COSMETIC

Abdominoplasty: Risk Factors, Complication

Rates, and Safety of Combined Procedures
Julian Winocour, M.D.
Background: Among aesthetic surgery procedures, abdominoplasty is associ-
Varun Gupta, M.D.
ated with a higher complication rate, but previous studies are limited by small
J. Roberto Ramirez, M.D.
sample sizes or single-institution experience.
R. Bruce Shack, M.D. Methods: A cohort of patients who underwent abdominoplasty between 2008
James C. Grotting, M.D. and 2013 was identified from the CosmetAssure database. Major complications
K. Kye Higdon, M.D. were recorded. Univariate and multivariate analysis was performed evaluating
Nashville, Tenn.; and Birmingham, risk factors, including age, smoking, body mass index, sex, diabetes, type of
Ala. surgical facility, and combined procedures.
Results: The authors identified 25,478 abdominoplasties from 183,914 pro-
cedures in the database. Of these, 8,975 patients had abdominoplasty alone
and 16,503 underwent additional procedures. The number of complications
recorded was 1,012 (4.0 percent overall rate versus 1.4 percent in other aes-
thetic surgery procedures). Of these, 31.5 percent were hematomas, 27.2 per-
cent were infections and 20.2 percent were suspected or confirmed venous
thromboembolism. On multivariate analysis, significant risk factors (p < 0.05)
included male sex (relative risk, 1.8), age 55 years or older (1.4), body mass
index greater than or equal to 30 (1.3), multiple procedures (1.5), and proce-
dure performance in a hospital or surgical center versus office-based surgical
suite (1.6). Combined procedures increased the risk of complication (abdomi-
noplasty alone, 3.1 percent; with liposuction, 3.8 percent; breast procedure,
4.3 percent; liposuction and breast procedure, 4.6 percent; body-contouring
procedure, 6.8 percent; liposuction and body-contouring procedure, 10.4
percent).
Conclusions: Abdominoplasty is associated with a higher complication rate
compared with other aesthetic procedures. Combined procedures can sig-
nificantly increase complication rates and should be considered carefully in
higher risk patients.  (Plast. Reconstr. Surg. 136: 597e, 2015.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

A
bdominoplasty is a body-contouring proce-
dure for functional and aesthetic improve-
ment, often performed in combination with
other procedures. It addresses deformity from
excess skin and fat and musculofascial laxity, mini-
mizes visible scars, and leaves a natural-appearing
umbilicus.1 According to the American Society for
Aesthetic Plastic Surgery, it is currently the sixth
most common surgical procedure performed
From the Department of Plastic Surgery, Vanderbilt Univer-
sity; and the Department of Plastic Surgery, University of
Alabama.
Received for publication January 16, 2015; accepted April
24, 2015.
Presented at Plastic Surgery The Meeting 2014: American
Society of Plastic Surgeons Annual Meeting, in Chicago, Il-
linois, October 10 through 14, 2014.
Copyright © 2015 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001700
in the United States, with 111,986 procedures
performed in 2013.2 In the past 13 years, the
number of abdominoplasties performed in the
United States has increased by 79 percent.2 This
is partially attributed to the massive increase in
weight loss procedures being performed, with a
16-fold increase in the past decade, and because of
increased media attention to cosmetic surgery.2–5
Equally, according to previous published reports,
abdominoplasty is increasingly being performed
Disclosure: Dr. Grotting is a founder and share-
holder of CosmetAssure. He is an author for Qual-
ity Medical Publishing and Elsevier. He is a share-
holder of Keller Medical and Ideal Implant. None of
the other authors have a financial interest in any of
the products or devices mentioned in this article. No
funding was required for this project.

