Is plastic surgery or general surgery preferred for managing pannus?

Pannus Management: Plastic Surgery vs General Surgery

For pannus resection (panniculectomy), either plastic surgery or general surgery is appropriate, as both specialties have demonstrated safe and effective outcomes in managing this condition, with the choice depending primarily on local institutional expertise, surgeon experience with morbidly obese patients, and whether concurrent body contouring is desired.

Surgical Specialty Considerations

Both Specialties Are Appropriate

• General surgeons have successfully performed panniculectomy in morbidly obese patients with documented safety and efficacy, particularly when managing the chronically infected or severely morbid pannus 1, 2.

• Plastic surgeons routinely perform panniculectomy and have extensive experience with tissue handling, wound closure techniques, and aesthetic considerations that may be relevant even in functional panniculectomy 3, 4.

• The literature demonstrates successful outcomes from both specialties, with no evidence-based superiority of one over the other for standard panniculectomy 1, 3, 2.

Key Factors Influencing Specialty Choice

Complexity and Associated Procedures

• Plastic surgery should be strongly considered when:

  • Concurrent body contouring or abdominoplasty is desired beyond simple pannus removal 3
  • Complex reconstruction is needed, such as buried penis syndrome requiring coordination between urology and plastic surgery 4
  • Aesthetic outcomes are a primary concern alongside functional improvement 3

• General surgery may be preferred when:

  • The pannus is chronically infected, lymphedematous, or causing severe medical complications requiring urgent intervention 2
  • The procedure is part of broader abdominal surgery or bariatric surgical management 1
  • Institutional protocols designate general surgery for morbidly obese surgical patients 1

Surgeon-Specific Experience

• The most critical factor is surgeon experience with morbidly obese patients and large pannus resections, regardless of specialty designation 1, 3.

• Surgeons performing giant panniculectomy (resection weight >13.6 kg) must have specific expertise in managing:

  • Massive tissue resection and hemostasis 1, 3
  • Anesthetic challenges in morbidly obese patients 1
  • High-risk wound complications (reported in 29-57% of giant panniculectomy cases) 3

Surgical Approach and Team Considerations

Two-Team Approach

• A two-team surgical approach has demonstrated advantages including minimized blood loss, reduced operative time, decreased pulmonary compromise, and shorter hospital stays 1.

• This approach can involve collaboration between plastic surgery and general surgery, or two surgeons from the same specialty 1.

Multidisciplinary Planning

• Early preoperative involvement of the entire operative team—including the surgeon (regardless of specialty), anesthesiologist, and nursing staff—is essential for proper evaluation of medical comorbidities and detailed surgical planning 1.

• For complex cases involving buried penis syndrome, coordination between plastic surgery and urology is paramount for optimal functional and cosmetic outcomes 4.

Clinical Outcomes and Quality of Life

Expected Benefits

• Panniculectomy, when performed by experienced surgeons of either specialty, provides:
  • Dramatically improved quality of life in 100% of patients in long-term follow-up 3
  • Resolution of chronic infection and sepsis 2
  • Restored ambulation and mobility 2
  • Increased exercise frequency and walking ability 3
  • Improved ability to work and perform daily activities 3

Risk Profile

• Complication rates are substantial regardless of specialty, with 29-57% experiencing postoperative complications in giant panniculectomy series 3.

• Common complications include wound dehiscence, infection, seroma, and need for reoperation 3, 4.

• Careful patient selection and meticulous intraoperative technique are more important than specialty designation in ameliorating these risks 3.

Critical Pitfalls to Avoid

• Do not delay surgical intervention for chronically infected, morbid pannus based on specialty availability—protracted nonsurgical management consistently fails in these patients 2.

• Avoid arbitrary specialty assignment without considering the specific surgeon's experience with morbidly obese patients and large tissue resections 1, 3.

• Do not underestimate anesthetic complexity—thoracic epidural anesthesia can reduce requirements for general endotracheal anesthesia in these high-risk patients 2.

• Ensure adequate preoperative medical optimization of obesity-related comorbidities (present in 86% of giant pannus patients) before proceeding with surgery 3.