Abdominoplasty

2023-09-11T17:10:43Z

Yiqiaobao: Created this page and put in all the info in this page so far

{{Infobox surgical procedure
| anesthesia_type = General Anesthesia (most common), Conscious Sedation with Tumescent Technique/Neuraxial Techniques also feasible
| airway = ETT (most common)
| lines_access = PIV
| monitors = Standard
| considerations_preoperative = Potential difficult airway, cardiac/pulm conditions, bleeding/clotting
| considerations_intraoperative = IV prophylactic antibiotic, thrombosis prophylaxis, hypothermia precaution
| considerations_postoperative = DVT/PE, respiratory compromise, abdominal compartment syndrome
}}

Abdominoplasty is a surgery done to remove excess fat, skin, and repair rectus diastasis to help improve health and appearance. This can occur after a person undergoes massive weight loss. Depending on physical examination findings, several procedures can be done, including mini-abdominoplasty, traditional abdominoplasty, circumferential, high lateral tension, Fleur-de-lis, and reverse abdominoplasty<ref name=":0">{{Cite book|title=Essentials of plastic surgery|date=2023|publisher=Thieme|isbn=978-1-62623-847-3|editor-last=Janis|editor-first=Jeffrey E.|edition=Third edition|location=New York Stuttgart Delhi Rio de Janeiro|editor-last2=Bunch|editor-first2=Brenda|editor-last3=Tomasikiewicz|editor-first3=Amanda|editor-last4=Taylor|editor-first4=Sarah|editor-last5=Gentry|editor-first5=Jennifer|editor-last6=Chambers|editor-first6=Graeme}}</ref>.

==Overview==

===Indications===
Excess fat, skin, and abdominal wall weakness <ref name=":0" />.

==Preoperative management==

===Patient evaluation <ref name=":0" />===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|obesity
|-
|Cardiovascular/Pulmonary
|cardiac conditions, OSA
|-
|Gastrointestinal
|IBS, constipation, previous abdominal surgeries, abdominal scarring
|-
|Genitourinary
|C-sections, desire for future pregnancy, abdominal scarring
|-
|Hematologic
|bleeding/clotting disorders, history of bleeding/clotting
|-
|Endocrine
|T2DM, hormone use
|-
|Other
|smoking status, A1C
|}

===Operating room setup <ref name=":0" />===
IV antibiotics 30-59 min before the incision

SCDs (DVT prophylaxis)

Avoid intraoperative hypothermia

===Patient preparation and premedication===
IV antibiotics 30-59 min before the incision

===Regional and neuraxial techniques===
A. Conscious Sedation + Tumescent Technique <ref>{{Cite journal|last=Shestak|first=Kenneth C.|date=2004-05|title=The Outcome of Abdominoplasty Performed under Conscious Sedation: Six-Year Experience in 153 Consecutive Cases|url=http://dx.doi.org/10.1097/01.prs.0000118267.35908.01|journal=Plastic and Reconstructive Surgery|volume=113|issue=6|pages=1818–1819|doi=10.1097/01.prs.0000118267.35908.01|issn=0032-1052}}</ref><ref>{{Cite journal|last=Rosenberg|first=Michael H.|last2=Palaia|first2=David A.|last3=Bonanno|first3=Philip C.|date=2001-05|title=Abdominoplasty With Procedural Sedation and Analgesia|url=http://dx.doi.org/10.1097/00000637-200105000-00005|journal=Annals of Plastic Surgery|volume=46|issue=5|pages=485–487|doi=10.1097/00000637-200105000-00005|issn=0148-7043}}</ref><ref name=":1">{{Cite journal|last=Bagatin|first=Dinko|date=2019|title=Influence of Local Infiltration Analgesia on Postoperative Pain in Abdominoplasty Patients|url=http://dx.doi.org/10.20471/acc.2019.58.s1.03|journal=Acta Clinica Croatica|doi=10.20471/acc.2019.58.s1.03|issn=0353-9466}}</ref>

