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Office Based Full Abdominoplasty Can Be Safe

ABSTRACT
Background: As demand for outpatient procedures has increased, abdominoplasties are now judiciously being done in accredited outpatient facilities. The term outpatient is changing from Medicare’s original definition of a patient staying in the hospital less than 24 hours, to a patient being discharged home within hours of surgery.
Objective: Previous reports on outpatient abdominoplasties are limited due to their small cohorts and do not distinguish between different types of body contouring procedures. These reports also include patients that were kept overnight. Our objective is to review only full abdominoplasties done in an outpatient facility with the patient discharged home the same day.
Methods: All consecutive full abdominoplasties performed by the senior author from 1992 to 2010 were reviewed retrospectively. The charts of 206 patients were reviewed and their demographic, operative, and postoperative data were collected. Systemic and local complications were assessed, as well as, revision rates.
Results: No patients developed any systemic complications including deep venous thrombosis or pulmonary embolism, blood transfusion, intra-abdominal perforation, and death. The most common local complication seen overall was seroma, with a rate of 19.4%.
Conclusions: Currently, no report looks solely at patients sent home from the recovery area. This report serves to add to the literature a large cohort of patients having full abdominoplasties sent home within hours of surgery. The ever present sentiment that abdominoplasties have the highest rate of venous thromboembolism needs to be carefully evaluated. Our study shows that full abdominoplasties can be safely performed without any systemic complications including VTE in an outpatient setting.
Key Words: Abdominoplasty, VTE, thromboembolism, complications, tummy tuck

INTRODUCTION
Outpatient cosmetic procedures are becoming increasingly popular. Office-based procedures were up 6% in 2009 and now 88% of cosmetic procedures are done outside of a hospital setting. Of these cosmetic procedures, abdominoplasty is one of the top 5 most commonly performed procedures and is up 84% from 2000 to 2009. In 2009, 115,191 abdominoplasties were performed.1 Conventionally, abdominoplasties have been inpatient procedures. As the demand for outpatient procedures has increased, based on patient preference and economic concerns2, body contouring is now judiciously being done in accredited outpatient facilities. Data has been coming out over the last decade showing that these procedures have equal complication rates as the same procedures done in an inpatient setting.3-7
Abdominoplasties are most often sited as the procedure with the highest risk of venous thromboembolism (VTE).8-10 These reports are limited due to their small patient cohorts and often do not distinguish among different body contouring procedures. Additionally, these reports include patients that were kept overnight or were hospitalized for several days. The term outpatient is changing from medicare’s original definition of a patient staying in the hospital less than 24 hours, to a patient being discharged home within hours of surgery. To date, there has been no large study of true outpatient abdominoplasties. Stevens et al3 reviewed 519 patients, including full and mini-abdominoplasties, and most of their patients stayed overnight at an aftercare facility. Antonetti and Antonetti11 reported on 517 patients, but only 80 were exclusively done in an outpatient setting. We need to have verifiable evidence that sending patients directly home after an abdominoplasty is safe. The objective of this study is to evaluate the senior author’s 18 years of experience doing full abdominoplasties done in an outpatient-based setting (i.e., with all patients discharged directly home) and analyze the complications and revision rates.

