Abdominoplasty for male truncal obesity: case report

Truncal obesity and its associated health risk is an enormous burden. The traditional surgical treatment modality is liposuction or lipoabdominoplasty. An uncommon mode of the treatment is the use of abdominoplasty alone or as a surgical component. The aim of this report is to show a satisfactory outcome of abdominoplasty as the only surgical component in the management of severe truncal obesity in elderly male patient. We report a 75 year old Nigerian trader who had truncal obesity with gross abdominal asymmetry and cardiovascular and diabetes mellitus co-morbidities as well as bilateral knee osteoarthritis and social isolation due to truncal disfigurement. He was offered abdominoplasty as a sole surgical option for correction of anterior abdominal wall asymmetry. Apart from post operative wound complications and blood transfusion reactions, the patient had a good recovery and improved quality of life. Abdominoplasty is a rewarding treatment when used as a sole surgical option in centrally obese patients with anterior abdominal wall asymmetry and significant subcutaneous fat thickness.


Introduction
Truncal obesity or central obesity refers to the abnormal fat distribution in the trunk relative to the rest of the body in an obese patient with BMI ≥ 30 kg/m 2 as well as in those with normal body mass index [1]. It is an important health concern most commonly found among the middle aged and elderly men [2] and is characterized by excessive subcutaneous and visceral fat mass that more often than not produces an embarrassing beer belly or pot belly effect. The excessive abdominal protrusion with its deforming looks and the psychological distress associated with truncal obesity is an enormous burden. Published reports indicate that truncal obesity correlates strongly with cardiovascular diseases, diabetes mellitus type 2 and dyslipidemias [3,4]. Thus, in addition to this burden, excessive truncal adiposity is a depot that conveys serious health risks.
Therefore, treatment of truncal obesity is of medical and aesthetic importance. The mainstay of abdominal contour surgery in men is liposuction/lipoabdominoplasty [5]. In developing countries, aesthetic surgery is under developed [6] and there is paucity of centres with capacity for treatment modality that involves liposuction.
Consequently, abdominoplasty is a viable option of abdominal contour surgery in such settings [7,8]. However, published reports indicate preponderance of 30-50 years age group, overwhelming female gender bias and rarity of septuagenarian among patients for abdominoplasty [7][8][9][10]. Thus, that a male septuagenarian with a protracted burden of severe truncal obesity sought for aesthetic surgical intervention and had abdominoplasty with a satisfactory outcome and improved quality of life is uncommon in our setting, hence this case report.

Patient and observation
A 75 year old man who presented with a 15 year history of asymmetrical abdominal enlargement with the right half more greatly enlarged. It started insidiously as a part of generalized weight gain before persisting as a truncal weight excess. There was no symptom of intra-abdominal pathology. He experienced a lot of difficulty with lying prone or supine. He subsequently could not drive his car or walk without a walking stick due to bilateral knee pains and feeling of dragging weight tilt on the right side of the trunk. There was occasional waist pain. He had a positive history of alcohol consumption (an average of 4 bottles of beer per day for 40 years) but stopped drinking 6 years after onset of his symptoms. He also stopped attending social gatherings. He had associated lipoma on the right thigh. He is a known diabetic with hypertensive heart disease on medications. His concerns were both cosmetic and functional.
Although the burden was enormous, he was unaware of the availability of aesthetic surgery in our setting till he opened up to a radiologist (during a routine investigation) who refereed him to the plastic surgery clinic. Examination showed an obese looking elderly man in no obvious distress but with a moody affect. His weight was 123 kg and the height was 1.8 metres with a BMI of 38 kg/m 2 . His waist circumference was 145 cm compared to the normal for males which is 102 cm.

Discussion
In our setting, the level of awareness of availability of aesthetic surgery among the general populace and even among doctors is low [6]. In this case, lack of awareness was the main reason the patient presented for treatment at an age far above the usual age of patients for surgical intervention in truncal obesity. Winoccour et al. demonstrated that male sex, BMI > 30Kg/m 2 and age ≥ 50 years are significant risk factors for complications in abdominoplasty and that the risk of complication in combined procedures is higher than in abdominoplasty alone [10]. All these risk factors for complication were present in this case. Thus, abdominoplasty alone was finally considered the best surgical option of treatment though his consent for abdominoplasty plus or minus liposuction was obtained. The use of abdominoplasty as a sole approach for treatment of central obesity is uncommon. It is more common to employ either liposuction only or lipoabdominoplasty [5]. Abdominoplasty is a procedure of choice for reconstituting the rectus sheath following its diverification especially in multiparous women. In truncal obesity however the abdominal protrusion may be caused mainly by the excessive visceral fat rather than the excessive subcutaneous fat.
But in selected cases where the subcutaneous fat excess is significant cause of abdominal protrusion and medical co-morbidities, abdominoplasty may be a veritable option as has been shown in this case. The presumed cause of truncal obesity is imbalance in diets and energy expenditure in those who are genetically predisposed. Greater consumption of meat is specifically associated with truncal obesity [11]. Alcohol consumption also directly correlates with increased waist circumference and truncal obesity [11]. Thus, to sustain this satisfactory outcome on a long term basis patient was advised to continue with alcoholic abstinence and maintain a balance in his diet and energy expenditure. Treatment approaches have included dietary modifications, exercises, drugs and operative treatment. In men however the visceral fat is more predominant being found twice as much as in the premenopausal women. This limits the place of surgery in treatment of truncal obesity in males. Truncal obesity is defined as absolute waist circumference > 102 cm in men and > 88 cm in women. It is also defined in terms of waist-hip ratio with 0.9 and 0.85 being the respective cut-off for the adult male and female respectively [12,13]. In this case, the outcome of abdominoplasty was very satisfactory to the patient although his post operative waist circumference was 10 cm above normal for men.

Conclusion
In elderly male patient with truncal obesity, the outcome of abdominoplasty as a sole surgical treatment modality is satisfactory with improvement in overall quality of life.

Competing interests
The authors declare no competing interests.

Authors' contributions
All the authors contributed to this article in compliance to ICJME authorship criteria. All the authors have read and agreed to the final manuscript.