www.PRSJournal.com 597e
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • November 2015
as a combined operation with other aesthetic
procedures.6,7 This has the presumed benefit of
requiring a single anesthetic, reduced overall
recovery period, and reduced costs.1,8 Numerous
previous studies have not shown this to increase
the rate of major complications, but these studies
are limited by small sample sizes and often reflect
single-institution experience.1,6,7,9–11 Certain survey-
based larger studies have suggested otherwise and
emphasized the need for further investigation.12
Among aesthetic surgery procedures, abdomi-
noplasty is associated with a higher overall com-
plication rate (as high as 51.8 percent has been
reported).5,13,14 Previous studies have classified
complications into minor and major with incon-
sistent definitions. Major complications have been
loosely considered those requiring surgical inter-
vention, aspiration, parenteral antibiotics, and/
or hospitalization (including hematoma, seroma,
abscess, severe cellulitis, and venous thromboem-
bolism), with minor complications considered
everything else.5,13 Major complications have been
reported in as high as 18.1 percent of patients.5,13
Obesity is the only established risk factor, whereas
data on smoking, hypertension, diabetes melli-
tus, male sex, and previous surgery are inconsis-
tent.1,5,13,15–19 Many of these factors are related to
wound healing and other minor rather than major
complications.1 Although minor complications will
vary among practices and techniques, it is impor-
tant to have a fundamental knowledge of major
complication rates to educate patients and provid-
ers and offer them realistic outcome expectations.
The purpose of this study was to determine the
incidence of major postoperative complications
in patients undergoing abdominoplasty, using
the CosmetAssure (Birmingham, Ala.) insurance
database. Additional goals were to evaluate signifi-
cant risk factors associated with complications and
to compare complication rates of different proce-
dure combinations in this large, prospective, mul-
ticenter database.
PATIENTS AND METHODS
This prospective cohort study was approved by
the university’s institutional review board (insti-
tutional review board no. 140082). The study
population consisted of a cohort of patients who
enrolled in the CosmetAssure insurance program
and underwent cosmetic surgical procedure(s)
between May of 2008 and May of 2013.
598e
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Database
CosmetAssure is an insurance program that
covers the cost of unexpected major complications
from 24 covered cosmetic surgical procedures,
which may not be reimbursed by the patient’s
primary insurer. CosmetAssure was introduced in
2003 and has been collecting data on patient risk
factors since 2008. This insurance program cov-
ers all 50 states in the United States. It is available
to American Board of Plastic Surgery–certified
plastic surgeons and is endorsed by the American
Society of Plastic Surgeons. The program is also
available to American Society of Plastic Surgeons
candidates for membership who have passed the
American Board of Plastic Surgery written exami-
nation. Every patient undergoing any covered
procedure at participating practices is required to
enroll in the program. Patients are entered into
the database before undergoing the operation or
occurrence of a complication, thus making it a
prospective cohort. Surgeon-reported major com-
plications, filed as a claim, are recorded in the
database. Major complication is defined as that
occurring within 30 days of the operation that
requires hospital admission, emergency room
visit, or a reoperation. This excludes complica-
tions that can be managed in the clinic, includ-
ing minor wound infections and seromas, as they
are not applicable for insurance claim. The cov-
ered major complications include hematoma,
infection, pulmonary dysfunction, cardiac com-
plication, wound-related problems, nerve injury,
suspected or confirmed venous thromboembo-
lism, myocardial infarction, and fluid overload.
The database lists all procedures performed on
the patient, making it possible to study specific
individual procedures and procedure combina-
tions (i.e., patients undergoing multiple proce-
dures under the same anesthetic). The database
also records demographic and comorbidity data
including age, sex, body mass index, smoking, dia-
betes mellitus, and type of surgical facility (accred-
ited surgical centers, hospitals, and office-based
surgical suites).
Exposure
In this study cohort, exposure was defined as
the type of cosmetic surgical procedure(s) per-
formed. Abdominoplasty was studied as the pri-
mary exposure, whether performed alone or in
combination with liposuction, breast procedures
(i.e., augmentation, reduction, revision breast
implant procedures, mastopexy, male breast
surgery), body procedures (i.e., brachioplasty,
 Volume 136, Number 5 • Safety of Abdominoplasty