METHODS
Patient Selection
All consecutive abdominoplasties performed by the senior author from January 1992 to May 2010 were reviewed retrospectively. Two patients were done as inpatients and were excluded from this study; one was due to his BMI of 52 and the other was due to a concomitant procedure being done by another surgeon. Three-hundred nineteen patients underwent outpatient full abdominoplasties. Only patients with an ASA classification of I or II were chosen to be done as outpatients. These were conducted in a fully accredited class C office-based surgery facility by the American Association for Accreditation of Ambulatory Surgery Facilities. Their demographic, operative, and postoperative data were collected from their charts. The patients usually presented with complaints of abdominal lipodystrophy and skin laxity after pregnancy or weight loss. The risks and benefits were discussed at length with the patient and the planned incisions were drawn. If the patients smoked, they are asked to stop and wait 6 weeks after cessation for their operation. The patient was brought to the office 2 weeks prior to the procedure to answer any further questions and sign the informed consent. At this time, the patients are asked to stop taking any NSAIDS or aspirin. They were also asked to not take anything by mouth after midnight the day before surgery. Most importantly, time was taken to discuss the surgeon’s expectations of them postoperatively with heavy emphasis on ambulating prior to discharge and to continue ambulation at home.
Surgical technique
All patients were marked standing up prior to entering the operating room. Once on the operating room table, pneumatic compressions devices were placed on the lower extremities and antimicrobial prophylaxis was administered intravenously. General anesthesia was commenced using either a laryngeal mask airway or an endotracheal tube. The patients were induced using propofol. Balanced anesthesia was maintained with an inhalational agent (sevoflurane or isoflurane) along with fentanyl for added analgesia. Additionalluy, a muscle relaxant (rocuronium or mivacurium) was used to facilitate the rectus plication. Ondansetron, metoclopramide, and occasionally decadron were used to prevent postoperative nausea and vomiting. No DVT chemoprophylaxis was given. In all patients, a full abdominoplasty was carried out with undermining to the xiphoid and subcostal margins. The patient was then placed in a flexed position and the excess abdominal tissue was removed. The rectus fascia was plicated from xiphoid to umbilicus and umbilicus to pubis. One or two 15 French Blake drains were placed coming out just below the incision near the inguinal crease. Before the patient was awoken from anesthesia, a 60 cc mixture of half and half 1% lidocaine with epinephrine and 0.5% Marcaine was placed through the drains and allowed to bathe the abdominal wall. The drains were not charged for 30 minutes once the patient was in the recovery room. This facilitated ambulation very early in the postoperative period. Concurrent procedures most often performed were bilateral augmentation mammoplasty and liposuction. Liposuction was performed in the hips and/or thighs. No liposuction was performed on the abdominal flap.
Postoperative Care
The incisions were dressed and no abdominal binders were placed. The patient was taken to the recovery room and discharged once they could void, tolerate fluid intake, and ambulate. The ambulation required was walking to the bathroom and transferring to the vehicle for return home. Instructions for care and recording drain output were given to the patient and the adult responsible for caring for the patient in the next 24 hours. They were instructed to ambulate with assistance and as erect as comfortable several times that evening. Prescriptions for an antibiotic, a narcotic and Colace 100 mg BID are given to the patient. They are seen in the clinic at 2 days, 1 week, 2 weeks, 4 weeks, 2 months, and 6 months postoperatively or more frequently if needed. The drains are kept in place until there is less than 30 cc’s output in a 24-hour period. If the patient notes that the output reaches this amount prior to their subsequent clinic visit, they are encouraged to come in for drain removal.
Outcome Measures and Statistical Analysis
Baseline characteristics were collected for the following: age, gender, BMI, medications, comorbidities, prior abdominal surgeries, smoking habits and ASA. Furthermore, information was gathered regarding operative time, recovery time, and length of time until removal of drains. The outcomes measured in this study include complications and treatment of the complications. The complications were divided into local and systemic complications. The local complications recorded were seroma, hematoma, flap epidermolysis, wound dehiscence, wound necrosis, umbilical wound dehiscence, hypertrophic scar, contour irregularity, wound infection, suture reaction, and superficial nerve entrapment. Systemic complications were deep venous thrombosis, pulmonary embolism, blood transfusion, intra-abdominal perforation, and death. Anyone that had fluid, which could be aspirated from beneath their abdominal skin flap, was defined as a seroma. Seromas were appreciated either by palpation or ultrasound. Anyone with ecchymosis and blood that was either aspirated or surgically evacuated were defined as having a hematoma. Any scar or skin excess (i.e., dog ears or mons ptosis) that was deemed unfavorable by the patient or the surgeon were counted as hypertrophic scars or contour deformities, respectively.
Data were statistical analyzed using the chi-squared test, Fisher’s t-test, and two-tailed t-test.

