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abdominal surgery marked the beginning of
efforts to combine abdominoplasty with other
procedures. One of the rst favorable reports on
combing abdominoplasty with intra-abdominal,
pelvic, or other aesthetic procedures came from
Hester, who noted comparable complication rates
and cited only obesity as a risk factor for unfavorable outcomes [6]. Other early reports were less
encouraging. Voss reported higher morbidity,
longer operative times, and protracted hospital
stays when abdominoplasty was combined with
common gynecologic operations [7]. Specically,
his data indicated that while no patients undergoing a single procedure had a pulmonary embolism (PE), 6.6% of patients undergoing combined
procedures did have a PE.While initially alarming, these data are tempered by the realization
that signicant practice modications have been
enacted since these studies were performed. In
the words of Beran, “comparison of DVT [deep
venous thrombosis]/PE rates in these combined
procedures before and after the adoption of these
[venous thromboembolism prophylaxis] modalities is like comparing infection rates before and
after the time of Fleming” [1].
The literature also informs our understanding
of local complication rates related to adjacent
combined procedures. Ali demonstrated, for
example, that combining abdominoplasty with
cesarean section leads to higher complication
rates and inferior aesthetic results due to distorted
local anatomy and compromised healing secondary to contamination [8]. More recent studies
have reiterated that combining obstetrical procedures with aesthetic operations of the abdomen is
ill-advised. For example, one group specically
recommends waiting at least 6 months after an
obstetric procedure to perform a cosmetic
abdominal procedure [9]. Fortunately, local problems that may arise during adjacent combined
procedures, such as wound contamination and
excess tension, are fairly easy to avoid as they are
straightforward to conceptualize. According to
Rubin’s group, in the massive weight loss population, performing multiple procedures in the
same operative setting increases the total number
of complications for a given number of trips to
the operating room. However, the absolute num-
ber of complications is the same as would be
expected if all procedures had been performed
individually [10].
We and others have discussed the concept of
combining abdominoplasty with liposuction for
ap suctioning or contouring of adjacent areas.
Strategies for perioperative decision-making and
approaches to intraoperative technical details to
ensure synergistic aesthetic benets from this
combination have been addressed and are continuing to evolve [5, 11–14]. Dillerud showed
that neither obesity nor suction lipectomy
increased ap necrosis in abdominoplasty [15],
and Ousterhout demonstrated the feasibility of
combining abdominoplasty and high-volume
liposuction in the obese patient [16]. It should be
noted, however, that obesity is widely thought to
be an independent risk factor for systemic morbidity and local wound healing complications
[17–19].
9.3.2 Combining Abdominoplasty
withAnatomically Distant
Procedures, Including Breast
Surgery
Combining abdominoplasty with proximate procedures such as liposuction, umbilical herniorrhaphy [20], and ventral hernia repair is now a
regularly accepted practice. Present concern
focuses on whether combining abdominoplasty
with anatomically distant procedures increases
risk, especially DVT/PE. Abdominoplasty and
breast surgery are anatomically distinct. The procedure performed on one site does not necessarily impact the other (i.e., we have not seen any
impact on inframammary fold location from tension on the abdominoplasty ap). Therefore, the
issues in combined abdominoplasty and breast
surgery—and for most examples of combined
aesthetic procedures involving separate anatomical regions—often focus on systemic instead of
local complications and the logistics of lengthy
combined procedures rather than on the individual techniques themselves.
Although it does not seem to be clinically signicant, the increased systemic risk, such as of
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A. Matarasso and D. M. Smith
cardiac, pulmonary, blood loss, and anesthesiarelated complications, is important to consider.
The need for blood transfusions, for example,
increases most in relation to larger volumes of
liposuction, but is usually not related to the combination of abdominal and breast surgery. The
literature supports these ndings [2, 21–24].
Stevens reports no increase in complications
when comparing abdominoplasty combined with
breast surgery or facial rejuvenation to isolated
abdominoplasty [2, 22]. He reports a revision rate
of 13% for these combined procedures, noting
that while a 13% revision rate is not insignicant,
all of these patients would have required a second
operation should their procedures have been
staged from the outset [23].
