In 2009 Germany has become the nation with the most obese people in the whole of Europe. This statistic reveals that obesity with its comorbidities has developed into a widespread disease.

There are numerous conservative and operative strategies for the treatment of obesity. Plastic surgeons are increasingly confronted with the need for body contouring after massive weight loss through dietetic methods or bariatric surgery.1–5

A few superobese patients, however, do not respond to the conventional treatment regimens. Then follows a vicious circle with reduced mobility and thus reduced calorie consumption. Reduced food intake alone is in this case often not sufficient to achieve an appropriate weight loss.

Patients with marked pannus usually have, in addition to significant medical comorbidities such as metabolic syndrome and premature arthritis, massive problems of hygiene in the lower abdominal fold, with recurrent furuncles, abscesses, and fistulas. In addition, distinct functional problems exist such as immobility, with the development of secondary lymphedema, chronic ulceration on the extremities, and pressure sores. Some patients with high body mass index show severe elephantiasis in the entire abdominal wall. Quite often there are additional problems in micturition, especially in male patients whose genitalia are completely obstructed6 (Fig. 27.1).

Current European guidelines recommend bariatric surgery in those patients with a body mass index of 40 and in those with an index of 35 accompanied by significant comorbidities. For patients with a body mass index higher than 60, the surgical treatment is often difficult, because the abdominal wall is very fat, and what can be achieved with the instruments is often limited. The parallel existing immobility is often an additional postoperative risk.

Historically, panniculectomy was done only in selected cases, when there was complete immobility, or patients were not suitable for bariatric surgery. The aim of such intervention was to interrupt the vicious circle of lack of mobility and insufficient calorie consumption. This was usually followed by a successful conservative weight reduction or bariatric surgery.11–15

Today, such procedures are often performed together with bariatric surgery.5–7 The plastic surgeon performs the panniculectomy, thus the general surgeon gains access to the abdominal wall and then laparoscopically places the gastric banding or performs a gastric bypass or sleeve.

The subsequent weight loss leads to an immediate increase in mobility. If the process of losing weight is completed and there is weight maintenance of about 1 year, subsequent plastic-reconstructive surgical operations are possible to complete the surgical treatment.8