Skip to main content

Panniculectomy (Urologic Indications)

Panniculectomy — excision of the overhanging abdominal pannus — is functionally relevant to reconstructive urology in four settings: adult-acquired buried penis (AABP) repair, facilitation of kidney transplantation in obese patients with end-stage renal disease, improvement of stress urinary incontinence, and revision of complicated urostomies ("uro-abdominoplasty"). It is anatomically distinct from escutcheonectomy: the escutcheon is the localized suprapubic fat pad over the pubic symphysis; the pannus is the overhanging abdominal apron above the escutcheon.[1][2]

For the closely related and more commonly performed suprapubic fat-pad excision, see Buried Penis Repair (which covers escutcheonectomy + skin grafting in depth).

Indications​

1. Adult-acquired buried penis (AABP)​

Panniculectomy is added to AABP repair when the abdominal pannus itself is contributory to penile concealment (PAS axis A2), distinct from a contributory escutcheon (axis P). It is typically a limited / infraumbilical panniculectomy and is performed in ~7–28% of AABP repairs.[3][4][5][6]

  • NSQIP + SR analysis (Barrow 2024): adding panniculectomy to buried-penis repair does not significantly increase 30-day complications on multivariate analysis[6]
  • Hampson UW series (n = 42): 85% long-term surgical success, 74% positive life change, BMI the only independent complication predictor (OR 1.1 per BMI unit)[7]
  • Staniorski high-complexity series (n = 103): 28% included panniculectomy; revision 3.9%; low-grade complications 50% (dehiscence 31%, infection 30%); frailty was the strongest predictor (OR 6.41)[8]
  • Outpatient feasibility: Figler trapezoid-incision panniculectomy + STSG harvested from the pannus itself — ≥ 95% graft take in 19 patients, no DVT[9]

2. Facilitation of kidney transplantation​

A large abdominal panniculus in obese ESRD patients is a recognized barrier to kidney transplant because of high wound-complication risk at the iliac fossa incision. KDIGO 2020 notes that pre-transplant panniculectomy may improve wound outcomes.[10]

StrategyApproachKey data
Staged (pretransplant panniculectomy)Panniculectomy first, then list / transplant laterTroppmann 2016 pilot (n = 36): 100% wait-listed after panniculectomy, 62% subsequently transplanted, posttransplant wound complications 5%, 5-yr survival 95%[11]
Concurrent (LRT-PAN)Living-donor renal transplant + panniculectomy in one operationNgaage 8-yr (n = 58): 100% graft survival; wound complication 24%; 90-day readmission 52% (mostly medical, not wound)[12]
Multidisciplinary LRT-PAN techniquePlastic team panniculectomy first → transplant team graft anastomosis → plastic team closureNgaage (n = 20): 100% graft survival with primary function; mean OR 363–394 min; panniculectomy = 17% of total OR time[13]

3. Improvement of stress urinary incontinence​

Abdominoplasty / panniculectomy with rectus plication is associated with significant SUI improvement, likely via reduced intra-abdominal pressure and restored abdominal-wall support after rectus diastasis repair.[14][15]

  • Karunaratne 2025 SR (13 studies, 719 pts): SUI rate 72.8% → 38.9% post-op; 55% improved, 6.8% worse; rectus plication in 91%[16]
  • Cao 2026 meta-analysis (n = 196): SUI improvement 54.4% after abdominal body contouring[17]
  • Taylor 2018 multicenter (n = 214): ICIQ-UI 6.5 → 1.6 at 6 mo (p < 0.001)[15]
  • Mushin 2017 massive-weight-loss cohort (n = 102): significant decrease in incidence and severity of incontinence symptoms[18]

Evidence is mostly Level IV–V; the effect on urge incontinence is less well characterized.

4. Uro-abdominoplasty (urostomy revision)​

A novel application: abdominoplasty techniques are used to revise complicated urostomies (ileal conduits) in patients whose large pannus / deep skin creases / multiple scars prevent proper appliance fitting and produce chronic urinary leakage.[19] Mickute series (n = 4, mean BMI 32): 3 / 4 reported improved appliance fit and > 50% reduction in urinary leakage.