While the breasts and the abdomen are anatomically distinct with regard to operative intervention, they are physiologically linked. Possible
respiratory compromise after combined breast
surgery and abdominoplasty with concomitant
compressive surgi-bra and abdominal binder use
was reported by De Castro [25]. No difference in
complication rates between combined and isolated abdominoplasty was ultimately reported by
this author. In our experience, performing combined aesthetic procedures on anatomically distinct areas such as the breasts and abdomen
generally does not lead to an increase in systemic
morbidity when instituting proper safety
measures.
9.3.3 VTE Risk inCombined
Abdominoplasty andBreast
Surgery
VTE is the universally feared complication—the
“elephant in the room”—that must be addressed
during any discussion of combined, lengthy procedures in plastic surgery [26–29]. VTEs can be
life-threatening, devastating events that occur as
frequently as in 1.1% of abdominoplasties [5, 6,
30, 31]. DVTs are, in fact, evolving from random
events to ostensibly preventable complications
(“never events”) for which government and
insurance companies are making surgeons
directly accountable in the modern healthcare
environment.
Abdominoplasty is not a benign procedure in
this regard. VTE was found to occur most frequently with abdominoplasty and abdominoplasty combined with another procedure (there
was no signicant difference in frequency
between the two) in a survey of more than 1100
plastic surgeons on VTE occurrence and prevention in their practices [32]. The American Society
of Plastic Surgeons (ASPS) VTE Task Force considers VTE risk in abdominoplasty high enough
to warrant specic consideration [33].
Abdominoplasty was found to be the procedure
most frequently associated with death and with
death secondary to PE in the American
Association for Accreditation of Ambulatory
Surgery Facilities (AAAASF) data on 411,670
cases [34]. This study included 12 abdominoplasties resulting in death; 9 were performed in combination with another procedure. As this study
was conducted as a retrospective multi-surgeon
database review and no information about the
patients’ genetic predisposition to VTE was
included, it is difcult to comment on the signicance of this nding.
It is difcult to interpret data comparing the
risk of VTE, PE, and death in abdominoplasty
combined with other procedures to that in
abdominoplasty alone. Broughton, for example,
reported an increased VTE rate in a group of
patients undergoing combined abdominoplasty
and liposuction; however, these ndings do not
comment on the relative risk of VTE in abdominoplasty versus that in abdominoplasty plus
liposuction as the only groups compared to
abdominoplasty and liposuction in this study are
face-lift and liposuction in isolation [35].
Alternatively, Simon reported ndings consistent with those of the authors. That report demonstrates that VTE risk is not increased by
combining abdominoplasty with other procedures including mastopexy, breast reduction,
colostomy revisions, hysterectomy, and ventral
hernia repairs. It also stresses the importance of
careful patient selection and vigilant VTE prophylaxis [21].
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The data surrounding this issue is quite complex, as highlighted by recent AAAASF data
implying, counterintuitively, that combining
abdominoplasty with three procedures is safer
than combining abdominoplasty with two procedures [36]. Intuition, in contrast, would have us
believe that additional procedures would increase
risk depending on multiple factors (e.g., length,
nature, and sequence of procedures). This dataset
does not dene or address these variables. This
series does demonstrate, however, that combining abdominoplasty with one additional procedure has comparable VTE risk to performing
abdominoplasty alone [36].
In addition to complexities within a given
dataset, differences between datasets with their
inherent biases (e.g., which cases they capture
and what data they collect) should also be considered. For example, CosmetAssure data will not
include metrics on complications dealt with in an
outpatient ofce because its coverage does not
extend to these situations. Alternatively, TOPS™
(Tracking Operations and Outcomes for Plastic
Surgery) surveys and data are limited by the fact
that they are dependent on self-reporting. AAASF
data is skewed as it includes only data from
accredited outpatient surgical centers.
Abdominoplasty is particularly prone to VTE
for several reasons. Third spacing, increased
intra-abdominal pressure [37, 38], tight external
compression garments, and exed positioning
that decreases venous return from the lower
extremities may exacerbate venous stasis [24].
Other predisposing VTE risk factors include
decreased peripheral vascular resistance associated with general anesthesia, vessel injury
incurred secondary to intense dissection of
supercial veins, and decreased postoperative
mobility [39].
