Shermak, Michele A. MD
Abdominoplasty is the fifth most common plastic surgery procedure performed in the United States, according to the American Society of Plastic Surgeons' 2009 statistics. The number of abdominoplasty procedures performed annually has risen 84% over the past 10 years, with over 115,000 abdominoplasties performed in 2009.1 This trend is secondary to the growing massive weight loss patient population requiring abdominal reduction and contouring procedures.
"Abdominoplasty" broken down into its root terms is exactly defined as "plastic surgery of the abdomen." Procedures cover a broad spectrum. When thinking about surgical correction of the abdomen, the surgeon will consider issues related to improving the skin, subcutaneous fat layer, musculature, possible hernias, and/or the umbilicus, which also might have an associated hernia. Skin may be lax, redundant, and overhanging. The fat layer may be deflated or thick. The musculature may require approximation centrally due to either diastasis or hernias. The umbilicus may be stretched from significant weight change necessitating shortening.2 The particular steps taken in abdominoplasty consider each patient's individual physical findings.
There's a great deal of confusion surrounding the terms that describe abdominal contouring surgery. "Panniculectomy" is defined as direct removal of abdominal skin and fat overlying the pubis without any undermining involved. This procedure is occasionally covered by insurance plans for functional issues secondary to overhanging skin such as rashes and pain (see Figure 1).3 "Diastasis rectus" is widening of the space between the rectus abdominis muscles, which occurs secondary to significant weight change or denervation of the rectus muscles from surgical incision across the muscles such as a cesarean section or hysterectomy access incisions (see Figure 2). A mini-abdominoplasty removes only the lower abdominal skin without an incision around the umbilicus, and may involve repair of diastasis rectus and downward floating of the umbilicus. Liposuction of the flanks may be performed as well, but isn't always part of a mini-abdominoplasty (see Figure 3). A true abdominoplasty is typically associated with skin removal, repair of diastasis rectus, and replacement of the umbilicus through a higher part of the abdominal skin, which is pulled down to the native umbilical position as loose epigastric skin is pulled taut (see Figure 4). "Reverse abdominoplasty" removes upper abdominal skin and involves closure at the inframammary fold. This procedure is typically performed in a staged fashion after traditional abdominoplasty to address residual upper abdominal laxity (see Figure 5). Any of these procedures may involve adjunctive liposuction, but none of them are definitively associated with liposuction, so whether liposuction is part of the abdominal contouring procedure or not would require a specific discussion between the surgeon and the patient.
Liposuction vs. abdominoplasty?
Some patients are better candidates than others for abdominal liposuction without skin removal and muscle tightening. The benefit of liposuction is thinning of a thick subcutaneous fat layer with a relatively easy postoperative recovery (see Figure 6). Liposuction doesn't result in remarkable skin tightening, nor does it tighten a lax abdominal wall. It also can't address excessive intra-abdominal fat cushioning the abdominal organs, which is often the site of lipodystrophy in men. A common complaint after liposuction is creasing and folding of skin that occurs particularly when sitting, due to deflation of the subcutaneous fat layer with liposuction. Traditional abdominoplasty will result in more taut abdominal muscles and skin; however, there's more postoperative discomfort, recovery, and complexity of care, with management of drainage tubes and possibly a local anesthetic pain pump. Duration of recovery from abdominoplasty ranges from 3 to 8 weeks, whereas recovery after liposuction requires about a week, with resolving bruising. The pros and cons of liposuction and abdominoplasty must be weighed by the surgeon and discussed with the patient to determine the best procedure resulting in the highest level of satisfaction.
Potential abdominoplasty patients need to be further optimized for surgery once they're determined to be surgical candidates (see Indications and contraindications for elective abdominoplasty surgery). All patients should have a preoperative history and physical exam performed by their primary care provider with lab tests including chemistries, hematology, and coagulation studies. Any ongoing or new medical issues need to be addressed and treated as well. For example, a patient who has a very low hematocrit or elevated creatinine requires further investigation by his or her primary care provider because there may be an issue that overrides the abdominal contouring procedure or may complicate its outcome. Possible nutrient deficiency is particularly important to contemplate in massive weight loss patients, which would require the consultation of a nutritionist.
