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Panniculectomy (Urologic Indications)

Panniculectomy removes an overhanging abdominal apron of skin and fat. In reconstructive urology, it may help selected patients with buried penis, an abdominal contour that prevents a reliable urostomy appliance seal, or a pannus that complicates kidney-transplant access. It is distinct from localized suprapubic Escutcheonectomy. Unlike abdominoplasty, panniculectomy generally does not include abdominal muscle tightening and is not a substitute for weight management.[1][2][3][4]

Clinical role​

Adult-acquired buried penis​

Add panniculectomy when the abdominal pannus contributes to concealment or impedes the planned reconstruction. Penile skin, escutcheon and scrotal components should be assessed separately. A PAS category can describe the anatomy, but does not require every component to be excised or grafted.[5][6] See Buried Penis Repair.

Barrow's review identified four reports with 57 patients and a separate NSQIP analysis. Adding panniculectomy was not independently associated with more 30-day complications in that adjusted analysis. This does not establish absence of added risk: the groups differed in comorbidity and the evidence is observational.[7]

In Staniorski's 103-patient high-complexity AABP cohort, 28% underwent panniculectomy. The overall complication rate was 50%, with 41% Clavien I–II. Its 3.9% revision rate and frailty association describe the whole combined-repair cohort, not panniculectomy in isolation.[8]

Kidney-transplant candidates​

A troublesome pannus may create a technical or wound-healing barrier in selected candidates. KDIGO recommends individual transplant-surgeon assessment, offers weight-loss interventions and advises against exclusion based on obesity alone; it does not impose a universal BMI cutoff. Its discussion describes possible benefit from pretransplant panniculectomy, without making the procedure mandatory.[3]

ApproachRelevant experienceInterpretation
Panniculectomy before transplantationTroppmann: 36 patients were subsequently listed; 22 received a transplant. One of the 22 recipients had a minor posttransplant wound complicationThe 5% wound rate applies to recipients after transplantation, not to all panniculectomy wounds
Concurrent living-donor transplant and panniculectomyNgaage: 58 selected patients; allograft survival was reported at one year, with 24% wound complications and 52% 90-day readmissionAn uncontrolled series, without a transplant-alone comparison

These approaches require coordinated transplant and plastic-surgical planning, considering operative access, wound healing under immunosuppression and the consequences of delaying transplantation. In the staged pilot, the reported five-year survival difference was between those who were transplanted and those who were not; it does not demonstrate a survival effect caused by panniculectomy.[9][10]

Difficult urostomy contour​

First assess the stoma, abdominal wall and appliance with a stoma-care specialist and reconstructive team. Contouring can be considered when folds, scars or a pannus cause persistent mechanical leakage despite simpler measures. Mickute's report included four patients: three reported better fit and substantially less leakage, while the fourth required further contouring. This is limited salvage experience, not a standard first-line stoma revision.[4]

Urinary incontinence: evidence boundary​

Panniculectomy should not be presented as an established operation for stress urinary incontinence. Karunaratne's 2025 review included 719 patients, predominantly women, and rectus plication was performed in about 91%. Reported continence improvements after these mixed body-contouring procedures cannot isolate the effect of panniculectomy or prove a mechanism such as reduced intra-abdominal pressure. Incontinence requires its own diagnosis and established treatment pathway.[11] See Female Stress Urinary Incontinence.

Preoperative planning​

Assess the pannus, prior incisions, skin disease, hernia, stoma, nutritional status, diabetes, smoking and functional capacity. Arrange anesthetic assessment, appropriate equipment and perioperative thromboprophylaxis for the complete operation. Imaging and abdominal-wall specialist input are appropriate when a hernia is suspected or examination is inadequate.[12]

Mark with the patient standing and confirm the proposed closure supine. Plan umbilical management, genital or stoma displacement and closure tension explicitly. Incorporate the patient's ongoing weight-loss plans, wound-care capacity and functional goals. Nutrition and glycemic decisions should follow the current Perioperative Care pathways rather than a universal laboratory cutoff from an operative case series.[1][12]