Many recommendation schemes exist for VTE
risk reduction in surgical patients. The Seventh
American College of Chest Physicians Consensus
Conference on Antithrombotic Therapy stratied
patients into four VTE risk categories (low, moderate, high, and highest) dened by age, type of
surgery, and additional risk factors [40]. While an
important theoretical step in the direction of
appropriate risk-based VTE prophylaxis in plas-
tic surgery and its schema is often considered by
plastic surgeons, there are limitations to applying
this system to our patients. It is not clear, for
example, if plastic surgery procedures qualify as
“minor,” “non-major,” or “major,” and the system
is therefore not necessarily directly generalizable
to our eld [39].
The Davison-Caprini model is a widely
accepted framework for VTE risk stratication
and prophylaxis in plastic surgery despite its
development for inpatients undergoing nonplastic surgery procedures [41, 42]. Typically, an otherwise uncomplicated abdominoplasty in a
healthy patient is rated at four points (two for
“major surgery” and two for a patient over age
40), immediately classifying the operation as
high risk [42]. Others consider the operation
itself to be worth ve points [43].
Hatef retrospectively reviewed several hundred body-contouring procedures to assess the
validity of the Davison-Caprini framework in an
effort to provide VTE prophylaxis recommendations specic to body-contouring procedures
[39]. This group found that the Davison-Caprini
model effectively straties body-contouring
patients. All patients in the Hatef study experiencing VTE were in the highest risk group as
dened by the Davison-Caprini model [41, 42].
Enoxaparin (Sano-Aventis U.S. LLC,
Bridgewater, NJ) use in the highest risk group
demonstrated a trend towards VTE risk reduction
[39]. In other groups, the VTE rate was too low to
assess the effect. Higher hematoma rates, bleeding requiring transfusion, and increased intraoperative blood loss were also associated with
enoxaparin use [39]. The timing of enoxaparin
administration did not affect VTE rate, intraoperative bleeding levels, or transfusion requirements [39]. Prolonged enoxaparin administration
(3days or longer) did lead to greater transfusion
requirements, but hematoma rate was not
increased [39]. This group ultimately recommended starting enoxaparin, 40mg daily, on the
rst morning after abdominoplasty [39]. Other
guidelines are based on the mode of anesthesia
and operative modality: one report, for example,
suggests mechanical VTE prophylaxis with the
administration of systemic anesthesia, along with
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frequent assisted postoperative walks, and administration of low-molecular-weight heparin if
operative time exceeds 4h [1].
The role of pharmacologic intervention for
VTE prophylaxis is controversial and remains an
active conversation [35, 39, 41, 42, 44–59].
Swanson maintains that there is presently “no
evidence of a benet from anticoagulation in
reducing the rate of VTE in plastic surgery
patients” [60]. He cites Pannucci’s VTEP study
[52] as the only large-scale controlled trial of
VTE chemoprophylaxis in plastic surgery
patients. While the authors of that study conclude that enoxaparin is protective against VTE
in high-risk plastic surgery patients, Swanson
maintains that his review of the data presented in
the Pannucci paper does not offer evidence of
VTE protection with enoxaparin [45, 47, 60].
Instead, Swanson advocates for other forms of
VTE prophylaxis including total intravenous
anesthesia, avoidance of prone positioning, and
avoidance of paralysis [45, 60]. Alternative chemoprophylaxis agents have been investigated as
well. For example, Dini attempted to investigate
the efcacy of the oral VTE prophylactic agent
rivaroxaban. Unfortunately, this study was terminated early due to high hematoma rates in the
treatment group [61]. It is also interesting, for
context, to consider ndings from a New England
Journal of Medicine study funded by Sano
(manufacturer of Lovenox) of over 8000 acutely
ill medical patients showing that Lovenox
administration conferred no benet with regard
to mortality rate [62].
This debate is fraught with conicting data
that has yet to be clearly parsed. Particularly
interesting is an ongoing randomized, doubleblind trial evaluating the role of weight-based
versus xed-dose chemoprophylaxis [63].
Therefore, decisions about the use of chemoprophylaxis should be made by the individual surgeon on a case-by-case basis depending on the
unique characteristics of each situation.
Pannucci et al. put it well when they recommended “using the 2005 Caprini score as a
‘jumping-off’” point for surgeons to consider
and conceptualize VTE risk among the aesthetic
population [44]. A maximally informed decision can then be made for each patient.
9.3.4 The Signicance ofOperative
Procedure Length
Combined aesthetic procedures can be very long
operations. A variety of “moving parts” must be
optimized to successfully complete a single-stage
abdominoplasty and breast procedure. These can
be broadly categorized as patient selection, perioperative preparation, procedural nuance, and
postoperative protocol.