·    Appears to be safe

·    May have a lower risk of DVT compare to general anesthesia

·    Tumescent local infiltration anesthesia also helps with post-op pain <ref name=":1" /><ref>{{Cite journal|last=Kakagia|first=Despoina D.|last2=Fotiadis|first2=Spartakos|last3=Tripsiannis|first3=Gregory|last4=Tsoutsos|first4=Dimosthenis|date=2007-01-04|title=Postoperative Analgesic Effect of Locally Infiltrated Levobupivacaine in Fleur-de-Lys Abdominoplasty|url=http://dx.doi.org/10.1007/s00266-006-0187-4|journal=Aesthetic Plastic Surgery|volume=31|issue=2|pages=128–132|doi=10.1007/s00266-006-0187-4|issn=0364-216X}}</ref>

·    Increased risk of respiratory depression, usually resolves with simple stimulation

·    Increased fentanyl use is associated with longer stay in recovery unit <ref>{{Cite journal|last=Pechter|first=Edward A.|date=2000-04|title=The Clinical Outcome of Abdominoplasty Performed Under Conscious Sedation: Increased Use of Fentanyl Correlated with Longer Stay in Outpatient Unit|url=http://dx.doi.org/10.1097/00006534-200004040-00074|journal=Plastic & Reconstructive Surgery|volume=105|issue=4|pages=1577|doi=10.1097/00006534-200004040-00074|issn=0032-1052}}</ref>

B.    Neuraxial Techniques: useful when the patient has higher risk cardiac complications, respiratory complications, malignant hyperthermia (HM), and rhabdomyolysis from anesthesia <ref name=":2">{{Cite journal|last=Leal|first=Plinio da Cunha|last2=Lima|first2=Wildney Leite|last3=Oliveira|first3=Eduardo José Silva Gomes de|last4=Oliveira|first4=Caio Márcio Barros de|last5=Gomes|first5=Lyvia Maria Rodrigues de Sousa|last6=Servin|first6=Elizabeth Teixeira Noguera|last7=Moura|first7=Ed Carlos Rey|date=2021-04|title=Combined spinal-epidural anesthesia for abdominoplasty and liposuction in Limb-Girdle Muscular Dystrophy: case report|url=http://dx.doi.org/10.1016/j.bjane.2021.02.046|journal=Brazilian Journal of Anesthesiology (English Edition)|doi=10.1016/j.bjane.2021.02.046|issn=0104-0014}}</ref>.

o Combined spinal-epidural anesthesia <ref name=":2" /><ref>{{Cite journal|last=Kodeih|first=Mohammad G.|last2=Al-Alami|first2=Achir A.|last3=Atiyeh|first3=Bechara S.|last4=Kanazi|first4=Ghassan E.|date=2009-03|title=Combined Spinal Epidural Anesthesia in an Asthmatic Patient Undergoing Abdominoplasty|url=http://dx.doi.org/10.1097/prs.0b013e31819a35c9|journal=Plastic and Reconstructive Surgery|volume=123|issue=3|pages=118e–120e|doi=10.1097/prs.0b013e31819a35c9|issn=0032-1052}}</ref>

·    Safely provide adequate pain control in high risk GA patients

o Spinal anesthesia <ref>{{Cite journal|last=Metry|first=AymanAnis|last2=Nakhla|first2=GeorgeM|last3=Wahba|first3=WahbaZ|last4=Wahba|first4=RamiM|last5=Kamel|first5=IbrahimH|date=2019|title=Abdominoplasty under spinal anesthesia: A feasibility study|url=http://dx.doi.org/10.4103/aer.aer_69_19|journal=Anesthesia: Essays and Researches|volume=13|issue=2|pages=243|doi=10.4103/aer.aer_69_19|issn=0259-1162}}</ref>

·    May consider when the surgery is expected to be <3h

·    Decreased needs for post-op opiates

·    Patients able to ambulate in shorter amount of time (better DVT prevention)

o Epidural anesthesia <ref>{{Cite journal|last=Gutowski|first=K.A.|date=2013-01|title=Epidural Anesthesia as a Thromboembolic Prophylaxis Modality in Plastic Surgery|url=http://dx.doi.org/10.1016/j.yprs.2012.07.012|journal=Yearbook of Plastic and Aesthetic Surgery|volume=2013|pages=74|doi=10.1016/j.yprs.2012.07.012|issn=1535-1513}}</ref>

