Body Contouring in the Male Weight Loss
Population: Assessing Gender as a Factor
Tae Chong, M.D.
Background: Growing numbers of men are presenting for consultation and
Devin Coon, M.D. potential postbariatric body contouring surgery. Due to concerns about whether
Jonathan Toy, M.D. men might have increased rates of complications or dissatisfaction with aesthetic
Chad Purnell, B.A. surgery, the authors assessed their clinical experience with male patients.
Joseph Michaels, M.D. Methods: The authors examined male patients in their prospective database
J. Peter Rubin, M.D. who had undergone body-contouring surgery. Chi-square analysis, regression
Dallas, Texas; Baltimore and Chevy analysis, and a binary logistic regression model were used to study categorical
Chase, Md.; and Pittsburgh, Pa. 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 compli-
cations is an area for further study. (Plast. Reconstr. Surg. 130: 325e, 2012.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.
ender-dependent differences have been medicine, and cardiovascular surgery. Meaningful
well studied in the clinical outcomes of conclusions have been drawn from these studies
medical and surgical patients. Although the because male subjects tend to represent the ma-
direction of the role that gender plays varies de- jority of patients in those cohorts. In contrast,
pending on the study, statistically significant dif- body-contouring patients are overwhelmingly fe-
ferences have been shown in trauma, critical care male, as the pool for these patients is derived
primarily from the post– gastric bypass population
From the Department of Plastic and Reconstructive Surgery, seeking reconstructive surgery. Men account for
University of Texas Southwestern Medical Center; Division only 9.3 percent to 20 percent of patients in cur-
of Plastic and Reconstructive Surgery, Johns Hopkins Med- rent studies on body-contouring surgery.1–9
ical Institutions; Department of Plastic and Reconstructive Despite the growing interest in body-contouring
Surgery, University of Pittsburgh Medical Center; and pri- surgery, it has been challenging to study these pa-
Received for publication February 1, 2012; accepted February
This work was presented at the 2008 Annual Meeting of the Disclosure: The authors have no commercial asso-
American Society of Plastic Surgeons, in Chicago, Illinois, ciations or financial disclosures that might pose or
October 31 to November 5, 2008. create a conflict of interest with information pre-
Copyright ©2012 by the American Society of Plastic Surgeons sented in this article.
Plastic and Reconstructive Surgery • August 2012
tients, as only a small percentage of postbariatric regression analysis. Significant factors were then
patients eventually undergo body contouring. There evaluated using a binary logistic regression model,
are approximately 15 million morbidly obese adults and odds ratios were then calculated. Statistical
in the United States, but despite the well-docu- significance was assigned if p values were less than
mented benefits, only an estimated 205,000 people 0.05. SPSS (Chicago, Ill.) software was utilized for
underwent bariatric surgery in 2007.10 Only a frac- data analysis.
tion of these gastric-bypass patients ever elect to have
body-contouring surgery, making it difficult to col- RESULTS
lect significant data on the risks and complications Over the 4-year period, 481 patients under-
for these procedures. As a result of the small sample went body-contouring procedures. The patient
size and low number of male patients, there are few demographics in our sample reflected the demo-
studies that demonstrate any statistically significant graphics of the bariatric patient population overall
difference in outcome based on gender. (Table 1). There were 48 men, who accounted for
In the current literature, overall complication 10 percent of the study population, and the aver-
rates after body-contouring surgery in the massive age age of our patients was 45 10 years. Up to
weight loss population ranges from 23 to 50 per- 44 percent of the patients reported a history of
cent. Wound complications account for the ma- hypertension, and 22 percent reported a history of
jority of all complications and include the follow- diabetes. Most of the patients in this series had
ing: seromas, wound dehiscence, surgical-site more than one procedure at the time of surgery
infection, and bleeding. A few studies have shown (60 percent), with breast and abdominal contour-
a tendency for male gender to be associated with ing accounting for a majority of the procedures, at
a greater incidence of wound complications. 24 percent and 84 percent, respectively (Table 2).