RESULTS
We present two sets of results. One for the larger group of 319 patients and another for the smaller group of 206 patients for which the complete EMR was available. Over an 18-year period, a total of 319 outpatient abdominoplasties were performed. All of these operations were done under general anesthesia. Everyone had sequential compression devices placed prior to induction of anesthesia. None of the patients had a complication of VTE, or any other systemic complication.
As record keeping and the addition of electronic medical systems have evolved, significantly more data is available for a cohort of this patient population. The following results are based on 206 patients, which had pre-operative, operative, anesthetic, and postoperative records available for review. All but three of the patients were women (1.5% percent males). The age range of the patients was from 21 to 69 years (mean, 40 years). The BMI range was 18 to 39 (mean, 25) and 12.1% had a BMI of >30. All patients had an ASA classification of I or II. Thirty-seven patients (17.9 percent) were taking estrogen, either in oral contraceptives or hormone replacement therapy. Twelve percent continued to smoke at the time of the operation. More than half had prior open abdominal surgeries (56.3 percent). The length of follow-up ranged from 2 weeks to 9.5 years (mean, 13 months). Only 4 patients were followed for less than 3 weeks because they were from out of town.
Of the 206 patients, 88 underwent only abdominoplasties. The average operative time for these patients was 105 minutes. The average recovery room time was 86 minutes. The concurrent procedures performed included liposuction (of hips and/or thighs) 27.7%, breast augmentation 17.5%, mastopexy 15.5%, as well as hernia repair, reduction mammoplasty, removal of implants, implant exchange, brachioplasty, blepharoplasty, hysterectomy, bilateral salpingo-oophorectomy, laparoscopic cholecystectomy, fat grafts to lips, and scar revision (Fig. 1). Average operating time including concurrent procedures was 147 minutes and recovery time was 90 minutes.
No patients in either the cohort of 206 or the larger group of 319 patients developed any systemic complications including deep venous thrombosis or pulmonary embolism (VTE), blood transfusion, intra-abdominal perforation, and death. The local complications for the cohort of 206 patients were seroma, hematoma, wound dehiscence, epidermolysis, wound necrosis, wound infection, suture reaction, umbilical wound dehiscence, hypertrophic scar, contour irregularity, and superficial nerve entrapment (Table 1). None of the complications required hospitalization. The most common complication seen overall was seroma, with a rate of 19.4%. The amount aspirated ranged from 5cc to a total of 900cc during serial aspirations. Two of the 40 patients with seromas required surgical excision of the seroma cavity. Six patients required either a Penrose drain or seroma catheter placement under local anesthesia. Hypertrophic scars were the next most common complications (9.2 percent). Three of the 19 hypertrophic scars were revised operatively, the rest were treated with either steroid injections or massage and silicone therapy. Of the 15 patients that had contour irregularities, 11 were operatively revised. There were 14 patients with hematomas and 4 of them required surgical evacuation, the remainder were treated with aspiration or placement of a Penrose drain. All wound infections were successfully treated with oral antibiotics. Of the 5 patients that had wound necrosis, which included underlying fat necrosis, 3 patients required surgical debridement and revision. Umbilical wound dehiscence, wound dehiscence, suture reaction, and epidermolysis were all treated with local wound care and healed uneventfully. The patient with superficial nerve entrapment was treated with Xylocaine and steroid injections. A total of 21 patients (10.2%) required a surgical revision. See Figures 2-4 for examples of pre and postoperative patients having undergone full abdominoplasties.
Until May 2006, the senior author used mostly one drain and occasionally placed two drains. Since then, he always places two drains. The incidence of seroma formation before May 2006 was 25.3% and after 2006 was 14.4% (P=0.05). The drains were left in place for an average of 11 days. Overall, the mean BMI was 24.6 +/- 3.6 in the patients that did not develop seromas (n=165) and 26.2 +/- 4.6 in those that did have a seroma (n=40). One patient did not have a recorded BMI. Using a two-tailed t-test, this difference was significant at P=0.01. Additionally, the mean BMI for the group of patients that had at least one complication was 25.5 (n=96) and 24.4 (n=109) for the group that did not have any complications. The difference closely approached significance at P=0.052.
The incidences of the following wound complications were analyzed in smokers: wound infection, umbilical wound dehiscence, wound necrosis, wound dehiscence, and epidermolysis. The rate of wound complications was 11.5% (n=174) in non-smokers, 12.5% (n=8) in those who quit in the 6 weeks prior to surgery, and 16.7% (n=24) in smokers (P=0.77).