buttock lift, calf implant, labioplasty, lower body
lift, thigh lift, upper body lift), and/or face pro-
cedures (i.e., blepharoplasty, brow lift, cheek
implant, chin augmentation, face lift, facial resur-
facing, hair replacement, otoplasty, rhinoplasty).
Outcome
Primary outcome was occurrence of any major
complication(s) (as defined above) within 30 days
of the procedure. Secondary outcome studied was
the type of complication.
Risk Factors
The potential risk factors evaluated included
age, sex, body mass index, smoking, diabetes mel-
litus, type of facility, and combined procedures.
Statistical Analysis
Two separate, deidentified data sets were
obtained from CosmetAssure, one with the enroll-
ment data and other with claims information. The
enrollment data set contained entries for each
unique procedure. Thus, a patient undergoing
combined procedures had separate entries for
each procedure. A unique identifier was created
using variables: date of birth, date of surgery, and
body mass index. Using this unique identifier, the
enrollment data set was restructured such that a
patient undergoing combined procedures was
counted once, with each of the procedures listed
as a separate variable. Another unique identifier
was created with variables shared between the
enrollment and claims data sets; date of birth,
date of surgery, and sex. This identifier was then
used to match the claims data set to the restruc-
tured enrollment data set. Of the 2506 patients in
the claims data set, 20 did not match the enroll-
ment data using the identifier. These cases were
matched manually to enrollees with the closest
demographic characteristics. The Kolmogorov-
Smirnov statistic was used to check normal distri-
bution of continuous variables (age and body mass
index). Patient characteristics, risk factors, and
complication rates between patients undergoing
different procedure combinations were compared
by two-tailed t, Fisher’s, or chi-square test. Univari-
ate analysis for risk factors of complication was
performed after stratifying data by type of proce-
dure combinations. For the purpose of univariate
analysis, age and body mass index were recorded
as ordinal variables with clinically appropriate cat-
egories. Standard logistic regression analysis was
performed to identify the independent risk fac-
tors for postoperative complications. For purpose
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
of logistic regression analysis, age and body mass
index were recorded to a dichotomous scale (age
≥ 55 years / < 55 years, BMI ≥30/<30  kg/m2).
Unless otherwise noted, the probability of a type
I error of less than 5 percent (p < 0.05) was used
to determine statistical significance. All analyses
were performed using SPSS 17.0 statistical soft-
ware (SPSS, Inc., Chicago, Ill.).
RESULTS
Between May of 2008 and May of 2013, a total
of 183,914 cosmetic surgery procedures were per-
formed on 129,007 patients who enrolled in the Cos-
metAssure program (Fig. 1). Overall, mean age was
40.9 ± 13.9 years, body mass index was 24.3 ± 4.4 kg/
m2, and the majority of patients were women (93.5
percent). A total of 25,478 abdominoplasties were
performed, representing 13.8 percent of all proce-
dures. Of these, 8975 patients (35.2 percent) had
an isolated abdominoplasty performed, whereas
16,503 (64.8 percent) underwent additional pro-
cedures (combined procedure). This is in contrast
to other nonabdominoplasty cosmetic procedures,
where only 24.5 percent of patients underwent com-
bined procedures. From 2008 to 2013, although
there was a steady increase in the overall number
of abdominoplasties performed, the percentage
of patients undergoing combined abdominoplasty
procedures remained stable (67.6 percent and
65.5 percent, respectively). In the abdominoplasty
cohort, there were fewer male patients (3.4 percent
versus 6.5 percent; p < 0.01) and smokers (6.4 per-
cent versus 8.2 percent; p < 0.01) but more diabetics
(2.8 percent versus 1.8 percent; p < 0.01) (Table 1).
Similar to other procedures, abdominoplasties were
most commonly performed in accredited surgical
centers (48.8 percent), followed by hospitals (39.1
percent) and finally in office-based surgical suites
(12.1 percent). Half the patients were between the
ages of 40 and 59 years.
A total of 2506 major complications occurred
(1.9 percent overall rate), of which 1012 were in
the abdominoplasty group (4.0 percent compli-
cation rate). The most common complications
seen with abdominoplasty were hematoma (1.3
percent), infection (1.1 percent), suspected or
confirmed venous thromboembolism (0.8 per-
cent), and pulmonary dysfunction (0.3 percent).
This had a similar distribution to other cosmetic
procedures, as depicted in Table 2 and Figure 2.
On univariate analysis, male sex, diabetes,
increasing age, and high body mass index were
associated with increased complications. Mor-
bidly obese patients (body mass index ≥40 kg/m2)
599e
 Plastic and Reconstructive Surgery • November 2015

