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COSMETIC

Body Contouring in the Male Weight Loss Population: Assessing Gender as a Factor in Outcomes
Tae Chong, M.D. Devin Coon, M.D. Jonathan Toy, M.D. Chad Purnell, B.A. Joseph Michaels, M.D. J. Peter Rubin, M.D.
Dallas, Texas; Baltimore and Chevy Chase, Md.; and Pittsburgh, Pa.

Background: Growing numbers of men are presenting for consultation and potential postbariatric body contouring surgery. Due to concerns about whether men might have increased rates of complications or dissatisfaction with aesthetic surgery, the authors assessed their clinical experience with male patients. Methods: The authors examined male patients in their prospective database who had undergone body-contouring surgery. Chi-square analysis, regression analysis, and a binary logistic regression model were used to study categorical variables, surgical outcomes, continuous variables, and significant factors. Odds ratios were calculated. Results: Of 481 patients, 48 (10 percent) were male. There were no significant differences in baseline comorbidities between the genders, except that women had a higher incidence of anxiety/depression. Men had a greater weight loss before body-contouring surgery, but this did not correlate with greater operative time or estimated blood loss. Male gender, however, was associated with a 14.6 percent incidence of postoperative hematoma and a 25 percent incidence of seroma, in contrast to female gender, with 3.5 and 13 percent, respectively. Logistic regression showed that male gender was associated with an increased incidence of hematoma, seroma, and postoperative complications. It was an independent risk factor for hematoma and seroma formation, with odds ratios of 3.76 and 2.65, respectively. Gender was not an independent predictor of wound dehiscence, flap loss, transfusion, or surgical-site infection. Conclusions: Men who are considering body-contouring surgery should be advised that they are at an increased risk of postoperative hematoma and seroma formation. The causal relationship between gender and postoperative complications is an area for further study. (Plast. Reconstr. Surg. 130: 325e, 2012.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

ender-dependent differences have been well studied in the clinical outcomes of medical and surgical patients. Although the direction of the role that gender plays varies depending on the study, statistically significant differences have been shown in trauma, critical care
From the Department of Plastic and Reconstructive Surgery, University of Texas Southwestern Medical Center; Division of Plastic and Reconstructive Surgery, Johns Hopkins Medical Institutions; Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center; and private practice. Received for publication February 1, 2012; accepted February 14, 2012. This work was presented at the 2008 Annual Meeting of the American Society of Plastic Surgeons, in Chicago, Illinois, October 31 to November 5, 2008. Copyright 2012 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182589adb

medicine, and cardiovascular surgery. Meaningful conclusions have been drawn from these studies because male subjects tend to represent the majority of patients in those cohorts. In contrast, body-contouring patients are overwhelmingly female, as the pool for these patients is derived primarily from the post gastric bypass population seeking reconstructive surgery. Men account for only 9.3 percent to 20 percent of patients in current studies on body-contouring surgery.19 Despite the growing interest in body-contouring surgery, it has been challenging to study these pa-

Disclosure: The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article.

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tients, as only a small percentage of postbariatric patients eventually undergo body contouring. There are approximately 15 million morbidly obese adults in the United States, but despite the well-documented benefits, only an estimated 205,000 people underwent bariatric surgery in 2007.10 Only a fraction of these gastric-bypass patients ever elect to have body-contouring surgery, making it difficult to collect significant data on the risks and complications for these procedures. As a result of the small sample size and low number of male patients, there are few studies that demonstrate any statistically significant difference in outcome based on gender. In the current literature, overall complication rates after body-contouring surgery in the massive weight loss population ranges from 23 to 50 percent. Wound complications account for the majority of all complications and include the following: seromas, wound dehiscence, surgical-site infection, and bleeding. A few studies have shown a tendency for male gender to be associated with a greater incidence of wound complications. These studies have been limited by low numbers overall and other confounding variables, such as tobacco use. These data suggest that men undergoing plastic surgery may be at a higher risk for postoperative wound complications. We sought to assess our experience with body contouring, looking specifically for any differences between the genders in outcomes. regression analysis. Significant factors were then evaluated using a binary logistic regression model, and odds ratios were then calculated. Statistical significance was assigned if p values were less than 0.05. SPSS (Chicago, Ill.) software was utilized for data analysis.