DISCUSSION
As the trend increases to do more abdominoplasties in an outpatient setting, it is important to selectively look at these patients to better understand their complications risks.3-5, 12 A thorough review of the English literature shows that information solely on outpatient full abdominoplasties is lacking. As society is focusing more on outcomes-based performance measurements, it is imperative that we document the risks pertaining precisely to the procedure being performed. We define outpatient as patients discharged from the ambulatory facility directly home within hours of surgery and not kept overnight.
A total of 319 consecutive full abdominoplasty patients from the senior surgeon’s AAAASF accredited class C office-based surgery clinic were reviewed retrospectively. All were done under general anesthesia. The majority were done with ancillary procedures, most often liposuction (27.7%). No systemic complications occurred, including VTE’s. The ever-present sentiment that abdominoplasties have the highest rate of venous thromboembolism needs to be carefully evaluated. The incidence of deep venous thrombosis and pulmonary embolism continues to be ill defined in aesthetic surgery. The most often sited incidence is from Grazer and Goldwyn13, who reported DVT incidence of 1.1%and PE incidence of 0.8%. Their survey in 1975 took place before the advent of sequential compression devices, which are known to decrease the incidence of venous thromboembolisms by 60%.14 Many surgeons in this survey reported that their abdominoplasty patients stayed in bed for greater than 36 hours. More recently, van Uchelen et al15 reported a 1.4% incidence of DVT and 1.4% incidence of PE. Again, all 86 of these abdominoplasties were done as inpatients and were not discharged until postoperative day 5. Neaman and Hansen16 reviewed 206 abdominoplasties and found a 0.5% incidence in DVT and PE alike, but 118 were inpatients. Matarasso et al.’s17 survey includes 11,016 abdominoplasties and they found a 0.04% incidence of DVT and 0.02% of PE. They do not differentiate mini-abdominoplasties versus full abdominoplasties. Furthermore, a survey such as this one is subject to nonresponsive bias. Stevens et al.3 reviews a much larger cohort of patients (519), but does not separate their complications for mini-abdominoplasties and most of their patients stayed overnight before being discharged home. His complication rate of 0% DVTs and 0.02% PEs approach our findings most closely (Table 2). Additionally, 17.9% of our patients were taking some form of estrogen and 12.1% were obese with a BMI of >30, both of which have been shown to be risk factors for venous thromboembolism (VTE).10 We did not ask our patients to stop their use of estrogen. Our lack of VTE complications supports the guidelines that moderate to high-risk (depending on the guideline) individuals can be adequately prophylaxed with intermittent pneumatic compression and early ambulation.8 We believe that discussing our expectations of early ambulation with our patients prior to surgery is important. We have the patient ambulate in the recovery room to the bathroom and then ask that they ambulate as erect as comfortable several times before going to sleep that night. Also, bathing the abdominal wall with lidocaine and Marcaine prior to extubation aids greatly in comfort with ambulation postoperatively. This is a subjective observation based on the surgeon’s observations.
Seroma formation was the most common complication at 19.4%, which is in the range of the reported rates from 1% to 38%.4, 11, 18, 19 Using 2 drains in every operation has decreased our rate of seroma formation significantly from 25.3% to 14.4%. As of June 2010, we have started to use progressive tension sutures based on evidence that seroma rate can be decreased even more.11 Like many others, our study supports that obesity is a significant factor in complications.16, 20 Moreover, our data is clinically significant when the mean BMI for the 2 groups, with and without seroma complications, were reviewed. The group without seroma as a complication had a mean BMI of 24, which is considered normal weight, versus the group that had seromas that had a mean BMI of 26, which is overweight. This is not to say that patients with a BMI less that 24 did not get seroma, but they trended to a lower incidence of seromas. In our study, we did not find an association with smoking and wound complications, but the number of smokers was small and patient selection was against those who were smokers.
The majority of seromas were treated conservatively with needle aspirations or Penrose drain placement. Of the 40 patients with recorded seromas of any size, only two patients required operative treatment for their seromas. Four patients with hematomas required surgical evacuation. All infections resolved with antibiotics. Half of the contour deformities and hypertrophic scars were operatively revised. Some do not consider these later two as true complications, but we wanted to be as comprehensive as possible. Other studies on outpatient abdominoplasties show similar complications and rates.3, 4, 18 Overall, the revision rate was 10.2%, similar to other reported rates.3, 21, 22
There is an increasingly strong push for procedures to be done not only in an outpatient setting, but also under conscious sedation. Those that advocate the use of conscious sedation site decreased risk of developing venous thromboembolism.21 Our study shows that general anesthesia, along with sequential compression devices and early ambulation, can provide equally comparable results.