These studies have been limited by low numbers Men had a higher incidence of upper body lifts
overall and other confounding variables, such as and genital procedures, whereas women had a
tobacco use. These data suggest that men under- higher incidence of lower body lifts and brachio-
going plastic surgery may be at a higher risk for plasties (Table 3).
postoperative wound complications. We sought to The overall incidence of complications was
assess our experience with body contouring, look- consistent with those reported in the literature.
ing specifically for any differences between the The overall complication rate was 42 percent, with
genders in outcomes. the most common complication, wound dehis-
cence, occurring in 22 percent of the patients
PATIENTS AND METHODS (Table 4). In this series, there was a 4.6 percent
Data were collected prospectively on all weight- incidence of hematoma formation after surgery
loss body-contouring patients and their operations and a 14.6 percent incidence of seroma postop-
by a single surgeon (J.P.R.) over a 4-year period at an eratively. Over the 4-year period, there were no
academic medical center. Preoperative patient char- episodes of postoperative deep venous thrombosis
acteristics included comorbid conditions, change in or pulmonary embolus. By using univariate anal-
body mass index (total weight loss before surgery), ysis, any differences in postoperative complica-
age, and gender. These patients underwent the fol- tions between the genders were analyzed. Male
lowing body-contouring procedures: breast mas- gender was associated with a 14.6 percent inci-
topexy/reduction, brachioplasty, upper body lift, ab- dence of postoperative hematoma and 25 percent
dominoplasty, monsplasty (listed as genital in incidence of seroma formation (Table 5). This is
tables), thighplasty, and lower body lifts. Operative
variables, such as operative time, operative site, num-
ber of procedures, and any revision surgery, were Table 1. Patient Demographics (481 Patients)
collected and added to the database. Value
Postoperative complications were assessed by Mean age SD, yr 45 10
J.P.R. and a dedicated body-contouring fellow, Gender 48/481 male (10%)
and they included the following: deep venous Change in BMI 22.6 7.6
Hypertension 193/441 (44%)
thrombosis, pulmonary embolism, seroma, hema- Diabetes 98/441 (22%)
toma, surgical-site infection, dehiscence, tissue Hyperlipidemia 114/441 (26%)
loss, transfusion, and need for reoperation. Chi- Cerebrovascular disease 14/441 (3%)
Anemia 75/441 (17%)
square analysis was utilized to study the association Hypercoagulability 8/441 (1.8%)
between our categorical variables and surgical out- Anxiety/depression 183/441 (42%)
comes. Continuous variables were assessed in our BMI, body mass index.
Volume 130, Number 2 • Body Contouring in Males
Table 2. Surgical Procedures In general, there were few differences between
Value the baseline comorbidities and the surgical vari-
ables when comparing the men and women in our
Operative time, hr 4.8 3.3
Any breast 114/481 (24%) study (Table 6). Women showed a higher inci-
Any thigh 68/481 (14%) dence of anxiety or depression, but there were no
Any arm 97/481 (20%) differences between the groups in incidence of
Any genital 5/481 (1%)
Any abdominal contouring 401/481 (84%) diabetes, hypertension, or age. Smoking history
Lower body lift 81/481 (17%) was not significant in our cohort (data not shown).
Upper body lift 9/481 (1.9%) Men did have a greater weight loss before surgery
Any revision 18/481 (3.8%)
Two or more procedures 290/481 (60%) (25.1 9.5 versus 22.3 7.4 kg; p 0.017), but
this did not correlate with any difference in op-
erative time or estimated blood loss.
