Panniculectomy (Removal of the Abdominal Apron)

After major weight loss, many people are left with an apron of skin and fat that hangs over the lower abdomen. Doctors call it a pannus. It can be heavy, it traps moisture, it rubs, and for some people it gets in the way of walking, exercise, hygiene and work. It does not respond to diet or exercise, because it is skin rather than fat.

• Why the apron forms
• Is it right for you?
• Panniculectomy or tummy tuck?
• The operation
• Recovery
• Risks
• Cost and Medicare
• Questions

Why an apron of skin forms after weight loss

Skin that has been stretched for years loses much of its elastic recoil. When the fat beneath it is lost, whether through bariatric surgery, weight-loss medication or diet and exercise, the skin cannot shrink back to match. On the abdomen gravity pulls that surplus downward, and it folds over the lower abdomen and pubic area as a single hanging apron.

The size of the apron is often described using a five-grade scale (Igwe and colleagues, 2000). At grade 1 the apron covers the pubic hairline; at grade 2 it covers the genitals; at grade 3 it reaches the upper thigh; at grade 4 the mid-thigh; and at grade 5 the knees or below. Grading helps plan the operation and anticipate recovery, but the problems it causes matter more than the grade.

Those problems are consistent. The fold beneath the apron stays warm and damp, so rashes (intertrigo), fungal infection, odour and skin breakdown are common and tend to recur however carefully the area is cared for. The weight of the apron can drag on the lower back, make walking and exercise uncomfortable and make clothing difficult to fit. Men and women are affected alike, and a large share of Dr Kumar’s post-weight-loss patients are men.

Is a panniculectomy right for you?

You are likely to be a suitable candidate if most of the following apply:

If you are using a weight-loss medication, the important question is whether your weight has plateaued. Surgery is planned once the weight is stable, and you will be told when to pause the medication before your anaesthetic, in line with current Australian anaesthetic guidance. More on this is on the page about loose skin after weight-loss medication.

Diabetes, a very high current BMI and an abdominal wall hernia do not automatically rule surgery out, but each changes the risk and the plan, so they are assessed carefully at consultation. Before surgery Dr Kumar’s team can introduce you to an Accredited Practising Dietitian, because protein intake and nutrition after bariatric surgery have a direct effect on wound healing.

Panniculectomy, abdominoplasty or fleur-de-lis?

These three operations are often confused. The difference lies in what else is done beyond removing skin.

	Panniculectomy	Abdominoplasty after weight loss	Fleur-de-lis abdominoplasty
Main aim	Remove the hanging apron	Remove skin and reshape the abdomen	Remove skin in both directions and restore the waist
Muscle repair	No	Usually	Usually
Belly button	Usually left in place	Repositioned	Repositioned
Scar	Low horizontal	Low horizontal	Low horizontal plus vertical midline
Possible Medicare item	30166	30177	30177
Suits	Function first; higher-risk patients; first stage	Loose skin mainly top to bottom	Loose skin side to side as well as top to bottom

A panniculectomy is shorter and has fewer components, which can make it the safer choice where health factors raise the risk of a longer operation. The trade-off is that the upper abdomen is not tightened and the waist is not reshaped. If you want those changes, see abdominoplasty (tummy tuck) and fleur-de-lis tummy tuck.

What the operation involves

Markings are made with you standing, because the apron hangs differently when you lie down. Under general anaesthetic, the apron is lifted and removed through an incision across the lower abdomen, positioned so that the scar sits as low as your anatomy allows and, where possible, within underwear.

The remaining skin is closed in layers. The belly button is usually left where it is. Drains are used and are removed by Dr Kumar’s nurses once the drainage has settled. Where the pubic area is also heavy or has descended, a monsplasty can be performed through the same incision, because removing the apron alone can leave the mons looking more prominent.

If you have an abdominal wall hernia, this is planned before surgery. Depending on its size, the repair may be done at the same operation with a general surgeon or treated separately.

Staging and combining procedures

A panniculectomy is often the first operation in a staged plan after major weight loss. It removes the heaviest tissue and the source of recurrent skin problems, and later operations such as a body lift, arm lift or thigh lift can follow once you have recovered. Some patients go on to have a formal abdominoplasty later; many find the panniculectomy is all they need.

