal failure, and dialysis dependence. Additionally, intraoperative findings were collected including operative time and wound classification. The attending surgeon subspecialty was evaluated, with a focus on general surgeons and plastic surgeons. Patients treated by physicians from other surgical specialties were not included, as these comprised <0.5% of possible cohort patients. This group totaled 51 patients of whom 17 were treated by otolaryngologists, 15 by obstetricians/gynecologists, 11 by urologists, 4 by vascular surgeons, 2 by orthopedic surgeons, and 2 by neurosurgeons. Given these small sample sizes, we cannot make assessments on the outcomes of each of these specialties. To ensure the outcomes measured were not influenced by morbid conditions, patients listed with formal cancer diagnoses or having undergone emergency surgery, chemotherapy, or radiation therapy were excluded.

The three primary outcomes of interest were postoperative wound and infectious complication rates, reoperation rate, and hospital length of stay. The total number of deaths within the population was fewer than 20, and therefore we did not include this outcome within our analysis. Postoperative wound and infectious complications included multiple categories (superficial surgical site infection, deep surgical site infection, organ space infection, wound dehiscence, sepsis, and hospital-acquired pneumonia).

Descriptive statistics were used to compare demographic and comorbid characteristics of patients operated on by plastic surgeons and those operated on by general surgeons. Outcomes were then compared with Pearson’s chi-square tests for categoric variables and Wilcoxon rank sum tests for continuous variables. Multivariate regression models were then constructed to identify independent factors associated with the outcomes. Models accounted for surgical specialty, ASA classification, age, diabetes, smoking status, sex, wound classification, and BMI. Logistic regression models were used for wound/infectious complications as well as reoperation rates, whereas a linear regression model with gamma distribution was used to evaluate length of stay.

Additionally, in order to further homogenize the patients treated by the 2 provider groups, subgroup analyses were conducted by excluding patients undergoing “complex abdominal wall” procedures in an attempt to control for patient variability and case complexity. These patients were identified to have CPT codes including panniculectomy (15830), component separation (15734), insertion of acellular dermal allograft (15330, 15331), implantation of biologic mesh with hernia repair (15777), repair of initial or recurrent incisional or ventral hernia (49560, 49565), mesh implantation for open incisional or ventral hernia repair (49568), and adjacent tissue transfer for closure of deep tissue and superficial fascia (14301, 14302). As panniculectomy comprised a significant segment of the “complex abdominal wall” procedures, we performed a separate analysis excluding only panniculectomy.

All analyses were performed with Stata Statistical Software release 14.2 (StataCorp LLC, College Station, TX) and the significance level was set as P < 0.05. The data were collected in May 2019 and analyzed from June to September. The search was conducted and results were reviewed by D.R.B., G.N.W., O.A., O.A.O., I.J., D.M.B., G.O., and H.P. All authors were in agreement with the interpretation of results.

RESULTS

Patient Characteristics

A total of 11,658 patients were included in our study cohort. Of these patients, 9502 (82%) were treated by plastic surgeons. The majority of patients were female (n = 10,544 female; n = 1106 male) and white (68%) (Table 1). Most patients were between the ages of 40 and 59 years (53%), with an age range of 18 to 90 years and average ages of 47 and 48 years in patients treated by plastic and general surgeons, respectively. Patients treated by general surgeons were more likely to be obese than were patients treated by plastic surgeons (61.4% vs 40.6%, P < 0.001). The majority of patients had an ASA classification of 2, indicating mild systemic disease, although general surgery patients had a larger proportion of patients with an ASA score of 3 or greater, indicating severe systemic disease (35.3% vs. 18.6%, P < 0.001)

A comparative assessment of patient comorbidities identified 1222 smokers, making up 13.6% of general surgery patients and 9.8% of plastic surgery patients (P < 0.001). On evaluation of cardiac comorbidities, 23.5% of plastic surgery patients and 33.7% of general surgery patients were diagnosed with hypertension, respectively (P < 0.001). In regard to pulmonary function, 2% of plastic surgery patients and 7.8% of general surgery patients reported dyspnea, with a further 1% and 3.6% reporting diagnoses of COPD. Type 2 diabetes was diagnosed in 5.2% of general surgery patients and in 2.2% of plastic surgery patients. Fewer than 1% of patients were dialysis dependent or diagnosed with congestive heart failure, whereas just over 1% of patients were taking steroids.

Intraoperative and Postoperative Characteristics

There were 8904 abdominoplasty patients and 2754 breast surgery patients. Of general surgery patients, 87% underwent abdominoplasty and 13% underwent breast procedures compared with 74% and 26% of plastic surgery patients. The majority of patients, 83% of general surgery patients and 95% of plastic surgery patients, had clean wound classification (Table 2). General surgery patients had a 7.5% rate of clean/contaminated wounds, a 6% rate of contaminated wounds, and a 4% rate of dirty/infected wounds. Plastic surgery patients had a 4.3% rate of clean/contaminated wounds, a <1% rate of contaminated wounds, and a <1% rate of dirty/infected wounds. The procedure lengths had median times of 119 minutes for general surgeons and 158 minutes for plastic surgeons (P < 0.001).