Fig. 1. Study design demonstrating the number of patients undergoing various therapies accord-
ing to the CosmetAssure database.

Table 1.  Clinical and Demographic Characteristics

Nonabdominoplasty (%) Abdominoplasty (%) p
No. 103,529 25,478
Male sex 7485 (7.2) 872 (3.4) <0.01
Smoking 8983 (8.7) 1638 (6.4) <0.01
Diabetes 1644 (1.6) 724 (2.8) <0.01
Type of facility
 Accredited surgical center 61,571 (59.5) 12,423 (48.8)
 Hospital 24,505 (23.7) 9972 (39.1)
 Office-based surgical suite 17,453 (16.9) 3083 (12.1) <0.01
Multiple procedures 25,382 (24.5) 16,503 (64.8) <0.01
Mean age ± SD, yr 40.52 ± 14.5 42.36 ± 11.2 <0.01
Age ≥60 yr 12,085 (11.7) 1998 (7.8) <0.01
BMI ≥25 31,639 (30.8) 14,686 (58.1) <0.01
Mean BMI ± SD, kg/m2 23.75 ± 4.3 26.68 ± 5.0 <0.01
Complication 1494 (1.4) 1012 (4.0) <0.01
BMI, body mass index.

had nearly double the complication rate com-
pared with normal-weight patients (body mass
index of 18.5 to 24.9 40  kg/m2) (6.4 percent
versus 3.3 percent, respectively; p < 0.01). Male
patients had a complication rate of 6.1 percent
compared with 3.9 percent in women (p < 0.01).
Patients aged 60 years or older had a complica-
tion rate of 5.3 percent compared with 3.9 percent
in younger patients (p < 0.01). Diabetic patients
had a 5.8 percent complication rate compared
with 3.9 percent in nondiabetics (p = 0.01). An
increased complication rate was also seen with
combined procedures (Fig.  3). Smoking was not
found to be a significant risk factor (4.5 percent
versus 3.9 percent; p = 0.23). An increased compli-
cation rate was seen in hospital-based procedures
(4.3 percent) compared with accredited surgical
centers (4.1 percent) and office-based surgical
suites (2.7 percent) (p < 0.01). On multivariate
logistic regression, independent risk factors
(p < 0.05) included male sex (relative risk, 1.8),
age 55 years or older (relative risk, 1.4), body mass
index greater than or equal to 30 (relative risk,
1.3), multiple procedures (relative risk, 1.5), and
the procedure being performed in a hospital or
accredited surgical center rather than office-based
surgical suites (relative risk, 1.6) (Table 3). Smok-
ing and diabetes (relative risk, 1.3; p = 0.098) were
not found to be independent risk factors on multi-
variate logistic regression.
The subgroup of abdominoplasty patients who
underwent combined procedures was specifically
analyzed. Patients undergoing combined proce-
dures included fewer male patients (3.1 percent
versus 3.9 percent), fewer diabetics (2.5 percent
versus 3.5 percent), fewer patients aged 60 years
or older (6.7 percent versus 9.9 percent), and
fewer overweight patients (57.5 percent versus

600e
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 136, Number 5 • Safety of Abdominoplasty

Table 2.   Type and Frequency of Complications

Abdominoplasty (%) Nonabdominoplasty (%) All Cases (%)
n=1012 n=1494 (n=2506)
Type of complication
 Hematoma 319 (31.5) 853 (57.1) 1172 (46.8)
 Infection 275 (27.2) 301 (20.1) 576 (23.0)
 Suspected or confirmed VTE 204 (20.2) 109 (7.3) 313 (12.5)
 Pulmonary dysfunction 71 (7.0) 77 (5.2) 148 (5.9)
 Fluid overload 35 (3.5) 29 (1.9) 64 (2.6)
 Hypotension 27 (2.7) 20 (1.3) 47 (1.9)
 Wound related 19 (1.9) 37 (2.5) 56 (2.2)
 Pain 13 (1.3) 8 (0.5) 21 (0.8)
 Pneumonia 11 (1.1) 4 (0.3) 15 (0.6)
 Cardiac 11 (1.1) 27 (1.8) 38 (1.5)
 Urinary retention 10 (1.0) 3 (0.2) 13 (0.5)
 Pneumothorax 3 (0.3) 7 (0.5) 10 (0.4)
 Other 14 (0.1) 17 (1.1) 31 (1.2)
 Death 0 (0.0) 1 (0.1) 1 (0.0)
VTE, venous thromboembolism; MI, myocardial infarction.

59.4 percent) than those having only abdomino-
plasty. Abdominoplasty performed alone had a
complication rate of 3.1 percent. Male sex, dia-
betes mellitus, body mass index, and age contin-
ued to be associated with complications in this
subgroup. When abdominoplasty was combined
with procedures on other body region (i.e., face,
breast, or body), the complication rate increased
with the number of body regions operated on, up
to 4.8 percent. When specific procedure combi-
nations were analyzed, there was significant varia-
tion in the complication rate: abdominoplasty
alone, 3.1 percent; abdominoplasty combined
with liposuction, 3.8 percent; abdominoplasty
combined with a breast procedure, 4.3 percent;
abdominoplasty combined with liposuction and
a breast procedure, 4.6 percent; abdominoplasty
combined with a body-contouring procedure,
6.8 percent; abdominoplasty combined with lipo-
suction and a body-contouring procedure, 10.4
percent; and abdominoplasty combined with lipo-
suction and a body-contouring procedure and a
breast procedure, 12.0 percent. Combining lipo-
suction with abdominoplasty also increased the
risk of possible or confirmed venous thromboem-
bolism from 0.5 percent to 1.1 percent (p < 0.05).

Fig. 2. Breakdown of major complications. DVT, deep venous thrombosis; PE, pulmonary embolism.