RESULTS
Over the 4-year period, 481 patients underwent body-contouring procedures. The patient demographics in our sample reflected the demographics of the bariatric patient population overall (Table 1). There were 48 men, who accounted for 10 percent of the study population, and the average age of our patients was 45 10 years. Up to 44 percent of the patients reported a history of hypertension, and 22 percent reported a history of diabetes. Most of the patients in this series had more than one procedure at the time of surgery (60 percent), with breast and abdominal contouring accounting for a majority of the procedures, at 24 percent and 84 percent, respectively (Table 2). Men had a higher incidence of upper body lifts and genital procedures, whereas women had a higher incidence of lower body lifts and brachioplasties (Table 3). The overall incidence of complications was consistent with those reported in the literature. The overall complication rate was 42 percent, with the most common complication, wound dehiscence, occurring in 22 percent of the patients (Table 4). In this series, there was a 4.6 percent incidence of hematoma formation after surgery and a 14.6 percent incidence of seroma postoperatively. Over the 4-year period, there were no episodes of postoperative deep venous thrombosis or pulmonary embolus. By using univariate analysis, any differences in postoperative complications between the genders were analyzed. Male gender was associated with a 14.6 percent incidence of postoperative hematoma and 25 percent incidence of seroma formation (Table 5). This is
Table 1. Patient Demographics (481 Patients)
Value Mean age SD, yr Gender Change in BMI Hypertension Diabetes Hyperlipidemia Cerebrovascular disease Anemia Hypercoagulability Anxiety/depression
BMI, body mass index.

PATIENTS AND METHODS


Data were collected prospectively on all weightloss body-contouring patients and their operations by a single surgeon (J.P.R.) over a 4-year period at an academic medical center. Preoperative patient characteristics included comorbid conditions, change in body mass index (total weight loss before surgery), age, and gender. These patients underwent the following body-contouring procedures: breast mastopexy/reduction, brachioplasty, upper body lift, abdominoplasty, monsplasty (listed as genital in tables), thighplasty, and lower body lifts. Operative variables, such as operative time, operative site, number of procedures, and any revision surgery, were collected and added to the database. Postoperative complications were assessed by J.P.R. and a dedicated body-contouring fellow, and they included the following: deep venous thrombosis, pulmonary embolism, seroma, hematoma, surgical-site infection, dehiscence, tissue loss, transfusion, and need for reoperation. Chisquare analysis was utilized to study the association between our categorical variables and surgical outcomes. Continuous variables were assessed in our

45 10 48/481 male (10%) 22.6 7.6 193/441 (44%) 98/441 (22%) 114/441 (26%) 14/441 (3%) 75/441 (17%) 8/441 (1.8%) 183/441 (42%)

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Table 2. Surgical Procedures
Value Operative time, hr Any breast Any thigh Any arm Any genital Any abdominal contouring Lower body lift Upper body lift Any revision Two or more procedures 4.8 3.3 114/481 (24%) 68/481 (14%) 97/481 (20%) 5/481 (1%) 401/481 (84%) 81/481 (17%) 9/481 (1.9%) 18/481 (3.8%) 290/481 (60%)

Table 3. Surgical Procedure by Gender


Male Any breast Any arm Any thigh Any abdomen Any genital Upper body lift Lower body lift Any revision Two or more procedures 9 (19%) 4 (8.5%) 7 (15%) 41 (87%) 2 (4.3%) 2 (4.3%) 6 (13%) 2 (4.3%) 28 (59.5%) Female 114 (24%) 97 (20%) 68 (14%) 401 (83%) 5 (1%) 9 (1.9%) 81 (16.9%) 18 (3.8%) 290 (60%)

Table 4. Complications
No. of Patients Deep vein thrombosis Pulmonary embolism Hematoma Seroma Tissue loss Infection Wound dehiscence Transfusion Take-back Any complication 0/481 (0%) 0/481 (0%) 22/481 (4.6%) 7/481 (14.6%) 32/481 (6.7%) 39/481 (8.1%) 105/481 (22%) 48/481 (10%) 11/481 (2.3%) 204/481 (42%)