Technique principles​

PatternReconstructive role
Transverse panniculectomyRemoves the contributory lower abdominal apron
Fleur-de-lis patternAdds vertical excision for selected horizontal/upper abdominal excess; creates an additional junction requiring attention to perfusion and tension
Modified trapezoid mobilization for AABPA described approach that can preserve superior attachments while suitable pannus skin is harvested for STSG

No incision pattern has universal superiority or proven equivalent complications across different patients.[12][13]

  1. Plan safe exposure. Use a suitable operating table, positioning and retraction system. If a massive pannus requires suspension, use equipment approved for the load and confirm the absence/location of herniated contents before penetrating fixation.
  2. Resect to the planned defect. Protect abdominal-wall structures and preserve flap perforators and lymphatic tissue where possible. Limit undermining to what the reconstruction requires.
  3. Secure hemostasis. Account for large superficial vessels and the potential for substantial blood loss in extensive resections.
  4. Manage dead space and tension. Select drainage, progressive-tension sutures and layered closure according to the actual wound. There is no universal requirement for two to four drains or one drain-removal day.

These are operative planning principles; extensive abdominal-wall, stoma or transplant reconstruction requires the relevant specialist team.[12]

When panniculectomy accompanies AABP repair, preserve adequate healthy shaft skin and graft only the deficient area. Suitable pannus or escutcheon skin can avoid a separate donor wound, but skin quality and hair must be assessed. Figler's outpatient technique harvested an unmeshed STSG from the pannus and used a bolster for 5–7 days; that protocol does not establish a universal graft thickness, dressing or admission duration.[13][14]

Concurrent ventral hernia repair​

Adding panniculectomy to ventral hernia repair can increase wound morbidity. A 2024 systematic review included 23,354 patients in 11 observational studies and two randomized trials; 2,972 underwent the combined operation. Compared with hernia repair alone, the combined approach was associated with more SSI (RR 1.31, 95% CI 1.13–1.51), skin necrosis and reoperation (RR 1.73, 95% CI 1.32–2.28). Lower recurrence was also reported, but selection, study design and follow-up limit causal interpretation.[15]

This comparison differs from asking whether a patient already requiring panniculectomy should also have a hernia repaired. Discuss the sequence, mesh/wound considerations and alternatives with an abdominal-wall surgeon rather than assuming any combined operation carries no additional risk.[15][12]

Wound management and recovery​

Choose standard dressings or closed-incision NPWT according to wound risk, device instructions and available support. A 2025 review combined 11 comparative studies across panniculectomy, abdominoplasty and abdominal flap donor sites; it associated incisional NPWT with less dehiscence and unplanned reoperation, but not a significant SSI, seroma, hematoma or skin-necrosis difference. Those mixed procedures do not define a mandatory panniculectomy protocol.[16]

The broader 2022 Cochrane review included 62 RCTs and 13,340 participants across several surgical populations. It found moderate-certainty evidence of fewer SSIs, but probably little or no difference in dehiscence; blistering may increase. Applicability, cost and outcomes vary by operation. Open-wound NPWT and deliberately partial closure are different strategies and should not be inferred to be superior from small uncontrolled reports.[17]

Counsel about infection, wound separation, seroma, hematoma, flap ischemia, transfusion, thromboembolism and revision according to the operation and patient. A low major-complication rate cannot be substituted for the total wound-complication rate, and comparison with historical cohorts does not establish a treatment effect. Ensure appropriate wound/drain review, mobilization and support after discharge.[12][8]

Same-day or next-day discharge is possible in selected AABP repairs. Figler's 19-patient cohort had graft take of at least 95%, five cellulitis cases and three minor dehiscences. No observed DVT in such a small series does not establish negligible thromboembolic risk.[13]

Documentation​

Document the functional impairment, the anatomy treated, conservative measures, combined procedures and intended goals. Coding and coverage depend on the actual procedure and current payer rules; a functional indication does not guarantee authorization.