601e
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • November 2015
Fig. 3. Univariate analysis of risk factors (*p<0.01).
DISCUSSION
Literature regarding complication rates with
abdominoplasty started with Grazer and Gold-
wyn’s survey of 958 surgeons in 1977, which
published an overall complication rate of 14.6
percent (including a wound infection rate of 7.3
percent, a dehiscence rate of 5.4 percent, and a
venous thromboembolism rate of 1.1 percent).20
Since that initial work, abdominoplasty has been
proven to be a safe aesthetic procedure with a low
overall major complication rate as shown in this
study (4.0 percent). Although the overall inci-
dence of major complications is low, such com-
plications can result in a potentially devastating
cosmetic outcome and pose a significant financial
burden on the patient and surgeon. It is for this
reason that it is imperative to have reliable stud-
ies about surgical outcomes and risk factors that
are generalizable to a variety of practice mod-
els. Existing literature on abdominoplasty com-
plications is limited by small sample size, single
institution or surgeon experience, and variation
in training and qualifications of the physicians
performing the procedure. Equally, previous lit-
erature on complications related to cosmetic sur-
gery divides complications into major and minor,
with inconsistent definitions.1,5–8,13,15,16,18,21 In this
study, only major complications were included,
602e
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
defined as requiring hospital admission, emer-
gency room visit, or reoperation within 30 days of
the procedure.
Obesity
According to the Centers for Disease Control
and Prevention, an adult who has a body mass
index of 25 to 29.9  kg/m2 is considered over-
weight; greater than or equal to 30 kg/m2, obese;
and 40 kg/m2 or higher, morbidly obese. Although
the number of obese patients in the United States
has increased steadily over the past decade, in
our study, the percentage of patients with a body
mass index of 25  kg/m2 or greater undergoing
abdominoplasty has remained stable between
2008 and 2013 (57.9 percent versus 59.7 percent;
p = 0.086). Previous studies have shown increased
complication rates (both minor and major) in
obese patients, with published major complica-
tion rates as high as 46.2 percent in the morbidly
obese.5,13,16,18 This has especially been shown with
regard to wound complications, seromas, and
venous thromboembolism.13,16,17 Increased risk
in overweight patients (body mass index of 25 to
29.9) has been more controversial.13,19 This study
demonstrated a clear trend of a statistically signifi-
cant increase in complication rates in overweight
(4.1 percent), obese (4.9 percent), and morbidly
 Volume 136, Number 5 • Safety of Abdominoplasty
Table 3.  Risk Factors for Complications from
Abdominoplasty*
Relative Risk p 95% CI
Male sex 1.8 <0.01
Facility (ASC or hospital) 1.6 <0.01
Procedures (combined) 1.5 <0.01
Age ≥ 55 yr 1.4 <0.01
BMI ≥25 1.3 <0.01
Diabetic 1.3 0.098
ASC, accredited surgical center; BMI, body mass index.
*Multivariate logistic regression
obese patients (6.4 percent) compared with a
3.3 percent complication rate in patients with a
body mass index of 18.5 to 24.9 kg/m2 (Fig. 3).
Smoking
Smoking has been looked at in numerous
other studies to determine its effect on cosmetic
outcomes, and it has traditionally been consid-
ered a risk factor for wound healing problems
and tissue loss following the whole spectrum of
cosmetic surgery procedures. Theories revolve
around the relationship of nicotine in decreasing
cutaneous blood flow through vasoconstriction
and the hypoxic effects of smoking, but no conclu-
sive pathophysiology has been defined.22 Momeni
et al. observed no relationship between smoking
and an increased complication rate in a study
examining 139 patients undergoing abdomino-
plasty, 48 of whom were active smokers.18 Manassa
et al. examined 132 patients, 53.8 percent of
whom smoked, and found a striking difference
in wound complications between smokers (47.9
percent) and nonsmokers (14.8 percent).15 This
was consistent with the study by Araco et al. from
2008, which demonstrated a 12-fold increase in
infection complications in smokers undergoing
abdominoplasty.23 In the present study, smoking
was not found to be a significant risk factor for
major complications (4.5 percent versus 3.9 per-
cent; p = 0.23). According to the Centers for Dis-
ease Control and Prevention, 18.1 percent of U.S.
adults smoke cigarettes.24 In our data, only 6.4
percent of patients undergoing abdominoplasty
were smokers. Moreover, the proportion of smok-
ers decreased from 7.3 percent in 2008 to 5.5 per-
cent in 2013, consistent with national trends. This
likely reflects the due caution exerted by board-
certified plastic surgeons when deciding to oper-
ate on patients who smoke. In addition, many of
the complications attributed to smoking in previ-
ous studies have been related to wound healing
and infections, the majority of which would not
be captured in the CosmetAssure database.
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Age
Age as a risk factor for any type of surgical
procedure has been controversial, often compli-
1.4–2.4
cated by physiologic aging-related changes and
1.3–2.0 underlying disease states.25 Previous data about
1.3–1.7 patient age as an independent risk factor in plas-
1.2–1.7 tic surgery are scarce. Our data suggest that age
1.1–1.5
0.9–1.8 can be an important factor to consider preop-
eratively in patients undergoing abdominoplasty.
Patients aged younger than 60 years had a sig-
nificantly lower complication rate compared with
those aged 60 years or older (3.9 percent versus
5.3 percent; p < 0.01).
Sex
Male sex has inconsistently been reported as
a risk factor in cosmetic surgery. Neaman et al.
previously demonstrated in their review of 1008
abdominoplasties an increased risk of both major
and minor complications and seroma formation
(OR, 4.07).13 This was consistent with the review by
Momeni et al. of 139 patients that demonstrated