Table 3. Surgical Procedure by Gender To identify factors independently associated
with these postoperative complications, a logistic
regression model was utilized. Male gender was
Any breast 9 (19%) 114 (24%) found to be associated with an increased inci-
Any arm 4 (8.5%) 97 (20%)
Any thigh 7 (15%) 68 (14%) dence of hematoma, seroma, and postoperative
Any abdomen 41 (87%) 401 (83%) complications after controlling for the other vari-
Any genital 2 (4.3%) 5 (1%) ables identified in univariate analysis. Male gender
Upper body lift 2 (4.3%) 9 (1.9%)
Lower body lift 6 (13%) 81 (16.9%) was confirmed to be an independent risk factor for
Any revision 2 (4.3%) 18 (3.8%) both hematoma and seroma formation with odds
Two or more procedures 28 (59.5%) 290 (60%) 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
Table 4. Complications body mass index), this was by itself not found to be
No. of Patients associated with an increased incidence of hema-
Deep vein thrombosis 0/481 (0%) toma or seroma formation. Male gender was not
Pulmonary embolism 0/481 (0%) an independent predictor of other postoperative
Hematoma 22/481 (4.6%) complications like wound dehiscence, flap loss,
Seroma 7/481 (14.6%)
Tissue loss 32/481 (6.7%) transfusion, or surgical-site infection.
Infection 39/481 (8.1%)
Wound dehiscence 105/481 (22%)
Transfusion 48/481 (10%) DISCUSSION
Take-back 11/481 (2.3%) This analysis of outcomes from a data registry
Any complication 204/481 (42%)
of body-contouring patients over 4 years demon-
strates that there is a higher incidence of postop-
erative hematoma and seroma seen in men. Al-
Table 5. Univariate Analysis of Complications Based
though the differences in outcomes between the
genders have been well documented in other sur-
Female Male p gical specialties, there are few studies demonstrat-
Hematoma 15/427 7/48 0.001* ing statistically significant differences between
Seroma 58/427 12/48 0.034*
Flap tissue loss 29/427 3/48 0.887
Infection 34/427 5/48 0.558 Table 6. Univariate Analysis of Differences
Dehiscence 96/427 9/48 0.555
Transfusion 41/430 7/48 0.270 between Genders
Take back 8/423 3/48 0.058
Any complication 178/427 26/48 0.098 Female Male p
*Statistical significance with p 0.05. Diabetes 84/399 14/42 0.069
Hypertension 174/399 19/42 0.840
Cerebrovascular 13/399 1/42 0.758
in contrast to women, who had a 3.5 percent in- Hyperlipidemia 104/399 10/42 0.751
Anemia 70/399 5/42 0.355
cidence of hematoma and a 13 percent incidence Hypercoagulability 7/354 1/38 0.786
of seroma formation (p 0.001 and 0.034, re- Anxiety/depression 173/354 10/38 0.008*
spectively). Although men had more overall com- Age 44.7 10.1 44.5 10.7 0.883
Delta BMI 22.3 7.4 25.1 9.5 0.017*
plications than women, this was not shown to be OR time 4.85 3.38 4.2 2.7 0.218
statistically significant in univariate analysis (p BMI, body mass index; OR, operating room.
0.098). *Statistical significance with p 0.05.
Plastic and Reconstructive Surgery • August 2012
Table 7. Logistic Regression risk factor for wound dehiscence.3 The beneficial
Odds Ratio role of estrogen on wound healing that has been
Outcome Factor (95% CI) p reported in several in vitro and clinical models
Hematoma Gender 3.76 (1.31–10.83) 0.014* suggests a possible mechanism for the lower inci-
Any genital 11.0 (1.55–78.06) 0.016* dence of wound complications in women.23–26
Seroma Gender 2.65 (1.10–6.4) 0.029* In this larger study of 481 patients (48 men),
Any arm 3.28 (1.6–6.9) 0.002*
Any genital 10 (1.27–79.5) 0.029* we demonstrate that male gender is an indepen-
Dehiscence OR time 1.28 (1.12–1.50) 0.001* dent risk factor for postoperative complications.
Tissue loss Two or more 3.14 (1.02–9.66) 0.046* Men were more likely to have postoperative he-
Infection Delta BMI 1.06 (1.02–1.1) 0.003*
Transfusion Delta BMI 1.059 (1.02–1.1) 0.003* matomas than women, with an odds ratio of 3.76.
