Is an asymmetric pannus (abdominal apron of skin) normal in a morbidly obese adult?

Asymmetric Pannus in Morbidly Obese Adults

Yes, an asymmetric pannus (abdominal apron of skin) can be normal in a morbidly obese adult and does not necessarily indicate pathology. While the panniculus in morbid obesity can vary in size and shape, asymmetry is a common finding that may result from various physiological and anatomical factors.

Understanding the Pannus in Morbid Obesity

Definition and Classification

• The medical term for lower abdominal folds in morbid obesity is "panniculus" or "pannus" 1
• Panniculus is classified into five grades based on severity:
  • Grade 1: Reaches the pubic hairline but not the pubis
  • Grade 2: Extends to cover the pubis
  • Grade 3: Extends to cover the upper thigh
  • Grade 4: Extends to mid-thigh
  • Grade 5: Extends to the knee or beyond 1

Factors Contributing to Asymmetry

Several factors can contribute to asymmetry in the pannus:

1. Fat Distribution Patterns:

   • Body fat distribution varies between individuals and can be influenced by genetics, hormones, and lifestyle factors
   • Obesity may impair walking mechanics and efficiency, especially with gynecoid form obesity 2

2. Anatomical Variations:

   • Underlying muscular structure and previous surgeries can affect how adipose tissue accumulates
   • Gluteal fat may increase friction on clothing and skin, affecting posture and weight distribution 2

3. Postural Adaptations:

   • Morbidly obese individuals often develop compensatory postures to manage their weight, leading to uneven distribution of adipose tissue
   • Severe obesity can alter walking mechanics, potentially contributing to asymmetric fat deposition 2

Clinical Significance and Evaluation

When to Be Concerned

While asymmetry is common, certain features warrant further investigation:

• Rapid change in asymmetry
• Pain or tenderness not explained by skin irritation
• Signs of infection or inflammation (redness, warmth, purulent drainage)
• Hardened areas or masses within the pannus

Evaluation Approaches

• Physical Examination: Careful inspection of the pannus, noting any skin changes, masses, or signs of panniculitis 3
• Measurement: Standard anthropometric measurements like waist circumference may be difficult to obtain or interpret accurately in patients with a significant panniculus 1
• Imaging: In cases where there is concern for underlying pathology, CT imaging may be appropriate to rule out hernias or other conditions 4

Management Considerations

Conservative Management

• Proper hygiene of the pannus area to prevent intertrigo, fungal infections, and panniculitis
• Use of moisture-wicking fabrics between skin folds
• Regular inspection of skin under the pannus for early detection of skin breakdown

Surgical Considerations

For patients with symptomatic pannus:

• Panniculectomy may be considered for patients with mobility issues, chronic skin conditions, or in preparation for other surgeries 4
• Surgical management should involve a multidisciplinary approach with careful preoperative cardiovascular evaluation 1
• Patients with a "supersize" pannus (≥10 kg and extending to mid-thigh or below) require specialized surgical planning 4

Complications of Pannus

• Skin breakdown and infections in the skin folds
• Panniculitis (inflammation of the pannus)
• Mobility limitations
• Hygiene challenges
• Psychological impact on body image and quality of life 5

In summary, asymmetry in the pannus of morbidly obese individuals is common and typically not a cause for concern unless accompanied by other concerning symptoms. Management should focus on skin care, prevention of complications, and consideration of surgical options when appropriate.