Preoperative Planning and Marking​

  • Patient standing — mark ASIS, pubic symphysis, umbilicus
  • Inferior incision in the suprapubic crease or just above the mons pubis
  • Superior incision determined by pinch test to ensure tension-free closure[20][21]
  • Preoperative CT for panniculus morbidus (≥ 10 kg or pannus to mid-thigh) — occult ventral hernias present in up to 50%[22][21]
  • Perioperative CDP (complex decongestive physical therapy) × 4–6 weeks reduces major complications (p = 0.001), transfusion (p = 0.028), and wound healing disorders (p = 0.021)[23]
  • BMI optimization, glycemic control, tobacco cessation (≥ 4–6 weeks)

Incision Patterns​

Traditional transverse panniculectomy​

  • Large transverse elliptical excision of the infraumbilical pannus
  • Inferior incision in suprapubic crease; superior incision sited by pinch test
  • Suprapubic wedge added to reduce upper/lower incision-length mismatch
  • Lateral V-flaps for lateral dog-ears
  • Minimal to no undermining of the superior flap (the principal distinction from cosmetic abdominoplasty)[24][25]

Fleur-de-lis (anchor-pattern) panniculectomy​

  • Adds a vertical midline component to the transverse excision (inverted-T resection)
  • Addresses supra-umbilical horizontal skin excess that a transverse pattern cannot
  • Limited undermining; complication rates equivalent to traditional pattern (17% vs 17% in O'Brien series of 130 patients)[26][27]
  • Modified fleur-de-lis with deepithelialized mediocaudal edges reduces T-junction full-thickness defects and seroma[28]
  • Absorbable dermal stapler (Insorb®) reduces closure time from 125 → 67 min[29]

Modified trapezoid incision (Figler, for AABP)​

  • Trapezoid pannus mobilization leaving superior attachments intact
  • The pannus itself serves as a split-thickness skin graft donor — STSG harvested at 18/1000 inch in 2-inch sections before the pannus is excised[9]

Operative Steps — Standard Technique​

  1. Positioning — supine. For massive panniculus, a mechanical lift system or 10–12 towel clips / K-wires through the central pannus suspended from overhead lighting facilitates exsanguination[24][30]; tumescent infiltration to reduce blood loss
  2. Inferior incision along the suprapubic line, through skin and subcutaneous tissue to abdominal-wall fascia
  3. Superior incision along the premarked line; tissue between the two is the resection specimen
  4. Conservative undermining — only what's needed for tension-free closure; extensive undermining → flap necrosis + seroma. Panniculectomy is distinguished from abdominoplasty by the absence of muscle tightening[2][27][25]
  5. Hernia evaluation and repair — concomitant ventral hernia repair in 37–50% of cases; does not increase wound-complication rates[20][27]
  6. Hemostasis — critical given large wound surface area; transfusion rates 20–39% in massive series; greater resection weight → higher transfusion rate[20][21]
  7. Drain placement — 2–4 closed-suction drains in the dead space; some series add small wound-VAC devices at each end of the incision[31]
  8. Closure in layers — fascial / Scarpa's → dermal → subcuticular; progressive tension (quilting) sutures to obliterate dead space and reduce seroma[31]

Panniculectomy in Buried Penis Repair​

Integrated with the AABP repair components:[2][32][1]

  1. Escutcheonectomy — suprapubic fat-pad excision down to rectus fascia
  2. Penile degloving and excision of diseased shaft skin (e.g., lichen sclerosus)
  3. Scrotoplasty — reduction of redundant / lymphedematous scrotal tissue
  4. STSG harvest + application — typically 12–18 / 1000 inch; harvested from thigh or from excised pannus / escutcheon; wrapped around shaft and bolstered 5–7 days; take 80–100%[33][9][2][34]
  5. Outpatient pathway — Figler trapezoid pannus-donor STSG: 19 patients, ≥ 95% take, no DVT[9]

Concurrent Panniculectomy + Living-Donor Renal Transplant (LRT-PAN)​

Coordinated multidisciplinary sequence:[13]

  1. Plastic surgery first — standard transverse panniculectomy provides wide exposure of the lower abdomen and iliac fossa
  2. Transplant team — graft anastomosis to iliac vessels and ureteral reimplantation through the now-cleared field
  3. Plastic surgery closes — layered abdominal-wall closure
  4. Outcomes — 100% graft survival with primary function; mean total OR 363–394 min; panniculectomy = 17% of total OR time[12][13]

Wound Management Strategies​

Closed-incision negative-pressure therapy (ciNPT)​

  • Espinosa-de-Los-Monteros 2025 meta-analysis (11 studies): significantly decreases wound dehiscence and unplanned reoperation; no significant difference in seroma, hematoma, or SSI[35]
  • Patel single-surgeon series (n = 91): major complications 5.5% vs historical 43–70%[36]
  • Ayuso AWR + panniculectomy (n = pooled): wound complications 35.5% → 15.6% (p = 0.01); wound-related reoperations 13.3% → 0%[37]

Partial open wound management​

For super-obese patients (BMI > 50), leaving the wound partially open under NPWT outperformed primary closure in a small series — no readmissions / reoperations in the open group vs 44% readmission, 33% reoperation in the closed group.[38]