Patients who are smokers should be encouraged to stop smoking before surgery, or at least cut down significantly. Many plastic surgeons won't perform surgery on smokers at all due to increased risk for healing complication, pulmonary issues, and thromboembolism, and the reasons for quitting smoking need to be clearly elucidated to patients to engage them. The physician may assist patients with recommendations for avoidance of tobacco, including medications for smoking cessation that help appease the urge to smoke.
Patients should be deemed psychiatrically stable before embarking on elective plastic surgery. They should be reasonable in their expectations of surgery and in their approach to surgery. They shouldn't have had frequent cosmetic procedures with little satisfaction, as this may be an indication of body dysmorphic disorder. Further, if potential patients list depression in their medical history, the surgeon should further discussion into whether suicidal ideation ever took place. It's also important to ensure a proper support network to optimize postoperative recovery.
The patient will arrive at the hospital on the day of surgery. The perioperative nurse should perform the preoperative assessment per the facility's policy and procedure. The surgical consent must be signed and witnessed. The surgical site must be verified with the patient and clearly marked by the surgeon before the patient is transferred to the OR. The anesthesia provider will evaluate the patient preoperatively. The patient will have an I.V. line inserted and antithrombotic stockings with sequential compression device sleeves applied before the procedure.
With regard to postoperative management, abdominal surgery is often associated with the use of drains and a pain pump, which need to be understood and managed by the perioperative nurse. The pain pump reservoir, filled with a local anesthetic (bupivacaine) solution, is attached to small catheters fed through the skin and traveling under the diastasis rectus repair. The pumps are powered differently, depending on the manufacturer, but there's always a maintenance flow, possibly augmented by a patient-controlled device.
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The patient will be transferred to the PACU from the OR. It's important that the OR nurse and anesthesia provider communicate to the PACU nurse the details of the procedure. Immediate postoperative care includes monitoring vital signs, oxygen saturation, assessing cardiopulmonary status, and assessing for any signs of bleeding. The PACU nurse will assess the patient's level of pain provide adequate pain management. Patients may be started on I.V. patient-controlled analgesia with morphine or hydromorphone. Surgical drains are often placed through the skin into the subcutaneous space. Additionally, patients may have a urinary drainage catheter in place to monitor urine output as a reflection of hydration status, and I.V. fluid intake may be regulated by urine output. If the abdominoplasty is performed in conjunction with other procedures, it's possible there may have been significant blood loss requiring monitoring with a blood draw (hemoglobin and hematocrit) and urine output, and the patient may require hospitalization post procedure. Stable patients without significant blood loss may be discharged to home directly from the PACU when discharge criteria are met, or may be admitted for typically just an overnight stay. The nurse will ensure that the patient and caregiver receive verbal and written instructions prior to discharge.
After discharge, the patient and the patient's caregivers are responsible for the surgical drain management, adequate hydration and ambulation, pain management with oral medication, and incision care. Dressings are often maintained in position by a firm, but not tight, abdominal binder. Patients may shower with the surgical drains and pain pump in place within days of surgery. Activities including lifting, pushing, pulling, climbing, and abdominal exercises are limited for approximately 6 weeks. More specific instructions vary according to the exact procedure done and surgeon preference. Patients will be seen on at least a weekly basis by the surgeon in follow-up until the drains are removed, then monthly, then every other month, as long as all goes well.
