Abdominoplasty
Anesthesia type

General Anesthesia (most common), Conscious Sedation with Tumescent Technique/Neuraxial Techniques also feasible

Airway

ETT (most common)

Lines and access

PIV

Monitors

Standard

Primary anesthetic considerations
Preoperative

Potential difficult airway, cardiac/pulm conditions, bleeding/clotting

Intraoperative

IV prophylactic antibiotic, thrombosis prophylaxis, hypothermia precaution

Postoperative

DVT/PE, respiratory compromise, abdominal compartment syndrome

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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[1].

Overview

Indications

Excess fat, skin, and abdominal wall weakness [1].

Preoperative management

Patient evaluation [1]

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 [1]

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

  • Conscious Sedation + Tumescent Technique [2][3][4]
    • 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 [4][5]
    • Increased risk of respiratory depression, usually resolves with simple stimulation
    • Increased fentanyl use is associated with longer stay in recovery unit [6]
  • Neuraxial Techniques
    • Useful when the patient has higher risk cardiac complications, respiratory complications, malignant hyperthermia (HM), and rhabdomyolysis from anesthesia [7].
    • Spinal, epidural or combined spinal-epidural anesthesia can be used [7][8][9]
    • Safely provide adequate pain control in high risk GA patients
    • Decreased needs for post-op opiates
    • Patients able to ambulate in shorter amount of time (better DVT prevention)
  • Regional techniques
    • Decreased time in recovery room, postoperative narcotics, postoperative nausea and vomiting[10]
    • Quadratus lumborum (QL) block
      • Inconsistent results with regard to sparing of post-op opioids [11][12]
      • Better pain control [11]
    • Transversus abdominis plane (TAP) block [13][14][15][16][17]
      • Decreased postoperative opioid use
      • Early ambulation
      • Possibly less effective in post-bariatric surgery patient due to more traumatic operation [17]
    • Erector spinae plane block [18]
      • Decreased postoperative opioid use
      • Early ambulation
    • Combined intercostal and pararectus blocks [19]
      • Decreased postoperative opioid use
      • Decreased time in recovery room
    • Others
      • Limited studies have been completed for paravertebral, rectus sheet, iliohypogastric/ilioinguinal [20][21] blocks, can possibly be used/helpful

Intraoperative management

Monitoring and access

  • Standard ASA monitors

Induction and airway management

  • Standard induction

Positioning

  • Supine

Maintenance and surgical considerations

  • Standard maintenance
  • Maintain normothermia

Emergence

  • Smooth emergence to minimize tension on the suture line
  • PONV prophylaxis

Postoperative management

Disposition [1]

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 as described above

Potential major complications [1]

DVT/PE, respiratory compromise, abdominal compartment syndrome, systemic infections