Operative time is the variable that is most
readily quantied across studies investigating the
safety of combining multiple procedures. The
exact signicance of operative duration is not
completely understood: it is not clear if one 4-h
procedure is preferable to two 2-h procedures
from an outcome standpoint. We do know, however, that prolonged exposure to general anesthesia and other potentially deleterious intraoperative
conditions (blood loss, hypothermia, hypotension, exposure to infection, etc.) interfere with
the body’s maintenance of physiologic homeostasis. Of course, every effort must be made to
maintain homeostasis during anesthesia regardless of procedure length. Meticulous hemostasis
should be ensured to minimize the physiologic
effects of continued blood loss over extended
operative procedures [1, 25, 64]. Maintaining
normotension and vigilance in recognizing and
treating postoperative hypertension may reduce
postoperative hematomas [65]. Attention must be
paid to maintaining normothermia: intraoperative
hypothermia has been associated with increased
blood loss, greater transfusion requirements,
more frequent infections, higher cardiac morbidity rates, and more seroma formation [66, 67].
It is logical that minimizing operative time is
paramount in reducing complication rates since
factors contributing to deleterious outcomes
increase in signicance over time as homeostasis
is progressively challenged [22, 68, 69]. De
Castro emphasizes the importance of careful preoperative planning and marking, possible pres-
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ence of assistants to close the breast incisions
when the surgeon turns his or her attention to the
abdomen, and well-trained surgical team (anesthesiologists, nurses, technicians) to streamline
the operative workow and minimize operative
time in combined abdominoplasty/breast cases
[70]. De Castro completed all combined abdominoplasties and breast procedures in his series in
less than 3h with these measures in place.
While it is intuitively clear that shorter operative times are desirable to minimize destabilization of homeostasis, precise guidelines regarding
the upper limits of operative duration are elusive.
Howland noted that after 6h, an increase in cardiovascular, pulmonary, and renal complications
occurred [68]. An association between operative
times exceeding 140min and occurrence of pulmonary embolism in a series of liposuction procedures was reported by Gravante [71].
It is difcult, however, to document causal
relationships between the length of an operation
and the risk of adverse outcomes due to abundant
confounding factors. For example, Gravante
attributed the increased PE rate he recorded after
140min to the volume of fat that was suctioned.
He noted that although these longer cases had
higher rates of PE, there was only an 8.8%
increase in patients with surgery exceeding
140min. Moreover, he reported that only those
with large volumes of liposuction (1500 g or
more) experienced this complication. Similarly,
in a comparison between patients undergoing
head and neck, limb, and breast reconstruction,
Fogarty concluded that it was the nature of the
operation itself, rather than the actual length of
the operation, that accounted for higher complication rates in long procedures [72]. Dr. Kim’s
group completed a 5-year study of over 15,000
plastic surgery procedures and demonstrated an
association between operative duration and surgical, medical, and overall complication rates. This
series demonstrated a sharp increase in complications in procedures that exceeded four-and-a-half
hours in length [73]. Kenkel’s group recently
demonstrated that operative time is an independently signicant predictor of morbidity in plastic surgery, with an increase in complications
after 3h [74]. As indicated by the extent of the
discussion inspired by this topic [75–77], we cannot reach an absolute conclusion about the relationship between operative time and morbidity in
this chapter.
VTE risk is widely believed to be impacted by
operative time [41, 42, 78, 79]. The time added to
an abdominoplasty by concomitantly performing
a breast procedure therefore might increase VTE
risk; this risk, moreover, may vary with the complexity of the breast procedure (i.e., it takes less
time to perform a breast augmentation than an
augmentation/mastopexy). In our experience,
however, in appropriate low-risk patients (ASA
category I), we have not observed increased VTE
occurrence while limiting combined procedure
length to less than 4h and following our protocols for technique and prophylaxis. We ultimately
use 4h and the volume of any planned concomitant liposuction as approximate and arbitrary
benchmarks when designing our operative plans.
The decision to combine multiple procedures
must be made on a case-by-case basis and account
for the nature of the procedures to be combined
as well as for patient-specic factors.