Complications​

ComplicationRateNotes
Overall wound complications24–50%Population-dependent; mostly Clavien I–II[6][12][8]
Major complications (reoperation)11–15%Lower with ciNPT and two-team approach[39][13]
Wound dehiscence~31%Suprapubic closure line; high-BMI cohorts[8]
Surgical-site infection26–41%Warm moist abdominal fold[6][8]
Seroma / hematomaVariableMitigated by drains, quilting sutures
Skin-flap necrosisRare with minimal underminingMore common after extensive undermining or fleur-de-lis T-junction
DVT / PE< 1–2%None in outpatient AABP series[9]
Blood transfusion20–39% in massive panniculectomyCorrelates with resection weight[20][21]

Risk factors​

  • BMI — the most consistent predictor across populations[40][7][8]
  • Diabetes, tobacco use, male sex, age > 60, frailty (mFI ≥ 2)
  • Pannus weight is independently associated with complications (p = 0.04)[27]

Key Technical Pearls​

  • Minimize undermining — the single most important principle distinguishing panniculectomy from abdominoplasty[2][26]
  • Two-team approach reduces OR time, blood loss, and pulmonary compromise in massive cases[24]
  • Preoperative CT for panniculus morbidus to rule out occult ventral hernia[22]
  • ciNPT strongly considered for BMI > 40, diabetes, concurrent hernia repair, or AWR[36][37][35]
  • For fleur-de-lis closures, the T-junction is the highest-risk area — deepithelialized flap modifications reduce dehiscence[28]
  • For AABP, the excised pannus / escutcheon doubles as the graft donor, eliminating thigh donor-site morbidity

Insurance and Coding​

CPT 15830 (panniculectomy) — generally reconstructive (not cosmetic) when performed for functional indications: buried penis repair, transplant facilitation, urostomy revision, recurrent panniculitis, inability to perform CIC. Documented functional impairment is essential for authorization.[2]

Cross-references​

References​

1. 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

2. American Society of Plastic Surgeons. "Abdominoplasty and Panniculectomy: Performance Measurement Set." 2017.

3. 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

4. Schlaepfer CH, Flynn KJ, Alsikafi NF, et al. "Clinical Validation of an Adult-Acquired Buried Penis Classification System." Urology. 2023;180:249–256. doi:10.1016/j.urology.2023.04.048

5. 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

6. 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

7. Hampson LA, Muncey W, Chung PH, et al. "Surgical and Functional Outcomes Following Buried Penis Repair With Limited Panniculectomy and Split-Thickness Skin Graft." Urology. 2017;110:234–238. doi:10.1016/j.urology.2017.07.021

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. 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

10. 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

11. 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

12. 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

13. Ngaage LM, Messner F, McGlone KL, et al. "A Multidisciplinary Technique for Concurrent Panniculectomy-Living Donor Renal Transplantation." Ann Plast Surg. 2020;84(4):455–462. doi:10.1097/SAP.0000000000002297

14. Subak LL, King WC, Belle SH, et al. "Urinary Incontinence Before and After Bariatric Surgery." JAMA Intern Med. 2015;175(8):1378–87. doi:10.1001/jamainternmed.2015.2609

15. Taylor DA, Merten SL, Sandercoe GD, et al. "Abdominoplasty Improves Low Back Pain and Urinary Incontinence." Plast Reconstr Surg. 2018;141(3):637–645. doi:10.1097/PRS.0000000000004100

16. 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

17. Cao Y, Li Y, Li F, Li J, Gu Y. "Abdominal Body Contouring Can Improve the Stress Urinary Incontinence: A Single-Arm Meta-Analysis." Aesthetic Plast Surg. 2026. doi:10.1007/s00266-026-05804-4

18. Mushin OP, Kraenzlin FS, Fazili A, Ghazi A, Bossert RP. "The Impact of Body Contouring Procedures on Urologic Outcomes in Massive Weight Loss Patients." Plast Reconstr Surg. 2017;139(5):1086e–1092e. doi:10.1097/PRS.0000000000003251

19. 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

20. Leahy PJ, Shorten SM, Lawrence WT. "Maximizing the Aesthetic Result in Panniculectomy After Massive Weight Loss." Plast Reconstr Surg. 2008;122(4):1214–1224. doi:10.1097/PRS.0b013e31818459ca

21. Manahan MA, Shermak MA. "Massive Panniculectomy After Massive Weight Loss." Plast Reconstr Surg. 2006;117(7):2191–7. doi:10.1097/01.prs.0000218174.89832.78

22. Pestana IA, Campbell D, Fearmonti RM, Bond JE, Erdmann D. "'Supersize' Panniculectomy: Indications, Technique, and Results." Ann Plast Surg. 2014;73(4):416–21. doi:10.1097/SAP.0b013e31827f5496