See Also​

References​

1. American Society of Plastic Surgeons. Panniculectomy. Procedure overview.

2. Pestana IA, Greenfield JM, Walsh M, Donatucci CF, Erdmann D. "Management of 'Buried' Penis in Adulthood: An Overview." Plast Reconstr Surg. 2009;124(4):1186–1195. doi:10.1097/PRS.0b013e3181b5a37f

3. Chadban SJ, Ahn C, Axelrod DA, et al. "2020 KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation." Transplantation. 2020;104(4S1 Suppl 1):S11–S103. doi:10.1097/TP.0000000000003136

4. Mickute Z, Chen YA, Som R, Malata CM. "'Uro-Abdominoplasty': An Adaptation of Abdominal Contouring for Revision of Complicated Urostomies." Ann Plast Surg. 2012;68(3):295–9. doi:10.1097/SAP.0b013e318212f3f9

5. Schlaepfer CH, Flynn KJ, Alsikafi NF, et al. "Clinical Validation of an Adult-acquired Buried Penis Classification System Based on Standardized Evaluation of the Penis, Abdomen, and Scrotum." Urology. 2023;180:249–256. doi:10.1016/j.urology.2023.04.048

6. Hesse MA, Israel JS, Shulzhenko NO, et al. "The Surgical Treatment of Adult Acquired Buried Penis Syndrome: A New Classification System." Aesthet Surg J. 2019;39(9):979–988. doi:10.1093/asj/sjy325

7. Barrow B, Laspro M, Brydges HT, et al. "Technical Considerations and Outcomes for Panniculectomy in the Setting of Buried Penis Patients: A Systematic Review and Database Analysis." Ann Plast Surg. 2024;93(3):355–360. doi:10.1097/SAP.0000000000004025

8. Staniorski CJ, Myrga JM, Vasan RV, Klein RD, Rusilko PJ. "Surgical Outcomes and Prediction of Complications Following High-Complexity Buried Penis Reconstruction." J Urol. 2023;210(5):782–790. doi:10.1097/JU.0000000000003669

9. Troppmann C, Santhanakrishnan C, Kuo JH, et al. "Impact of Panniculectomy on Transplant Candidacy of Obese Patients With Chronic Kidney Disease Declined for Kidney Transplantation Because of a High-Risk Abdominal Panniculus: A Pilot Study." Surgery. 2016;159(6):1612–1622. doi:10.1016/j.surg.2015.12.001

10. Ngaage LM, Elegbede A, Tadisina KK, et al. "Panniculectomy at the Time of Living Donor Renal Transplantation: An 8-Year Experience." Am J Transplant. 2019;19(8):2284–2293. doi:10.1111/ajt.15285

11. Karunaratne YG, Kim J, Fayers W, et al. "Can Abdominoplasty Relieve Symptoms of Urinary Incontinence?" Aesthetic Plast Surg. 2025. doi:10.1007/s00266-025-05178-z

12. Janis JE, Jefferson RC, Kraft CT. Panniculectomy: practical pearls and pitfalls. Plast Reconstr Surg Glob Open. 2020;8:e3029. doi:10.1097/GOX.0000000000003029.

13. Figler BD, Gan ZS, Mohan CS, Zhang Y, Filippou P. "Outpatient Panniculectomy and Skin Graft for Adult Buried Penis." Urology. 2020;143:255–256. doi:10.1016/j.urology.2020.04.129

14. Figler BD, Chery L, Friedrich JB, Wessells H, Voelzke BB. "Limited Panniculectomy for Adult Buried Penis Repair." Plast Reconstr Surg. 2015;136(5):1090–1092. doi:10.1097/PRS.0000000000001722

15. Rasador ACD, et al. The impact of simultaneous panniculectomy in ventral hernia repair: a systematic review and meta-analysis. Hernia. 2024;28:2125–2136. doi:10.1007/s10029-024-03149-y.

16. Espinosa-de-Los-Monteros A, Mosqueda-Larrauri VL, Sanchez-Pereda D, Gamboa-Lopez CA. "Postoperative Outcomes of Incisional Negative Pressure Wound Therapy in Patients Undergoing Abdominoplasty, Horizontal Panniculectomy, or Harvest of TRAM or DIEP Flaps: Systematic Review and Meta-Analysis." Ann Plast Surg. 2025;95(6):752–759. doi:10.1097/SAP.0000000000004478

17. Norman G, Shi C, Goh EL, et al. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev. 2022;4:CD009261. doi:10.1002/14651858.CD009261.pub7.