In general, there were few differences between the baseline comorbidities and the surgical variables when comparing the men and women in our study (Table 6). Women showed a higher incidence of anxiety or depression, but there were no differences between the groups in incidence of diabetes, hypertension, or age. Smoking history was not significant in our cohort (data not shown). Men did have a greater weight loss before surgery (25.1 9.5 versus 22.3 7.4 kg; p 0.017), but this did not correlate with any difference in operative time or estimated blood loss. To identify factors independently associated with these postoperative complications, a logistic regression model was utilized. Male gender was found to be associated with an increased incidence of hematoma, seroma, and postoperative complications after controlling for the other variables identified in univariate analysis. Male gender was confirmed to be an independent risk factor for both hematoma and seroma formation with odds ratios of 3.76 and 2.65, respectively (Table 7). Although male gender was noted to be associated with a greater weight loss before surgery (delta body mass index), this was by itself not found to be associated with an increased incidence of hematoma or seroma formation. Male gender was not an independent predictor of other postoperative complications like wound dehiscence, flap loss, transfusion, or surgical-site infection.

DISCUSSION
This analysis of outcomes from a data registry of body-contouring patients over 4 years demonstrates that there is a higher incidence of postoperative hematoma and seroma seen in men. Although the differences in outcomes between the genders have been well documented in other surgical specialties, there are few studies demonstrating statistically significant differences between
Table 6. Univariate Analysis of Differences between Genders
Female Diabetes Hypertension Cerebrovascular Hyperlipidemia Anemia Hypercoagulability Anxiety/depression Age Delta BMI OR time 84/399 174/399 13/399 104/399 70/399 7/354 173/354 44.7 10.1 22.3 7.4 4.85 3.38 Male 14/42 19/42 1/42 10/42 5/42 1/38 10/38 44.5 10.7 25.1 9.5 4.2 2.7 p 0.069 0.840 0.758 0.751 0.355 0.786 0.008* 0.883 0.017* 0.218

Table 5. Univariate Analysis of Complications Based on Gender


Female Hematoma Seroma Flap tissue loss Infection Dehiscence Transfusion Take back Any complication 15/427 58/427 29/427 34/427 96/427 41/430 8/423 178/427
0.05.

Male 7/48 12/48 3/48 5/48 9/48 7/48 3/48 26/48

p 0.001* 0.034* 0.887 0.558 0.555 0.270 0.058 0.098

*Statistical significance with p

in contrast to women, who had a 3.5 percent incidence of hematoma and a 13 percent incidence of seroma formation (p 0.001 and 0.034, respectively). Although men had more overall complications than women, this was not shown to be statistically significant in univariate analysis (p 0.098).

BMI, body mass index; OR, operating room. *Statistical significance with p 0.05.

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Table 7. Logistic Regression
Outcome Hematoma Seroma Dehiscence Tissue loss Infection Transfusion Any complication Factor Odds Ratio (95% CI) p 0.014* 0.016* 0.029* 0.002* 0.029* 0.001* 0.046* 0.003* 0.003* 0.05* 0.016* 0.012* 0.01* 0.005*

Gender 3.76 (1.3110.83) Any genital 11.0 (1.5578.06) Gender 2.65 (1.106.4) Any arm 3.28 (1.66.9) Any genital 10 (1.2779.5) OR time 1.28 (1.121.50) Two or more 3.14 (1.029.66) Delta BMI 1.06 (1.021.1) Delta BMI 1.059 (1.021.1) Gender 1.98 (1.04.0) Any arm Any thigh Delta BMI OR time 2.14 (1.153.96) 2.58 (1.245.41) 1.039 (1.011.33) 1.18 (1.051.33)

OR, operating room; BMI, body mass index. *Statistical significance with p 0.05.

genders in the plastic surgery population. Interestingly, worse outcomes have been associated with female gender in cardiac surgery and in critically ill patients after trauma.1115 However, in the gastric-bypass population, which makes up a majority of body-contouring patients, male gender is associated with a higher incidence of postoperative morbidity and mortality following bariatric surgery.16 18 There are a few studies that demonstrate that male gender is associated with a higher incidence of postoperative complications in plastic surgery. In patients undergoing rhytidectomy, men have been shown to have a higher incidence of postoperative hematoma after surgery, irrespective of perioperative hypertension.19 22 In the body-contouring literature, van Uchelen et al. reported on their experience with 86 abdominoplasty patients, with a 64.3 percent incidence of wound complications seen in men compared with 15.3 percent for women.4 Although this study did suggest that men had a higher incidence of complications, the findings were confounded statistically by the low number of patients overall and the higher incidence of smoking in the men (71 versus 34 percent). In a more recent study, Nemerofsky et al. report on a larger series of body-contouring patients (n 200).2 In this comprehensive evaluation, the authors report that men had a higher overall complication rate than women, specifically postoperative bleeding and seroma. They also found that women had a higher incidence of skin necrosis, but these findings were not statistically significant. Shermak et al. further contributed to the identification of gender as a risk factor in their study of 139 patients who demonstrated that gender was a