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Janis, Jeffrey E.; Bunch, Brenda; Tomasikiewicz, Amanda; Taylor, Sarah; Gentry, Jennifer; Chambers, Graeme, eds. (2023). Essentials of plastic surgery (Third edition ed.). New York Stuttgart Delhi Rio de Janeiro: Thieme. ISBN 978-1-62623-847-3. |edition= has extra text (help)
  2. ↑ Shestak, Kenneth C. (2004-05). "The Outcome of Abdominoplasty Performed under Conscious Sedation: Six-Year Experience in 153 Consecutive Cases". Plastic and Reconstructive Surgery. 113 (6): 1818–1819. doi:10.1097/01.prs.0000118267.35908.01. ISSN 0032-1052. Check date values in: |date= (help)
  3. ↑ Rosenberg, Michael H.; Palaia, David A.; Bonanno, Philip C. (2001-05). "Abdominoplasty With Procedural Sedation and Analgesia". Annals of Plastic Surgery. 46 (5): 485–487. doi:10.1097/00000637-200105000-00005. ISSN 0148-7043. Check date values in: |date= (help)
  4. ↑ 4.0 4.1 Bagatin, Dinko (2019). "Influence of Local Infiltration Analgesia on Postoperative Pain in Abdominoplasty Patients". Acta Clinica Croatica. doi:10.20471/acc.2019.58.s1.03. ISSN 0353-9466.
  5. ↑ Kakagia, Despoina D.; Fotiadis, Spartakos; Tripsiannis, Gregory; Tsoutsos, Dimosthenis (2007-01-04). "Postoperative Analgesic Effect of Locally Infiltrated Levobupivacaine in Fleur-de-Lys Abdominoplasty". Aesthetic Plastic Surgery. 31 (2): 128–132. doi:10.1007/s00266-006-0187-4. ISSN 0364-216X.
  6. ↑ Pechter, Edward A. (2000-04). "The Clinical Outcome of Abdominoplasty Performed Under Conscious Sedation: Increased Use of Fentanyl Correlated with Longer Stay in Outpatient Unit". Plastic & Reconstructive Surgery. 105 (4): 1577. doi:10.1097/00006534-200004040-00074. ISSN 0032-1052. Check date values in: |date= (help)
  7. ↑ 7.0 7.1 Leal, Plinio da Cunha; Lima, Wildney Leite; Oliveira, Eduardo José Silva Gomes de; Oliveira, Caio Márcio Barros de; Gomes, Lyvia Maria Rodrigues de Sousa; Servin, Elizabeth Teixeira Noguera; Moura, Ed Carlos Rey (2021-04). "Combined spinal-epidural anesthesia for abdominoplasty and liposuction in Limb-Girdle Muscular Dystrophy: case report". Brazilian Journal of Anesthesiology (English Edition). doi:10.1016/j.bjane.2021.02.046. ISSN 0104-0014. Check date values in: |date= (help)
  8. ↑ Kodeih, Mohammad G.; Al-Alami, Achir A.; Atiyeh, Bechara S.; Kanazi, Ghassan E. (2009-03). "Combined Spinal Epidural Anesthesia in an Asthmatic Patient Undergoing Abdominoplasty". Plastic and Reconstructive Surgery. 123 (3): 118e–120e. doi:10.1097/prs.0b013e31819a35c9. ISSN 0032-1052. Check date values in: |date= (help)
  9. ↑ Metry, AymanAnis; Nakhla, GeorgeM; Wahba, WahbaZ; Wahba, RamiM; Kamel, IbrahimH (2019). "Abdominoplasty under spinal anesthesia: A feasibility study". Anesthesia: Essays and Researches. 13 (2): 243. doi:10.4103/aer.aer_69_19. ISSN 0259-1162.
  10. ↑ Gutowski, K.A. (2011-01). "Outpatient Abdominoplasty Facilitated by Rib Blocks". Yearbook of Plastic and Aesthetic Surgery. 2011: 158–159. doi:10.1016/s1535-1513(09)79493-7. ISSN 1535-1513. Check date values in: |date= (help)
  11. ↑ 11.0 11.1 Efsun Ozgunay, Seyda; caglayan, Umit; Yilmaz, Canan (2018-05-16). "09 / Comparison of ultrasound guided transversus abdominis plane block and quadratus lumborum block for postoperative pain in cesarean section: A prospective, randomized-controlled study". dx.doi.org. Retrieved 2023-09-11.
  12. ↑ Bjelland, Thor W.; Yates, Thomas G.R.; Fagerland, Morten W.; Frøyen, Jan K.; Lysebråten, Karl R.; Spreng, Ulrich J. (2019-05-21). "Quadratus lumborum block for postoperative analgesia after full abdominoplasty: a randomized controlled trial". Scandinavian Journal of Pain. 19 (4): 671–678. doi:10.1515/sjpain-2019-0013. ISSN 1877-8879.
  13. ↑ Oppenheimer, Adam J.; Fiala, Thomas G.S.; Oppenheimer, Daniel C. (2016-11). "Direct Transversus Abdominis Plane Blocks With Exparel During Abdominoplasty". Annals of Plastic Surgery. 77 (5): 499–500. doi:10.1097/sap.0000000000000659. ISSN 0148-7043. Check date values in: |date= (help)
  14. ↑ Fiala, Thomas (2015-01-01). "Tranversus Abdominis Plane Block During Abdominoplasty to Improve Postoperative Patient Comfort". Aesthetic Surgery Journal. 35 (1): 72–80. doi:10.1093/asj/sju019. ISSN 1527-330X.
  15. ↑ Sforza, Marcos; Andjelkov, Katarina; Zaccheddu, Renato; Nagi, Hussein; Colic, Miodrag (2011-08). "Transversus Abdominis Plane Block Anesthesia in Abdominoplasties". Plastic and Reconstructive Surgery. 128 (2): 529–535. doi:10.1097/prs.0b013e31821e6f51. ISSN 0032-1052. Check date values in: |date= (help)
  16. ↑ Alotaibi, Nawaf Naif; Ahmad, Tawheed; Rabah, Sari Monzer; Hamza, Aljohara Mohmoud; Mohammad Tafazul, Sheikh (2021-01-05). "Evaluation of transversus abdominis plane (TAP) block in lipoabdominoplasty surgical procedure: a comparative study". Journal of Plastic Surgery and Hand Surgery. 55 (4): 216–219. doi:10.1080/2000656x.2020.1856676. ISSN 2000-656X.
  17. ↑ 17.0 17.1 Gravante, Gianpiero; Castrì, Francesca; Araco, Francesco; Araco, Antonino (2010-06-02). "A Comparative Study of the Transversus Abdominis Plane (TAP) Block Efficacy on Post-bariatric vs Aesthetic Abdominoplasty with Flank Liposuction". Obesity Surgery. 21 (3): 278–282. doi:10.1007/s11695-010-0203-2. ISSN 0960-8923.
  18. ↑ Perez, Mauricio E.; Hoyos, Alfredo E. (2020-10-08). "Invited Discussion on: Evaluation of the Effect of Erector Spinae Plane Block in Patients Undergoing Belt Lipectomy Surgery". Aesthetic Plastic Surgery. 44 (6): 2143–2146. doi:10.1007/s00266-020-01944-3. ISSN 0364-216X.
  19. ↑ Feng, Lu-Jean (2010-11). "Painless Abdominoplasty: The Efficacy of Combined Intercostal and Pararectus Blocks in Reducing Postoperative Pain and Recovery Time". Plastic and Reconstructive Surgery. 126 (5): 1723–1732. doi:10.1097/prs.0b013e3181ef8fe5. ISSN 0032-1052. Check date values in: |date= (help)
  20. ↑ Rudkin, Glenda E.; Gardiner, Sarah E.; Cooter, Rodney D. (2008-02). "Bilateral thoracic paravertebral block for abdominoplasty". Journal of Clinical Anesthesia. 20 (1): 54–56. doi:10.1016/j.jclinane.2007.06.020. ISSN 0952-8180. Check date values in: |date= (help)
  21. ↑ Seretis, Konstantinos; Bounas, Nikolaos (2022-12-06). "The Efficacy of Different Nerve Blocks on Postoperative Pain and Sequelae in Patients Undergoing Abdominoplasty: A Network Meta-Analysis". Aesthetic Surgery Journal. 43 (5): NP325–NP336. doi:10.1093/asj/sjac319. ISSN 1090-820X.

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