CONCLUSIONS
Our study shows that full abdominoplasties can be safely performed in an outpatient setting with patients sent directly home. There were zero venous thromboembolic events (0%). The patient selection should be rigorous and attention should be paid particularly to the BMI of the patient. The studies that are often quoted about the risks of abdominoplasties are fraught with nonresponsive bias and small cohort numbers. The optimal method of VTE prophylaxis remains to be clarified by a prospective trial that should include mechanical prohpylaxis and ambulation as well as pharmaceutical prophylaxis. It is our hope that this study will add to the literature a study of a significant number of true outpatient abdominoplasties done without serious morbidity or mortality.

REFERENCES
1. 2010 Report of the 2009 statistics National Clearing House of Plastic Surgery Statistics. http://www.plasticsurgery.org/Documents/Media/statistics/2009-US-cosmeticreconstructiveplasticsurgeryminimally-invasive-statistics.pdf. American Society of Plastic Surgeons. Accessed October 18, 2010.
2. Iverson RE. ASPS Task Force on Patient Safety in Office-Based Surgery Facilities. Patient safety in office-based surgery facilities: I. Procedures in the office-based surgery setting. Plast Reconstr Surg 2002;110:1337-1342.
3. Stevens WG, Spring MA, Stoker DA, Cohen R, Vath SD, Hirsch EM. Ten years of outpatient abdominoplasties: safe and effective. Aesthet Surg J 2007;27:269-275.
4. Spiegelman JI, Levine RH. Abdominoplasty: a comparison of outpatient and inpatient procedures shows that it is a safe and effective procedure for outpatients in an office-based surgery clinic. Plast Reconstr Surg 2006;118:517-522; discussion 523-514.
5. Chattar-Cora D, Okoro SA, Barone CM. Abdominoplasty can be performed successfully as an outpatient procedure with minimal morbidity. Ann Plast Surg 2008;60:349-352.
6. Byrd H, S,, Barton FE, Orenstein HH, et al. Safety and efficacy in an accredited outpatient plastic surgery facility: A review of 5316 consecutive cases. Plast Reconstr Surg 2003;11:636-641.
7. Kryger ZB, Fine NA, Mustoe TA. The outcome of abdominoplasty performed under conscious sedation: six-year experience in 153 consecutive cases. Plast Reconstr Surg 2004;113:1807-1817.
8. Davison SP, Venturi ML, Attinger CE, Baker SB, Spear SL. Prevention of venous thromboembolism in the plastic surgery patient. Plast Reconstr Surg 2004;114:43E-51E.
9. Venturi ML, Davison SP, Caprini JA. Prevention of venous thromboembolism in the plastic surgery patient: current guidelines and recommendations. Aesthet Surg J 2009;29:421-428.
10. Young VL, Watson ME. The need for venous thromboembolism (VTE) prophylaxis in plastic surgery. Aesthet Surg J 2006;26:157-175.
11. Antonetti JW, Antonetti AR. Reducing seroma in outpatient abdominoplasty: analysis of 516 consecutive cases. Aesthet Surg J 2010;30:418-425.