·    Appears to be feasible

·    May decrease risk of DVT

C.    Others

o Rib block + IV sedation <ref>{{Cite journal|last=Gutowski|first=K.A.|date=2011-01|title=Outpatient Abdominoplasty Facilitated by Rib Blocks|url=http://dx.doi.org/10.1016/s1535-1513(09)79493-7|journal=Yearbook of Plastic and Aesthetic Surgery|volume=2011|pages=158–159|doi=10.1016/s1535-1513(09)79493-7|issn=1535-1513}}</ref>

·    Decreased time in recovery room, postoperative narcotics, postoperative nausea and vomiting

==Intraoperative management==

===Monitoring and access===
Standard ASA monitors

===Induction and airway management===
Standard induction, consider video laryngoscopy if concern for difficult direct laryngoscopy

===Positioning===
Supine

Secure arms / Check IV

===Maintenance and surgical considerations===
Standard maintenance

Maintain normothermia

===Emergence===
Smooth emergence, minimize tension on the suture line

PONV prophylaxis

==Postoperative management==

===Disposition <ref name=":0" />===
PACU

·    Early ambulation is mandatory

·    Drain maintenance

·    Rest in flexed position (>30 degrees head of bed elevation)

·    Abdominal binder

===Pain management===
IV narcotics with possible regional anesthesia techniques below.

Regional Anesthesia Techniques

·    Quadratus lumborum (QL) block

   I. Inconsistent results with regard to sparing of post-op opiates <ref name=":3">{{Cite web|last=Efsun Ozgunay|first=Seyda|last2=caglayan|first2=Umit|last3=Yilmaz|first3=Canan|date=2018-05-16|title=09 / Comparison of ultrasound guided transversus abdominis plane block and quadratus lumborum block for postoperative pain in cesarean section: A prospective, randomized-controlled study.|url=http://dx.doi.org/10.26226/morressier.5aeb0ac707b0d6001a79a2a8|access-date=2023-09-11|website=dx.doi.org}}</ref><ref>{{Cite journal|last=Bjelland|first=Thor W.|last2=Yates|first2=Thomas G.R.|last3=Fagerland|first3=Morten W.|last4=Frøyen|first4=Jan K.|last5=Lysebråten|first5=Karl R.|last6=Spreng|first6=Ulrich J.|date=2019-05-21|title=Quadratus lumborum block for postoperative analgesia after full abdominoplasty: a randomized controlled trial|url=http://dx.doi.org/10.1515/sjpain-2019-0013|journal=Scandinavian Journal of Pain|volume=19|issue=4|pages=671–678|doi=10.1515/sjpain-2019-0013|issn=1877-8879}}</ref>

   II. Better pain control <ref name=":3" />

·    Transversus abdominis plane (TAP) block <ref>{{Cite journal|last=Oppenheimer|first=Adam J.|last2=Fiala|first2=Thomas G.S.|last3=Oppenheimer|first3=Daniel C.|date=2016-11|title=Direct Transversus Abdominis Plane Blocks With Exparel During Abdominoplasty|url=http://dx.doi.org/10.1097/sap.0000000000000659|journal=Annals of Plastic Surgery|volume=77|issue=5|pages=499–500|doi=10.1097/sap.0000000000000659|issn=0148-7043}}</ref><ref>{{Cite journal|last=Fiala|first=Thomas|date=2015-01-01|title=Tranversus Abdominis Plane Block During Abdominoplasty to Improve Postoperative Patient Comfort|url=http://dx.doi.org/10.1093/asj/sju019|journal=Aesthetic Surgery Journal|volume=35|issue=1|pages=72–80|doi=10.1093/asj/sju019|issn=1527-330X}}</ref><ref>{{Cite journal|last=Sforza|first=Marcos|last2=Andjelkov|first2=Katarina|last3=Zaccheddu|first3=Renato|last4=Nagi|first4=Hussein|last5=Colic|first5=Miodrag|date=2011-08|title=Transversus Abdominis Plane Block Anesthesia in Abdominoplasties|url=http://dx.doi.org/10.1097/prs.0b013e31821e6f51|journal=Plastic and Reconstructive Surgery|volume=128|issue=2|pages=529–535|doi=10.1097/prs.0b013e31821e6f51|issn=0032-1052}}</ref><ref>{{Cite journal|last=Alotaibi|first=Nawaf Naif|last2=Ahmad|first2=Tawheed|last3=Rabah|first3=Sari Monzer|last4=Hamza|first4=Aljohara Mohmoud|last5=Mohammad Tafazul|first5=Sheikh|date=2021-01-05|title=Evaluation of transversus abdominis plane (TAP) block in lipoabdominoplasty surgical procedure: a comparative study|url=http://dx.doi.org/10.1080/2000656x.2020.1856676|journal=Journal of Plastic Surgery and Hand Surgery|volume=55|issue=4|pages=216–219|doi=10.1080/2000656x.2020.1856676|issn=2000-656X}}</ref><ref name=":4">{{Cite journal|last=Gravante|first=Gianpiero|last2=Castrì|first2=Francesca|last3=Araco|first3=Francesco|last4=Araco|first4=Antonino|date=2010-06-02|title=A Comparative Study of the Transversus Abdominis Plane (TAP) Block Efficacy on Post-bariatric vs Aesthetic Abdominoplasty with Flank Liposuction|url=http://dx.doi.org/10.1007/s11695-010-0203-2|journal=Obesity Surgery|volume=21|issue=3|pages=278–282|doi=10.1007/s11695-010-0203-2|issn=0960-8923}}</ref>