risk factor for wound dehiscence.3 The beneficial role of estrogen on wound healing that has been reported in several in vitro and clinical models suggests a possible mechanism for the lower incidence of wound complications in women.2326 In this larger study of 481 patients (48 men), we demonstrate that male gender is an independent risk factor for postoperative complications. Men were more likely to have postoperative hematomas than women, with an odds ratio of 3.76. The incidence of hypertension, which has been identified as a risk factor for hematomas, did not differ between the genders, and it was not identified as a risk factor in our logistic regression model. Intraoperative and postoperative blood pressure measurements may, however, more accurately reflect the impact of hypertension, as intraoperative hypotension may mask the potential for postoperative bleeding. Our group is currently studying this prospectively. Any difference in procedural complexity and adequate hemostasis between the two genders was not borne out in our analysis of operative time and estimations of blood loss. Nonetheless, there may be differences in the conduct of the operation based on gender that are not identified in our study which merit further investigation in the future. Men were also more likely to have a postoperative seroma than women, with an odds ratio of 2.65. The other factors that were independently associated with postoperative seroma were any brachioplasty and any genital (monsplasty) operations. Gender, however, was shown to be independently associated with seromas in the logistic regression model, independent of type of contouring operation. Resection sample weight has been shown to correlate with postoperative seromas in other studies, but we did not routinely collect sample weights during this study. Variables that indirectly suggest a greater extent of dissection during surgery (operative time) or greater tissue resection (change in body mass index) did not, however, correlate with a higher risk of seroma formation. Nonetheless, we are collecting these data prospectively for our ongoing study in this patient population. Interestingly, despite the higher incidence of seromas and hematomas in men, the incidence of wound dehiscence or surgical-site infection was not increased. This may reflect greater diligence in the postoperative surveillance of these patients and early intervention (aspiration) once complications develop. There is also the potential that other patient variables that were not represented in our analysis could account for the higher rates of postopera-

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tive complications seen in our male subjects. Although the incidence of factors like diabetes, age, and hypertension were not different, there is still the possibility that factors like rate of weight loss and mechanism of weight loss could have an effect on the incidence of complications. In this study, most of the weight loss in the patients was from gastric bypass. Moreover, we have not found any increase in postoperative complications seen in patients who undergo massive weight loss after malabsorptive surgery versus diet and exercise alone.27 The lead investigator follows a strict protocol for patient selection and the patients must all be at a stable weight for at least 6 to 12 months before surgery. This minimizes any differences in nutritional status and tissue equilibration after weight loss and before surgery. Men did have a higher change in body mass index than women before surgery. We included this variable in a separate multivariate analysis for complications, and change in body mass index did not correlate with an increased incidence of hematoma or seroma. Gender, however, was independently associated with seroma and hematoma in our logistic regression when controlling for significant confounders. Postoperatively, all patients were managed under a standardized protocol of early ambulation, drain removal, and aggressive pulmonary toilet. Consequently, any differences in postoperative care should be minimal. This study identifies a patient population at greater risk of postoperative wound complications after body-contouring surgery. Although men represent only a minority of body-contouring patients, there has been a significant increase in men undergoing lower body lifts and abdominoplasty since 2000. In a recent survey study by Gusenoff et al., a significant number (75 percent) of male patients were interested in undergoing plastic surgery after gastric bypass.28 Furthermore, they observed that patients were more likely to undergo surgery at longer time intervals from gastric bypass. Collectively, one could then conclude that the number of male patients will increase. As such, future studies identifying postoperative complications must stratify patients based on gender. The etiology of these differences is clearly multifactorial and will require further study. Studies in patients undergoing gastric-bypass surgery demonstrate that male patients are at a higher risk of postoperative complications, and we are now accumulating data to suggest that they are also at a greater risk for complications after body contouring.29 As more patients are accrued in these studies, we can further isolate factors that may contribute to the greater risk in men and potentially minimize their effect.
Tae Chong, M.D. 1801 Inwood Road Dallas, Texas 75390 tae.chong@utsouthwestern.edu

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