Reoperation was necessary for 370 patients, comprising 6.5% of general and 2.4% of plastic surgery patients (P < 0.001). The median length of stay for general surgery patients was 2 days compared with 1 day for plastic surgery patients (P < 0.001). Overall wound and infectious complications were experienced by 880 patients, comprising 363 (16.8%) general surgery patients and 517 (5.4%) plastic surgery patients (P < 0.001). Superficial wound infections were seen in 6.9% and 2.5% of general and plastic surgery patients. Deep infections were seen in 2.1% and 1% of general and plastic surgery patients. Less than 1% of patients had organ space infections for both groups. Wound dehiscence was encountered in 1.9% of general and 0.8% of plastic surgery patients. Fewer than 1% of patients experienced signs of systemic inflammatory response syndrome, systemic sepsis, pneumonia, or pulmonary embolism.

Analysis of the subgroup of the 3748 patients remaining after excluding panniculectomies revealed similar trends. Overall wound and infectious complications were seen in 2.5% (n = 84) of plastic surgery patients and 7.5% (n = 27) of general surgery patients (P < 0.001). Seventy-six patients required further surgery: 1.7% (n = 57) of plastic surgery patients and 5.2% (n = 19) of general surgery patients (P < 0.001). The median length of stay for both patient groups was 0 days.

These trends continue to hold when both panniculectomy and “complex abdominal wall” procedures were excluded (n = 3322). Overall wound and infectious complications were seen in 2.4% (n = 72) of plastic surgery patients and 7.4% (n = 25) of general surgery patients (P < 0.001). A total of 65 patients required further surgery: 1.6% (n = 47) of plastic surgery patients and 5.4% (n = 18) of general surgery patients (P < 0.001).

Multivariate Analysis

After conducting multivariate analysis, the general surgery subspecialty had a higher risk of infectious and wound complications than the plastic surgery subspecialty (adjusted odds ratio [aOR], 1.81; 95% confidence interval [CI], 1.44-2.27]) (Table 3). Other factors associated with a statistically significant increase in risk of infectious and wound complications included increasing ASA class (aOR, 1.35; 95% CI, 1.1-1.65), increasing age (aOR, 1.01; 95% CI, 1-1.02), smoking (aOR, 1.75; 95% CI, 1.29-2.36), and increasing wound classification severity (aOR, 1.5; 95% CI, 1.3-1.73). Compared with normal BMI, underweight (aOR, 3.96; 95% CI, 0.86-18.2), overweight (OR, 1.63; 95% CI, 1.00-2.37), and obese (OR, 3.21; 95% CI, 2.02-5.08) and morbidly obese (OR, 6.99; 95% CI, 4.2-11.5) patients were all found to have a greater risk of infectious and wound complications.

The general surgery subspecialty was additionally associated with increased odds of reoperation compared with the plastic surgery subspecialty (aOR, 1.85; 95% CI, 1.31-2.62). Other factors associated with reoperation included ASA class (aOR, 1.53; 95% CI, 1.13-2.07) and increasing wound classification severity (aOR, 1.41; 95% CI, 1.16-1.71).

After controlling for patient characteristics, the linear regression analysis of length of stay revealed that patients treated by general surgeons had a mean predicted hospital length of stay 1.12 days longer than that of patients treated by plastic surgeons (95% CI, 0.64-1.60 days).

Analysis of the subgroups yielded results consistent with the main cohort. Within the subgroups excluding only panniculectomy and excluding both panniculectomy and “complex abdominal wall” procedures, the general surgery subspecialty had a higher risk of infectious and wound complications than the plastic surgery subspecialty (aOR, 2.47; 95% CI, 1.25-4.88 and aOR, 3.04; 95% CI, 1.51-6.12, respectively) (Table 4). Additionally, in both cohorts, the general surgery subspecialty was associated with higher odds of repeat surgery than the plastic surgery subspecialty (aOR, 4.24; 95% CI, 2.06-8.74 and aOR, 5.84; 95% CI, 2.72-12.52). With the exclusion of panniculectomy and “complex abdominal wall” procedures, the relative length of hospital stay decreased on linear regression analysis. Compared with patients treated by plastic surgeons, patients in the two cohorts treated by general surgeons had a mean predicted hospital length of stay of 0.31 days (range, 0.09-0.53 days) and 0.27 days (range, 0.05-0.50 days) longer.

DISCUSSION

The rate of body contouring procedures continues to increase.⁶ With the continuous rise in bariatric surgery, body contouring has had a significant impact on the psychological, emotional, and physical well-being of patients, thereby improving their quality of life.^8-11 Some of the potential reasons explaining this effect include increased consciousness of self-image, promotion of certain body types in the media, improved surgical techniques, and rapid increases in the number of eligible patients following weight loss surgery related to its overall lasting efficacy. With an increased demand for such procedures, a variety of surgeons with different specialty training are performing body contouring surgery.⁵ The overwhelming majority of specialists in this study were plastic and general surgeons. Our data demonstrate differential outcomes for the individuals operated on by plastic surgeons compared with those operated on by general surgeons. Compared with the general surgery group, the plastic surgery group exhibited a decreased risk of postoperative infectious complications, a decreased risk of reoperation, and a decreased length of stay. Given these considerable differences in outcomes between the 2 groups, identifying the causes of these findings will be an important strategy to standardize approaches and improve outcomes related to body contouring.