Any Gender 1.98 (1.0–4.0) 0.05* The incidence of hypertension, which has been
complication identified as a risk factor for hematomas, did not
Any arm 2.14 (1.15–3.96) 0.016*
Any thigh 2.58 (1.24–5.41) 0.012* differ between the genders, and it was not iden-
Delta BMI 1.039 (1.01–1.33) 0.01* tified as a risk factor in our logistic regression
OR time 1.18 (1.05–1.33) 0.005* model. Intraoperative and postoperative blood
OR, operating room; BMI, body mass index. pressure measurements may, however, more ac-
*Statistical significance with p 0.05.
curately reflect the impact of hypertension, as in-
traoperative hypotension may mask the potential
for postoperative bleeding. Our group is currently
genders in the plastic surgery population. Inter- studying this prospectively. Any difference in pro-
estingly, worse outcomes have been associated cedural complexity and adequate hemostasis be-
with female gender in cardiac surgery and in crit- tween the two genders was not borne out in our
ically ill patients after trauma.11–15 However, in the analysis of operative time and estimations of blood
gastric-bypass population, which makes up a ma- loss. Nonetheless, there may be differences in the
jority of body-contouring patients, male gender is conduct of the operation based on gender that are
associated with a higher incidence of postopera- not identified in our study which merit further
tive morbidity and mortality following bariatric investigation in the future.
surgery.16 –18 Men were also more likely to have a postop-
There are a few studies that demonstrate that erative seroma than women, with an odds ratio of
male gender is associated with a higher incidence 2.65. The other factors that were independently
of postoperative complications in plastic surgery. associated with postoperative seroma were any bra-
In patients undergoing rhytidectomy, men have chioplasty and any genital (monsplasty) opera-
been shown to have a higher incidence of post- tions. Gender, however, was shown to be indepen-
operative hematoma after surgery, irrespective of dently associated with seromas in the logistic
perioperative hypertension.19 –22 In the body-con- regression model, independent of type of con-
touring literature, van Uchelen et al. reported on touring operation. Resection sample weight has
their experience with 86 abdominoplasty patients, been shown to correlate with postoperative sero-
with a 64.3 percent incidence of wound complica- mas in other studies, but we did not routinely
tions seen in men compared with 15.3 percent for collect sample weights during this study. Variables
women.4 Although this study did suggest that men that indirectly suggest a greater extent of dissec-
had a higher incidence of complications, the find- tion during surgery (operative time) or greater
ings were confounded statistically by the low number tissue resection (change in body mass index) did
of patients overall and the higher incidence of smok- not, however, correlate with a higher risk of se-
ing in the men (71 versus 34 percent). roma formation. Nonetheless, we are collecting
In a more recent study, Nemerofsky et al. re- these data prospectively for our ongoing study in
port on a larger series of body-contouring patients this patient population. Interestingly, despite the
(n 200).2 In this comprehensive evaluation, the higher incidence of seromas and hematomas in
authors report that men had a higher overall com- men, the incidence of wound dehiscence or sur-
plication rate than women, specifically postoper- gical-site infection was not increased. This may
ative bleeding and seroma. They also found that reflect greater diligence in the postoperative sur-
women had a higher incidence of skin necrosis, veillance of these patients and early intervention
but these findings were not statistically significant. (aspiration) once complications develop.
Shermak et al. further contributed to the identi- There is also the potential that other patient
fication of gender as a risk factor in their study of variables that were not represented in our analysis
139 patients who demonstrated that gender was a could account for the higher rates of postopera-
Volume 130, Number 2 • Body Contouring in Males
tive complications seen in our male subjects. Al- greater risk in men and potentially minimize their
though the incidence of factors like diabetes, age, effect.
and hypertension were not different, there is still
Tae Chong, M.D.
the possibility that factors like rate of weight loss 1801 Inwood Road
and mechanism of weight loss could have an effect Dallas, Texas 75390
on the incidence of complications. In this study, firstname.lastname@example.org
most of the weight loss in the patients was from
gastric bypass. Moreover, we have not found any REFERENCES
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