   I. Decrease needs for post-op opiates

   II. Early ambulation

   III. Possibly less effective in post-bariatric surgery patient due to more traumatic operation <ref name=":4" />

·    Erector spinae plane block <ref>{{Cite journal|last=Perez|first=Mauricio E.|last2=Hoyos|first2=Alfredo E.|date=2020-10-08|title=Invited Discussion on: Evaluation of the Effect of Erector Spinae Plane Block in Patients Undergoing Belt Lipectomy Surgery|url=http://dx.doi.org/10.1007/s00266-020-01944-3|journal=Aesthetic Plastic Surgery|volume=44|issue=6|pages=2143–2146|doi=10.1007/s00266-020-01944-3|issn=0364-216X}}</ref>

   I. Decrease needs for post-op opiates

   II. Early ambulation

·    Combined intercostal and pararectus blocks <ref>{{Cite journal|last=Feng|first=Lu-Jean|date=2010-11|title=Painless Abdominoplasty: The Efficacy of Combined Intercostal and Pararectus Blocks in Reducing Postoperative Pain and Recovery Time|url=http://dx.doi.org/10.1097/prs.0b013e3181ef8fe5|journal=Plastic and Reconstructive Surgery|volume=126|issue=5|pages=1723–1732|doi=10.1097/prs.0b013e3181ef8fe5|issn=0032-1052}}</ref>

   I. Decreased needs for post-op opiates

   II. Decreased time in recovery room

·    Others: limited studies have been completed in paravertebral, rectus sheet, iliohypogastric/ilioinguinal <ref>{{Cite journal|last=Rudkin|first=Glenda E.|last2=Gardiner|first2=Sarah E.|last3=Cooter|first3=Rodney D.|date=2008-02|title=Bilateral thoracic paravertebral block for abdominoplasty|url=http://dx.doi.org/10.1016/j.jclinane.2007.06.020|journal=Journal of Clinical Anesthesia|volume=20|issue=1|pages=54–56|doi=10.1016/j.jclinane.2007.06.020|issn=0952-8180}}</ref><ref>{{Cite journal|last=Seretis|first=Konstantinos|last2=Bounas|first2=Nikolaos|date=2022-12-06|title=The Efficacy of Different Nerve Blocks on Postoperative Pain and Sequelae in Patients Undergoing Abdominoplasty: A Network Meta-Analysis|url=http://dx.doi.org/10.1093/asj/sjac319|journal=Aesthetic Surgery Journal|volume=43|issue=5|pages=NP325–NP336|doi=10.1093/asj/sjac319|issn=1090-820X}}</ref> blocks, can possibly be used/helpful

===Potential major complications <ref name=":0" />===
DVT/PE, respiratory compromise, abdominal compartment syndrome, systemic infections

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
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|-
|Indications
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|Position
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|-
|Surgical time
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|EBL
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|Postoperative disposition
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|Pain management
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|Potential complications
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==References==

[[Category:Surgical procedures]]
<references />

WikiAnesthesia - User contributions [en]

Abdominoplasty