12. Williams TC, Hardaway M, Altuna B. Ambulatory abdominoplasty tailored to patients with an appropriate body mass index. Aesthet Surg J 2005;25:132-137.
13. Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with emphasis on complications. Plast Reconstr Surg 1977;59:513-517.
14. Urbankova J, Quiroz R, Kucher N, Goldhaber SZ. Intermittent pneumatic compression and deep vein thrombosis prevention. A meta-analysis in postoperative patients. Thromb Haemost 2005;94:1181-1185.
15. van Uchelen JH, Werker PM, Kon M. Complications of abdominoplasty in 86 patients. Plast Reconstr Surg 2001;107:1869-1873.
16. Neaman KC, Hansen JE. Analysis of complications from abdominoplasty: a review of 206 cases at a university hospital. Ann Plast Surg 2007;58:292-298.
17. Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. Plast Reconstr Surg 2006;117:1797-1808.
18. Dillerud E. Abdominoplasty combined with suction lipoplasty: a study of complications, revisions, and risk factors in 487 cases. Ann Plast Surg 1990;25:333-338; discussion 339-343.
19. Khan UD. Risk of seroma with simultaneous liposuction and abdominoplasty and the role of progressive tension sutures. Aesthetic Plast Surg 2008;32:93-99; discussion 100.
20. Rogliani M, Silvi E, Labardi L, Maggiulli F, Cervelli V. Obese and nonobese patients: complications of abdominoplasty. Ann Plast Surg 2006;57:336-338.
21. Kryger ZB, Fine NA, Mustoe TA. The outcome of abdominoplasty performed under conscious sedation: six-year experience in 153 consecutive cases. Plast Reconstr Surg 2004;113:1807-1817; discussion 1818-1809.
22. Stewart KJ, Stewart DA, Coghlan B, Harrison DH, Jones BM, Waterhouse N. Complications of 278 consecutive abdominoplasties. J Plast Reconstr Aesthet Surg 2006;59:1152-1155.

FIGURE LEGENDS
Figure 1. Percentage of concurrent procedures. *Includes the following: Hysterectomy, Bilateral Salpingo-Oophorectomy, Prior Scar Revision, and Fat Grafting to Lips.
Figure 2. A 32-year-old patient who underwent a full abdominoplasty (A, B, C) and 3-months postoperatively (D, E, F).
Figure 3. A 50-year-old patient who underwent a full abdominoplasty (A, B) and 3-months postoperatively (C, D).
Figure 4. A 36-year-old patient who underwent a full abdominoplasty (A, B) and 3-months postoperatively (C, D).

Table 1. Rates of local complications.
Complications (n = 206)
Seroma 19.4%
Hypertrophic scar 9.2%
Contour irregularity (dog ear) 7.3%
Hematoma 6.8%
Wound infection 6.8%
Umbilical wound dehiscence 5.3%
Wound necrosis 2.4%
Wound dehiscence 1.9%
Suture reaction 1.9%
Epidermolysis 1.5%
Superficial nerve entrapment 0.5%

Table 2. Comparison of various studies’ rates of deep venous thrombosis (DVT) and pulmonary embolism (PE).

Grazer and Goldwyn
1977
(n=10,490) van Uchelen
2001
(n=86) Mataraso
2005
(n=11,016) Hansen
2007
(n=206) Stevens
2007
(n=519) Moliver
2010
(n=319)
DVT 1.1% 1.4% 0.04% 0.5% 0.0% 0.0%
PE 0.8% 1.4% 0.02% 0.5% 0.02% 0.0%

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