an increased trend toward minor and major
complications, although this did not reach sig-
nificance.18 As expected, the majority of patients
undergoing abdominoplasty in this study were
female patients (96.6 percent). This distribution
remained stable from 2008 to 2013 (3.4 percent
versus 3.7 percent male patients; p = 0.62). Consis-
tent with the literature, male sex constituted the
largest preoperative risk factor for major compli-
cations in this study, with a relative risk of 1.8 on
multivariate regression.
Diabetes
There is a paucity of previous literature look-
ing specifically at the effect of diabetes mellitus on
major complications in abdominoplasty. Neaman
et al. published a review of 206 patients in 2007
and found a tendency toward increased seromas.5
Previous breast literature has demonstrated an
increased rate of major complications with dia-
betes in augmentation/mastopexy and a trend in
cosmetic breast surgery.26 Diabetes was not found
to be a significant risk factor for major complica-
tions in abdominoplasty in this current study.
The prevalence of diabetes mellitus in patients
undergoing abdominoplasty was 2.8 percent,
which is significantly less than the prevalence in the
general population (9.5 percent according to the
National Diabetes Statistics Report).27 The preva-
lence of diabetes in our data has remained stable
between 2008 and 2013. The likely explanation
is that patients undergoing abdominoplasty (or
603e
 Plastic and Reconstructive Surgery • November 2015
Table 4.  Complication Rates in Different Procedure Combinations*
Abdominoplasty alone
Abdominoplasty plus:
 Liposuction
 Breast
 Liposuction plus breast
 Body contouring
 Body contouring plus breast
 Liposuction plus body contouring
 Liposuction plus body contouring plus breast
*Body region: face (blepharoplasty, brow lift, cheek implant, chin augmentation, face lift, facial resurfacing, hair replacement, otoplasty, rhino-
plasty), breast (augmentation, reduction, revision breast implant procedures, mastopexy, male breast surgery), body contouring (brachioplasty,
buttock lift, calf implant, labioplasty, lower body lift, thigh lift, upper body lift), and liposuction.
other cosmetic surgical procedures) are in good
overall health, with fewer comorbid conditions.
Facility
The facility in which abdominoplasty is per-
formed was found to be a significant risk factor
in this study. A higher complication rate was seen
with the procedure being performed in a hospi-
tal/accredited surgical center rather than office-
based surgical suites (relative risk, 1.6). There is
little literature that has looked at this previously;
however, this is likely related to selection bias of
the providers.28
Combined Surgery
Although it is commonly presumed that the
rate of combined procedures with abdomino-
plasty is increasing steadily with the “makeover”
concept, our data indicate that this is not the case.
Between 2008 and 2013, the rate of combined pro-
cedures dropped from 67.6 percent to 65.5 percent
(p < 0.01). There have been many studies looking
at the effect of combined procedures on complica-
tion rates of cosmetic surgeries with mixed results.
In terms of abdominoplasty, previous studies have
looked at concurrent cosmetic or noncosmetic
(e.g., hernia repair, hysterectomy) procedures.
Neaman et al. in 2013, in addition to numer-
ous previous authors, concluded that concurrent
suction-assisted lipoplasty of the abdomen and
flanks correlated to seroma formation and minor
and major complications.13 However, other pro-
cedures, including breast, facial aesthetic, hernia
repair, and body contouring, were not associated
with an increase in complications.7,10,13,22,29 This is
contrasted by other studies that dispute any added
risk or increased seroma occurrence of suction-
assisted lipoplasty to abdominoplasty.6,16 This study
demonstrates an increased major complication
rate with combined procedures. When additional
regions operated on were looked at in general,
604e
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
No. of Cases (%) Complication Rate (%)
8977 (35.2) 3.1
6946 (27.3) 3.8
4259 (16.7) 4.3
3364 (13.2) 4.6
544 (2.1) 6.8
190 (0.7) 6.3
386 (1.5) 10.4
117 (0.5) 12.0
each additional region resulted in a statistically
significant increase in complication rates (Fig. 3).
Furthermore, we found increased complication
rates with all additional procedures when looked
at specifically, with the highest increase being seen
with other body-contouring procedures (6.8 per-
cent versus 3.1 percent; p < 0.01). Although the
increase in complication rate in combined pro-
cedures is less than the sum of the complication
rate of each procedure performed separately, a 12
percent incidence of major complication follow-
ing elective, non–medically necessary procedures
nonetheless needs careful consideration (Table 4).
To the best of our knowledge, this study represents
the largest single database series of abdominoplasty
patients. The CosmetAssure insurance database is
a powerful tool for assessment of clinical outcomes
of cosmetic surgery. It provides prospectively col-
lected data, which is necessary for determining the
true incidence of complications and risk factors. It
is a multicenter database encompassing hospitals,
accredited surgical centers, and office-based surgi-
cal suites, making the results generalizable to a wide
variety of practice models. Previous studies looking
at complications and risk factors often did not differ-
entiate patients undergoing combined procedures.
Our database is robust in establishing baseline com-
plication rate following abdominoplasty and any
procedure combination. The data set is validated by
a patient profile and procedure distribution similar
to that reported by the American Society for Aes-
thetic Plastic Surgery.2 Furthermore, complication
rates for abdominoplasty and breast augmentation
were similar in Tracking Operations and Outcomes
for Plastic Surgeons and CosmetAssure, providing a
measure of cross-validation.30
The database goes a step further by establish-