23. Koulaxouzidis G, Goerke SM, Eisenhardt SU, et al. "An Integrated Therapy Concept for Reduction of Postoperative Complications After Resection of a Panniculus Morbidus." Obes Surg. 2012;22(4):549–54. doi:10.1007/s11695-011-0561-4

24. Matory WE, O'Sullivan J, Fudem G, Dunn R. "Abdominal Surgery in Patients With Severe Morbid Obesity." Plast Reconstr Surg. 1994;94(7):976–87. doi:10.1097/00006534-199412000-00011

25. Cooper JM, Paige KT, Beshlian KM, Downey DL, Thirlby RC. "Abdominal Panniculectomies: High Patient Satisfaction Despite Significant Complication Rates." Ann Plast Surg. 2008;61(2):188–96. doi:10.1097/SAP.0b013e318158a7b2

26. O'Brien JA, Broderick GB, Hurwitz ZM, et al. "Fleur-de-Lis Panniculectomy After Bariatric Surgery: Our Experience." Ann Plast Surg. 2012;68(1):74–8. doi:10.1097/SAP.0b013e31820eb92d

27. Christopher AN, Morris MP, Patel V, et al. "A Comparative Analysis of Fleur-de-Lis and Traditional Panniculectomy After Bariatric Surgery." Aesthetic Plast Surg. 2021;45(5):2208–2219. doi:10.1007/s00266-021-02149-y

28. Ziegler UE, Ziegler SN, Zeplin PH. "Modified Fleur-de-Lis Abdominoplasty for Massive Weight Loss Patients." Ann Plast Surg. 2017;79(2):130–134. doi:10.1097/SAP.0000000000000990

29. Amro C, Ryan IA, Lemdani MS, et al. "Accelerating Fleur-de-Lis Panniculectomy With the Absorbable Dermal Stapler — A Study of Efficiency, Aesthetics, and Quality-of-Life." Aesthetic Plast Surg. 2024;48(16):3137–3146. doi:10.1007/s00266-024-04068-0

30. Reichenberger MA, Stoff A, Richter DF. "Dealing With the Mass: A New Approach to Facilitate Panniculectomy in Patients With Very Large Abdominal Aprons." Obes Surg. 2008;18(12):1605–10. doi:10.1007/s11695-008-9630-8

31. Friedrich JB, Petrov RV, Wiechman Askay SA, et al. "Resection of Panniculus Morbidus: A Salvage Procedure With a Steep Learning Curve." Plast Reconstr Surg. 2008;121(1):108–114. doi:10.1097/01.prs.0000293760.41152.29

32. Tang SH, Kamat D, Santucci RA. "Modern Management of Adult-Acquired Buried Penis." Urology. 2008;72(1):124–7. doi:10.1016/j.urology.2008.01.059

33. Fuller TW, Theisen K, Rusilko P. "Surgical Management of Adult Acquired Buried Penis: Escutcheonectomy, Scrotectomy, and Penile Split-Thickness Skin Graft." Urology. 2017;108:237–238. doi:10.1016/j.urology.2017.05.053

34. Erpelding SG, Hopkins M, Dugan A, Liau JY, Gupta S. "Outpatient Surgical Management for Acquired Buried Penis." Urology. 2019;123:247–251. doi:10.1016/j.urology.2018.10.002

35. 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

36. Patel AA, Wilcox K, Bhinder J, Reiser J, Upadhyaya P. "Low Complication Rates Using Closed-Incision Negative-Pressure Therapy for Panniculectomies: A Single-Surgeon, Retrospective, Uncontrolled Case Series." Plast Reconstr Surg. 2020;146(2):390–397. doi:10.1097/PRS.0000000000007026

37. Ayuso SA, Elhage SA, Okorji LM, et al. "Closed-Incision Negative Pressure Therapy Decreases Wound Morbidity in Open Abdominal Wall Reconstruction With Concomitant Panniculectomy." Ann Plast Surg. 2022;88(4):429–433. doi:10.1097/SAP.0000000000002966

38. Brown M, Adenuga P, Soltanian H. "Massive Panniculectomy in the Super Obese and Super-Super Obese: Retrospective Comparison of Primary Closure Versus Partial Open Wound Management." Plast Reconstr Surg. 2014;133(1):32–39. doi:10.1097/01.prs.0000436818.34332.34

39. Lesko RP, Cheah MA, Sarmiento S, Cooney CM, Cooney DS. "Postoperative Complications of Panniculectomy and Abdominoplasty: A Retrospective Review." Ann Plast Surg. 2020;85(3):285–289. doi:10.1097/SAP.0000000000002220

40. Samuel AR, Hakami L, Campbell C, et al. "Abdominal Panniculectomy: Identifying Complications and Potential Risk Factors." J Plast Reconstr Aesthet Surg. 2022;75(9):3534–3540. doi:10.1016/j.bjps.2022.04.061