Operations are combined only when the total operating time and your health allow it. After weight loss, a shorter safe operation is usually a better choice than a single very long one.

Recovery, week by week

Recovery depends on the size of the apron and your general health. This is a typical course.

When	What to expect
In hospital	Usually two to three nights at Westmead Private Hospital. You will be up and walking on the first day, with compression stockings and measures to reduce the risk of clots. A compression garment is fitted before you go home.
Weeks 1 to 2	Time off work. Tightness and swelling across the lower abdomen. Short walks several times a day. Drains are removed by Dr Kumar’s nurses once the drainage has settled. First review with Dr Kumar and his nurses at about one week.
Weeks 2 to 6	Most patients return to work from about two weeks, then gradually resume most everyday activities over the next four weeks. How quickly depends on how physical the activity is and the area operated on. No heavy lifting or straining, and drive only once you can do so comfortably and safely. The Prineo and Micropore dressings come off at six weeks, and the compression garment is worn for six weeks.
Weeks 6 to 12	After your six-week review, exercise and more physical work are built up progressively. Most patients are cleared for full activity at the 12-week review.
3 to 12 months	Swelling settles and the scars mature. Reviews at 6 months and 12 months.

Dressings, garments and scar care are managed by Dr Kumar’s nurses, who also work on the wards at Westmead Private Hospital. The nurses who prepare you for surgery are the same ones who look after you at every post-operative review.

Scars and sensation

The scar is long, often running from hip to hip and sometimes further toward the back when the apron wraps around the sides. It is placed as low as possible so that underwear and swimwear cover as much of it as possible. Scars are red and firm for the first few months and usually fade and flatten over 12 to 18 months, although how a scar matures varies from person to person.

Numbness of the skin just above the scar is expected, and sensation usually improves over months, though some reduction can be permanent.

Risks and complications

All surgery carries risk. After major weight loss, wound-healing problems are more common than in cosmetic surgery, and the risk rises with a higher BMI, diabetes and any nicotine use. Risks include:

Dr Kumar will go through your own risk profile at consultation. You can read more about the risks of surgery.

The three-month head start

If you have a rash in the fold, see your GP about it now — before you see a surgeon. Item 30177 asks for three months of conventional treatment that has failed. Starting that clock early is the single most useful thing you can do, and it costs nothing.

Cost and Medicare

Dr Kumar’s initial consultation fee is $400, with a Medicare rebate of approximately $88. A referral from your GP is required to see Dr Kumar. Surgical fees are quoted individually after consultation, once the operation and any staging are settled. The practice does not publish package prices for body surgery, because the quote depends on what is being done, how long it takes and where it is performed.

A panniculectomy performed for functional problems may attract a Medicare rebate under item 30166. The item covers removal of redundant abdominal skin as a wedge excision for functional problems following significant weight loss equivalent to at least five BMI points, where your weight has been stable for at least six months before surgery. Medicare benefits are not available for surgery performed for cosmetic reasons, and item 30166 cannot be claimed with a radical abdominoplasty under item 30177 at the same operation.

When a Medicare item applies, your private health fund may also cover the hospital costs, depending on your level of cover. The hospital runs a fund check before issuing its quote, so your itemised quote will show what your fund covers. Eligibility is a clinical judgement made at consultation, not something that can be settled by phone. The guide to Medicare rebates and plastic surgery explains how the system works, and costs and payment sets out what the quote includes and how the in-house payment plan works.

Results

Surgical photographs are restricted to viewers aged 18 and over. The outcomes shown in any photograph are relevant only to the patient pictured, and individual results will vary. You can view the body contouring after weight loss gallery and the full before and after gallery.

Where Dr Kumar operates

Consultations are held at Westmead, Penrith and Orange, so you can be seen at whichever is closest to you. If you live a long way from Sydney, you can send photos to Dr Kumar’s team before your first appointment.

All body contouring after weight loss, including panniculectomy, is performed at Westmead Private Hospital, an accredited Ramsay Health Care hospital with an inpatient ward set up for this surgery. Panniculectomy is one of a group of operations covered on the body contouring after weight loss page.

Common questions