ing the minimum surgeon qualification (board-
certified or board-eligible plastic surgeons), thus
avoiding variability in complications attributable
to the credentials of the health care provider. In
 Volume 136, Number 5 • Safety of Abdominoplasty
today’s age, where abdominoplasties and other
cosmetic operations are being performed by a
variety of health care providers, it is essential to
demonstrate, and compare, outcomes of these
providers with different board affiliations.
Although the CosmetAssure database has
many advantages, a few of its limitations need to
be addressed. First, the database fails to include
minor but clinically significant complications (e.g.,
seroma, nerve injury, wound breakdown). These
complications are significantly more common than
major complications and are important in cosmetic
outcomes and patient-perceived results. The data-
base does not register complications occurring after
30 days postoperatively. This results in unknown
final outcomes after the management of these
complications. The database does not differentiate
between different techniques of abdominoplasty,
which can predispose patients to certain compli-
cations. No information is available on measures
such as venous thromboembolism prophylaxis or
preoperative antibiotics and thus their impact can-
not be analyzed. The database lacks comprehensive
information about patients’ other comorbidities.
10. Hester TR Jr, Baird W, Bostwick J III, Nahai F, Cukic J.
However, assessment of available health conditions
(e.g., diabetes mellitus, obesity, and smoking) sug-
gests that the patient population seeking cosmetic
surgery is significantly healthier compared with the
general population of the United States, with a low
burden of comorbid conditions. Finally, CosmetAs-
sure is used by only a fraction of eligible plastic sur-
geons in the United States.
CONCLUSIONS
Concurrent with previous literature, abdomi-
noplasty is associated with a higher complication
rate compared with other aesthetic surgery pro-
cedures. Age, body mass index, and male sex are
independent risk factors for complications. Com-
bined procedures can result in an increased rate
of major complications, and preoperative risk
factors should be considered to help stratify high-
risk patients that might be better suited for staged
rather than combined procedures.
Julian Winocour, M.D.
Department of Plastic Surgery
D-4207 Medical Center North
Nashville, Tenn. 37232-2345
julian.winocour@vanderbilt.edu
references
1. Hensel JM, Lehman JA Jr, Tantri MP, Parker MG, Wagner
DS, Topham NS. An outcomes analysis and satisfaction
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
survey of 199 consecutive abdominoplasties. Ann Plast Surg.
2001;46:357–363.
2. American Society for Aesthetic Plastic Surgery. 2013 national
totals for cosmetic procedures. Available at: www.surgery.org.
Accessed December 15, 2014.
3. Zhao Y, Encinosa W. Bariatric surgery utilization and out-
comes in 1998 and 2004: Statistical brief #23. In: Healthcare
Cost and Utilization Project (HCUP) Statistical Briefs. Rockville,
Md: Agency for Health Care Policy and Research; 2007:1–7.
4. American Society for Metabolic and Bariatric Surgery.
American Society for Metabolic and Bariatric Surgery fact
sheets: Metabolic & bariatric surgery. Available at: http://
asmbs.org/. Accessed December 15, 2014.
5. Neaman KC, Hansen JE. Analysis of complications from
abdominoplasty: A review of 206 cases at a university hospi-
tal. Ann Plast Surg. 2007;58:292–298.
6. Stevens WG, Cohen R, Vath SD, Stoker DA, Hirsch EM. Does
lipoplasty really add morbidity to abdominoplasty? Revisiting
the controversy with a series of 406 cases. Aesthet Surg J.
2005;25:353–358.
7. Stevens WG, Repta R, Pacella SJ, et al. Safe and consistent
outcomes of successfully combining breast surgery and
abdominoplasty: An update. Aesthet Surg J. 2009;29:129–134.
8. Stewart KJ, Stewart DA, Coghlan B, Harrison DH, Jones BM,
Waterhouse N. Complications of 278 consecutive abdomino-
plasties. J Plast Reconstr Aesthet Surg. 2006;59:1152–1155.
9. Cardoso de Castro C, Cupelo AM. Analysis of 60 cases of
simultaneous mammoplasty and abdominoplasty. Aesthetic
Plast Surg. 1990;14:35–41.
Abdominoplasty combined with other major surgical proce-
dures: Safe or sorry? Plast Reconstr Surg. 1989;83:997–1004.
11. Pitanguy I, Ceravolo MP. Our experience with combined
procedures in aesthetic plastic surgery. Plast Reconstr Surg.
1983;71:56–65.
12. Hughes CE III. Reduction of lipoplasty risks and mortality:
An ASAPS survey. Aesthet Surg J. 2001;21:120–127.
13. Neaman KC, Armstrong SD, Baca ME, Albert M, Vander
Woude DL, Renucci JD. Outcomes of traditional cosmetic
abdominoplasty in a community setting: A retrospective anal-
ysis of 1008 patients. Plast Reconstr Surg. 2013;131:403e–410e.
14. Staalesen T, Elander A, Strandell A, Bergh C. A systematic
review of outcomes of abdominoplasty. J Plast Surg Hand
Surg. 2012;46:139–144.
15. Manassa EH, Hertl CH, Olbrisch RR. Wound healing prob-
lems in smokers and nonsmokers after 132 abdominoplas-
ties. Plast Reconstr Surg. 2003;111:2082–2087; discussion 2088.
16. Kim J, Stevenson TR. Abdominoplasty, liposuction of the
flanks, and obesity: Analyzing risk factors for seroma for-
mation. Plast Reconstr Surg. 2006;117:773–779; discussion
780–781.
17. Hurvitz KA, Olaya WA, Nguyen A, Wells JH. Evidence-
based medicine: Abdominoplasty. Plast Reconstr Surg.
2014;133:1214–1221.
18. Momeni A, Heier M, Bannasch H, Stark GB. Complications
in abdominoplasty: A risk factor analysis. J Plast Reconstr
Aesthet Surg. 2009;62:1250–1254.
19. Vastine VL, Morgan RF, Williams GS, et al. Wound compli-
cations of abdominoplasty in obese patients. Ann Plast Surg.
1999;42:34–39.
20. Grazer FM, Goldwyn RM. Abdominoplasty assessed by sur-
vey, with emphasis on complications. Plast Reconstr Surg.
1977;59:513–517.
21. Stokes RB, Williams S. Does concomitant breast sur-
gery add morbidity to abdominoplasty? Aesthet Surg J.
2007;27:612–615.
605e
 Plastic and Reconstructive Surgery • November 2015

