These precautions ensure safe one-stage abdominoplasty in combination with body-contouring procedures
It has become increasingly common for patients to request multiple aesthetic procedures during a single surgery. The advantages of combined procedures include a single recovery period, reduced surgery costs, and more rapid patient gratification. Despite patient demand, some combinations of procedures were not very common in the past because of technical constraints, as well as concerns about prolonged surgery times and the increased risk of complications.
Traditional surgical thinking has favored performing abdominoplasty and body-contouring procedures individually in an effort to minimize risks and avoid complications associated with prolonged anesthesia. The most serious complication is thromboembolism. In one type of thromboembolism, deep-vein thrombosis (DVT), blood clots commonly form in the lower extremities (particularly in the calf and behind the knee). DVT patients often present with tenderness, swelling, and warmth of the affected area. Occasionally, the vein involved may feel ropy due to the thrombosis.
Prolonged immobility, obesity, genetic predisposition, pregnancy or the postpartum state, a history of estrogen therapy (such as contraception or hormone-replacement therapy), and malignancy are a few of the factors that can encourage the development of a blood clot due to vascular damage, venous-blood stasis, or hypercoagulable states. If a patient presents with the clinical signs and symptoms that create a suspicion of DVT, he or she should immediately undergo a venous Doppler ultrasound study to rule out the possibility of a blood clot in the extremity. If DVT is present and remains undiagnosed, the clot could dislodge and travel to the lungs, causing pulmonary embolism.
Many cases of pulmonary embolism result from a blood clot that originated in the lower extremities. Pulmonary embolism, however, can also be due to a fat or air embolus. A patient can present with the sudden onset of shortness of breath, chest pain that radiates to either shoulder, anxiety, malaise, and, rarely, hemoptysis. Pulmonary embolism, if undiagnosed, can lead to pulmonary infarction, right-heart failure, and even death. The diagnosis of pulmonary embolism can be difficult to make and involves early detection by means of electrocardiography, chest radiography, ventilation–perfusion scanning, or spiral computed tomography.
At the Aesthetic Center for Plastic Surgery, our experience indicates that several strategies are useful for performing abdominoplasty in combination with other body-lift procedures. These steps can make the combined procedures safer and reduce the incidence of DVT and pulmonary embolism.
Offering safe, consistent, predictable results is a challenge for every plastic surgeon. DVT and pulmonary embolism are the most feared complications after a lengthy surgical procedure that involves extensive undermining with a large amount of skin and soft-tissue removal or fat aspiration. The combination of an abdominoplasty with body-contouring surgery and large-volume liposuction may precipitate DVT and pulmonary embolism if prevention measures are not implemented. The patient may experience shortness of breath, decreased breath sounds, sharp chest pain that radiates to the shoulder and arm, leg cramps, anxiety, general weakness,/or calf swelling within 3 to 10 days after surgery.
Our 5-year experience with 266 patients who underwent abdominoplasty with added procedures such as liposuction; lifts of the arms, legs, buttocks, or thighs; and various breast procedures (including augmentation and reduction) prompted us to investigate a regimen that could manage patients safely and effectively, and prevention pulmonary embolism and DVT.
Why offer abdominoplasty and various contouring procedures in one surgery session? A single procedure involves only one recovery period, with less time off work required. There is a higher level of patient satisfaction with an immediate, positive contour change. We have also observed the positive psychological and emotional impact of enhanced patient confidence and trust in the surgeon. There is an improved aesthetic result as well. The sculpting aspect of liposuction, combined with the surgical removal of excess sagging tissue, provides smoother contour lines.
We perform tumescent infiltration throughout the areas to be treated. The vasoconstrictive effect of the tumescent-infiltration solution in the tissues reduces blood loss dramatically. Clear, clean dissection planes are more easily identified and dissected, making the operation safer. Infiltration also reduces inflammation and swelling.
In addition, we reduce tension in the skin flap by using a wide, discontinuous mobilization and by applying progressive tension sutures. We believe that excessive tension exerted in the flap compromises the blood supply. In this series of 266 cases, there was no abdominal-flap loss.
We use the superwet infiltration technique with 30 mL of 1% lidocaine, 1 mL of 1:1000 epinephrine, and 1 L of lactated Ringer’s crystalloid solution for the first 5 L of infiltration. When larger volumes are used, the solution in excess of 5 L is prepared without lidocaine. The typical ratio of infiltration to aspiration volume is 1:1.
Lengthy procedures require safety measures to prevent DVT and pulmonary embolism. Our preventive measures begin with sequential compression devices used during surgery and continuously until the patient is discharged 1 day after surgery. Early, frequent mobilization of the patient is necessary, as is continuous dorsiflexion and plantar flexion of the feet while the patient is in bed. This prevents the stagnation of blood and the formation of clots.1
If the patient uses hormone therapy, it is discontinued 4 to 6 weeks prior to surgery and reinstated 4 to 6 weeks after surgery. Supplemental hormones have been reported to increase the incidence of thromboembolic complications.2
A low–molecular-weight heparin such as enoxaparin (40 mg) is administered subcutaneously in the recovery room immediately after surgery, with the dose repeated each morning for 72 hours.3 Aspirin (325 mg, given once daily) is administered beginning on the third postoperative day and ending 6 weeks later.4 During that period, all air travel is forbidden, as are ground-transportation rides lasting more than 2 hours.
An important technical point is that trying to reduce or minimize incision length has resulted in aesthetic imbalance. The final aesthetic contour of the abdomen should not be restricted by the length of the incision. Proper planning to ensure an ideal location for the abdominal incision is critical to the concealment of the resulting scar when the patient wears swimwear.
Reasons for Optimism
Our results from 266 abdominoplasties with added body-lift procedures performed in one stage demonstrate a 1.8% incidence rate of major complications such as DVT and pulmonary embolism and a decreasing trend for minor complications (seromas, cellulitis, and wound dehiscence of less than 2 cm). We are optimistic, because these results show a lower complication rate than previous studies.1,2,4–6 The main reasons, we believe, are appropriate patient selection, the specific technical points we have described, and the strict protocols observed during and after surgery to implement comprehensive care at all times.
We conclude that the combination of abdominoplasty with other body-lift procedures is not necessarily associated with an increased complication rate. This can be performed successfully and safely in one stage, provided that these procedures are conducted by an experienced surgeon, assisted by a highly competent team, in a fully accredited surgical facility equipped to provide comprehensive care. A strict, well-conceived protocol for abdominoplasty in combination with added body-lift procedures and large-volume liposuction must be implemented 100% of the time by a highly supportive, attentive staff. These combination surgeries should be performed routinely by the surgeon and the staff to ensure a high level of expertise.
Patients should be carefully selected; their body-mass indices should be no more than 35,7 and they should be well informed, motivated, and compliant. PSP
Christopher K. Patronella, MD, FACS, FICS, is a founding partner and the managing partner of the Aesthetic Center for Plastic Surgery LLP in Houston. Amado Ruiz-Razura, MD, FACS, FICS, is the medical director of the center and a professor of surgery in the Division of Plastic and Reconstructive Surgery at the University of Texas Medical School in Houston. Henry A. Mentz, MD, FACS, FICS, and German Newall, MD, FACS, FICS, are founding partners of the center. All of the authors can be reached at [email protected] or via their Web site, www. mybeautifulbody.com.
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