Complications and management
Complications may occur after abdominoplasty, and the risk must be weighed against the complexity of the abdominal surgery performed, tempered by preexisting conditions that exacerbate complication risk. The risks and benefits should be discussed in detail with the patient before surgery. Complication rates for abdominoplasty tend to be low and are hard to generalize due to the difference in contouring procedures and patient populations. Factors that exacerbate complications include obesity; diabetes; asthma; cardiac disease; history of venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE); nutritional status, which might be impaired by bariatric surgery and significant weight loss; prior surgical scars; and weight of skin removal.4–7 Complications that may occur after abdominoplasty include wound-healing problems, infection, seroma, hematoma, thromboembolism, scarring, numbness, and recurrent laxity.
Complication management is performed by the plastic surgeon. Wound-healing problems tend to be minor and require cleansing, dressing, and coverage. Larger wounds require debridement of necrotic tissue, negative pressure therapy with vacuum-assisted closure, and possible return to the OR. It may take weeks for a wound to declare itself. Nutrition must be optimized to expedite healing.
Infections after abdominoplasty are associated with prolonged intraoperative hypothermia. Infections are treated with local care if there's a wound and oral antibiotic therapy is prescribed based on the results of the cultures. Often, there's no fluid only erythema, and coverage for Gram-positive organisms with mindfulness to methicillin-resistant Staphylococcus aureus is best. With significant erythema and systemic symptoms such as fever, malaise, and dehydration, inpatient admission is best with I.V. antibiotic therapy. Infection may be paired with seroma, and this combination may require return to the OR for washout and drain placement.
Seromas tend to be associated with obesity and significant skin removal.8 Abdominoplasty associated with removal of excess lower back skin, as seen in massive weight loss, is particularly associated with seroma formation. Drains need to remain in place until fluid output drops adequately, and if drain outputs remain higher than 50 mL/day, then according to findings of a retrospective review study, sclerosants such as doxycycline may be injected into the drain to scar the seroma cavity and reduce drainage.8 If there's no drain in place, serial needle aspirations through the skin may be performed, but if more than three are needed, drain replacement should be considered and may need to be followed by sclerosis. Staging surgery and minimizing undermining for high-risk patients is the best strategy in avoiding seroma onset.
Hematoma risk increases in the setting of hypertension and often manifests itself within a day or two of surgery. The drain may become clogged, the surgical area becomes full and bruised, and the patient may become hypotensive and tachycardic. Identification of hematoma most often depends on these clinical indicators but may be confirmed with computed tomography scanning. Diagnosis of a hematoma should be followed by surgical evacuation and may require transfusion.
Thromboembolism is uncommon and risk factors are well understood, including obesity, venous disease, hormone therapy, positioning, and lack of mobility.9 Prior history of DVT or PE is the most significant risk factor. Patients must have conservative intraoperative prophylaxis against VTE, including a pillow under the knees, antithrombotic stockings, sequential compression devices, and careful positioning during surgery under anesthesia. If the patient will stay in the hospital after surgery, prophylactic dosing of unfractionated or low-molecular-weight heparin is necessary. Pain management, hydration, and ambulation must be encouraged after surgery. High-risk patients require postoperative anticoagulation or inferior vena caval filter placement paired with aspirin therapy.
Scarring, recurrent laxity, and numbness are minor issues after surgery. Scarring tends to be acceptable, but if hypertrophic scarring develops, injection with a dilute corticosteroid may help. Surgical scar revision is rarely necessary. Numbness often resolves over time and may take up to a year or more to achieve maximum improvement. Complete sensation might not return. Factors that contribute to laxity are associated with intrinsic quality of the patient's tissues and patients should understand that full tautness might not be possible.
Abdominoplasty is a plastic surgery procedure that is commonly performed in the United States. It's important to address patient desires, concerns, and needs, and to approach the procedure with safety being the utmost concern. Choosing a board-certified plastic surgeon is the best way to ensure safety and proper procedure. Treatment doesn't end when surgery is complete: early and more remote perioperative care is critical to the best possible patient outcome. The surgeon, nursing staff, and patient all play important roles in optimizing outcomes.
© 2011 Lippincott Williams & Wilkins, Inc.