22. Leow YH, Maibach HI. Cigarette smoking, cutaneous vascu-
lature, and tissue oxygen. Clin Dermatol. 1998;16:579–584.
23. Araco A, Gravante G, Sorge R, Araco F, Delogu D, Cervelli V.
Wound infections in aesthetic abdominoplasties: The role of
smoking. Plast Reconstr Surg. 2008;121:305e–310e.
24. Agaku IT, King BA, Dube SR; Centers for Disease Control and
Prevention. Current Cigarette Smoking Among Adults: United
States, 2005–2012. MMWR Morb Mortal Wkly Rep. 2014;63:29–34.
25. Lubin MF. Is age a risk factor for surgery? Med Clin North Am.
1993;77:327–333.
26. Hanemann MS Jr, Grotting JC. Evaluation of preoperative
risk factors and complication rates in cosmetic breast sur-
gery. Ann Plast Surg. 2010;64:537–540.
27. Centers for Disease Control and Prevention. National
Diabetes Statistics Report, 2014. Atlanta, Ga: U.S. Department
of Health and Human Services; 2014. Available at: www.cdc.
gov/. Accessed December 15, 2014.
28. Gray S, Gittleman E, Moliver CL. Safety in office-based full
abdominoplasty. Aesthet Surg J. 2012;32:200–206.
29. Najera RM, Asheld W, Sayeed SM, Glickman LT. Comparison
of seroma formation following abdominoplasty with or with-
out liposuction. Plast Reconstr Surg. 2011;127:417–422.
30. Alderman AK, Collins ED, Streu R, et al. Benchmarking out-
comes in plastic surgery: National complication rates for
abdominoplasty and breast augmentation. Plast Reconstr Surg.
2009;124:2127–2133.

606e
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.