A virtue in the discipline of plastic surgery is the multiplicity of procedural approaches to solve a given problem. Plastic surgery training includes a significant focus on the body as a whole as well as the integumentary system in particular.¹² Traditionally, plastic surgeons underwent general surgery training prior to matriculation into plastic surgery residency. We speculate that exposure to, and performance of, these procedures during general surgery training has created a confidence and perceived ability to perform certain body contouring procedures, specifically in the abdominal region. Thus, some non–plastic surgeons are “buying in” to the demand for body contouring procedures.^5,6

Although the capabilities for performing these procedures might be similar among plastic surgeons and surgeons of other surgical specialties, the outcomes may vary. The plastic surgery group’s lower rate of reoperation compared with that of the general surgery group might be attributable to differences in technique, case volume, and patient selection. Mioton et al⁶ showed that panniculectomy performed by plastic surgeons resulted in lower rates of overall postoperative complications than when this procedure was performed by non–plastic surgeons. Other studies have shown surgeons who routinely performed certain procedures have better outcomes than those who did not perform the procedures as frequently.^13-15 These data suggest that plastic surgeons might have a training advantage with respect to performing body contouring procedures compared with general surgeons.

Although it is likely that the infectious prophylaxis practices of plastic surgeons and general surgeons should be comparable, we found that there was a significant difference in infectious complications among the patients treated, with the plastic surgery group having lower complication rates. An important aspect to consider is the difference in patient population between the plastic surgery group and the general surgery group. In our study, the plastic surgery group had fewer comorbidities than the general surgery group. This might be a result of intentional or unintentional patient selection (engendered by training and experience with integumentary procedures) by plastic surgeons. Multiple studies have shown similar results among the patients selected by plastic surgeons.^16-18 It is also worth mentioning that plastic surgeons have strict guidelines for preoperative patients, especially with regard to smoking cessation.¹⁹ This preoperative patient selection may be a critical component in the number of postoperative infectious complications, as comorbidities have been shown to increase infection rates.^16,20 More compelling is the fact that after controlling for comorbid conditions and more complex procedures, general surgery patients were still at higher risk of developing postoperative wound and infectious complications in this study. Factors such as differences in wound care experience and tissue handling could potentially play a role in the variations seen. Such “procedural” differences were not measurable in our study.

Length of stay during a hospital admission can have important implications, as it directly correlates to patient morbidity and hospital costs. The longer a patient stays in the hospital, the higher the risk of nosocomial infections.²¹ Recent literature has consistently correlated cost overruns and loss of patient productivity with extended length of stay related to procedural complications. Postoperative complications such as surgical site infections can extend length of stay by up to 9.7 days and increase cost by $20,842 per admission.²² This study found that the plastic surgery group stayed in hospital 1 day less than the general surgery group.²² This decreased length of stay combined with fewer postoperative complications in the plastic surgery group is something to consider in reference to the potential fiscal impact. It is not clear if the lower complication rates alone were responsible for the decreased length of stay in the plastic surgery group. Analysis of our two subgroups indicates that the difference in length of stay decreases, although the difference remains statistically significant. The shorter length of stay is explained by the removal of patients who underwent more complex surgical procedures. Plastic surgeons have myriad postoperative protocols including protocols for wound dressing, wound checks, and activity restrictions.²³ This repertoire of postoperative management might play a role in the decreased length of stay. Further scrutinization of the postoperative care provided to plastic surgery patients might be helpful in identifying areas where changes can be made to improve outcomes globally.

There is an inherent limitation in the use of large patient databases which hinders our ability to understand each individual patient being treated. However, through regression analysis, we attempt to homogenize our patient population and account for these confounding factors. Our extrapolated data only include inpatient surgery at select hospitals, whereas many of these procedures are conducted at surgery centers not included in the database. Additionally, the NSQIP database is designed only to collect 30-day outcomes; thus, the long-term outcomes of body contouring are not available. Furthermore, the database does not provide the details of the operative techniques used among different surgeons. Only the basic operative categories were linked to a CPT code. Variations in specific styles and techniques in each body contouring operation were not identifiable, which may account for some of the differences we observed. Lastly, in this study, we discuss outcomes based on specialty training, yet we cannot provide information on when and where this training was completed. This could play a role in the exposure and experience a surgeon might have with body contouring.

CONCLUSIONS

To date, this is the largest study regarding the association between surgical specialty and outcomes of body contouring procedures. Specialty training of the surgeon is a significant predictor of hospital length of stay and complication rates, even when controlling for more complex procedures. It is important to characterize the potential etiologies for these outcome differences to appropriately tailor patient care. The differential outcomes associated with general surgeons and plastic surgeons performing body contouring possibly suggests the need for specialized skill and training to optimize procedural sequelae in this growing surgical niche.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

This project was supported in part by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number 2U54MD007597. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

REFERENCES