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Bota et al. Plast Aesthet Res 2018;5:30 I http://dx.doi.org/10.20517/2347-9264.2018.47 Page 3 of 8

tive wounds and poorly vascularized, excessive fatty tissue will most probably lead to fat necrosis, develop-
ment of seromas and cellulitis as well as wound dehiscence. Certain operative techniques have been devel-
oped in order to approach this problem.

Smoking can also have an important impact on wound healing. Some studies describe that in smokers the
relative risks of developing a wound infection after contouring breast surgery are 3.8 times higher and after
medial thigh lift 7.74 times higher respectively [15,16] . These studies suggest that patients should be advised to
quit smoking six weeks before the BCS.

The season in which the BCS takes place can also be an influential factor on wound healing. In a study on
[17]
602 patients after postbariatric BCS, Duscher et al. found a statistically significant difference in the devel-
opment of wound infections between patients operated in the warm seasons compared to those operated in
the cold seasons (10.29% vs. 4.08%, P = 0.0071). Although the frequency of BCS appears to be higher in the
cold seasons, the patients operated in spring and summer seem to develop more wound complications. This
could be attributed to a higher bacterial load at the surgical site as well as to deficient hygiene.

INTRAOPERATIVE FACTORS
The intraoperative administration of higher volumes of fluids has been associated with the formation of se-
[18]
roma, hematoma and wound healing problems . Longer periods of oxygen desaturation (≤ 92%) have also
been associated with wound complications, while longer periods of low (35.6°) intraoperative core tempera-
[19]
ture, seem to increase the rate of hematomas and bleeding . Transfusion of blood products has also been
[20]
associated with the development of wound complications .
Keeping a warm environment during surgery and a constant core temperature of 37°, accurate surgery with-
out bleeding and precise administration of fluids during surgery can significantly influence the outcome of
the operation and favour the uncomplicated, primary wound healing.

SURGICAL FACTORS
Brachioplasty, breast reduction/mastopexy, abdominoplasty/circumferential body lift and thigh lift are the
[7,8]
most common postbariatric BCS . Although the general patient features are the same, each body region
and intervention has different characteristics and different rates of wound complications. In our practice we
avoid addressing more than one body region per procedure. Studies have shown that multi-stage procedures
reduce the risk of postoperative complications in comparison to long one-stage procedures. Especially, in the
context of “pay for performance” probably future reimbursement from the health insurance will be reduced
in treated cases with high revision operations due to postoperative complications in single-step procedures.

In the following we will address each procedure separately, analyzing the probability of wound complica-
tions and the techniques to avoid them.

Brachioplasty is one of the least frequent postbariatric BCS and has a rather low rate of postoperative com-
plications compared to other forms of BCS. In a review on 1065 brachioplasties, there were 29.8% complica-
tions, whereby hematoma and seroma were found to be the most common early postoperative complication
and poor scarring the most common late complication [21,22] . In our experience, the use of liposuction in the
same procedure before performing the skin resection ensures a safe layer of dissection, without jeopardiz-
ing the superficial and deep veins as well as the lymph collectors, while ensuring the best aesthetical result
[Figures 1-4]. The approach of the axillary fold is best done by a M-Y axilloplasty, which ensures an optimal
[23]
aesthetic result while avoiding the postoperative wound complications and scar contractures .