9.4 Impressions
andRecommendations
fromOur Experience
The senior author published his initial experience
with combined abdominoplasty and distant liposuction in 1995 [13]. In that series, 50% of the
patients had concurrent procedures. Distant liposuction was the most common secondary procedure. Breast surgery and dermatolipectomy were
among the other secondary procedures included
in this series. There were no complications
related to undergoing a concurrent procedure. In
a more recent random analysis of the senior
author’s practice, 59 abdominoplasties were performed and evaluated over a 1-year period. All
were performed in combination with other aesthetic procedures including breast reductions,
mastopexies, augmentations, face- lifts, blepharoplasties, and rhinoplasties except for 16 cases.
Again, no systemic complications occurred in
this series.
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It is, therefore, more common than not for us
to combine abdominoplasty with an additional
procedure, and the most frequently associated
procedure is liposuction. We have found it feasible to combine breast surgery with abdominoplasty as long as appropriate logistical
precautions are taken, and operative time is
minimized. This course is consistent with the
majority of the literature on the topic of combining abdominoplasty with additional procedures
(Table 9.1), including recent AAAASF data
[36]. This analysis showed abdominoplasty plus
one additional procedure to be performed
slightly more frequently than abdominoplasty
Table 9.1 Review of studies evaluating risk in combined abdominoplasty procedures
Reference
Cardoso de Castro
and Daher (1978)
[65]
Pitanguy and
Ceravolo (1983) [72]
Voss etal. (1986) [7] Gynecologic procedures Yes
Hester etal. (1989)
[6]
Dillerud (1990) [15] Liposuction No Obesity noted not to predispose to wound
Cardoso de Castro
and Cupello (1990)
[23]
Ousterhout (1990)
[14]
Matarasso (1995)
[12]
Matarasso (2000)
[13]
Stevens etal. (2004)
[2]
Simon etal. (2006)
[19]
Stevens etal. (2006)
[20]
Stokes and Williams
(2007) [22]
Stevens etal. (2009)
[21]
Ali and Essam
(2011) [8]
Procedures performed with
abdominoplasty
Breast reduction No Avoid simultaneous compressive bras and
Multiple No “Quadrangle” model: surgeon, patient,
Assorted intra-abdominal
and aesthetic procedures
Breast reduction No
Liposuction No Obesity noted not to predispose to wound
Liposuction No
Liposuction No
Breast surgery and facial
surgery
Breast surgery, assorted
intra-abdominal
procedures
Breast surgery No
Breast surgery No
Breast surgery No
Cesarean delivery Ye s
alone (187,847 versus 176,092 cases, respectively), but abdominoplasty plus one, two, or
three procedures is performed over 1.5 times
more frequently than abdominoplasty alone
(286,742 versus 176,092 cases, respectively).
Critical elements in avoiding pitfalls with combined aesthetic procedures include careful
patient selection, efcient and meticulous operative planning and technique, a carefully
designed operative sequence including necessary changes in patient position, diligent uid
management, and a well-thought-out postoperative care plan including early ambulation and
blood pressure management. Following are our
Increased
complications? Additional comments
abdominal binders
anesthesiologist, and surgical team must
be optimized
No
healing problems
healing problems
No
No Obesity associated with increased
complications
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recommendations for the pre-, intra-, and postoperative periods to facilitate the practical and
safe execution of combined abdominoplasty and
breast surgery.
We do not nd that combining aesthetic procedures necessitates any specic changes in the
abdominoplasty markings, incision design, or
postoperative plan of care. Moreover, the breast
procedure (augmentation, reduction, mastopexy,
or augmentation/mastopexy) that is indicated is
not altered by the combined abdominoplasty.
9.4.1 Preoperative Practices
Several “red ag” patient characteristics emerged
from our experience that apply to combining
abdominoplasty with any procedure. Pulmonary
conditions, smoking, exposure to secondhand
smoke, clotting disorders, history of or increased
risk for VTE, cardiac insufciency, peripheral
vascular disease, hypertension, obesity, bleeding
diathesis, and diseases affecting microcirculation
(diabetes, lupus, chronic fatigue syndrome)
should warrant special consideration prior to
undertaking combined abdominoplasty and
breast surgery. If the patient’s history is concerning for VTE (Rubin’s group offers an excellent
historical battery, Table 9.2) [80], screening
should be performed for hereditary thrombophilias such as protein S deciency, factor V Leiden
mutation, protein C deciency, or prothrombin
20210 A mutation. Fifteen percent of the Western
population has some form of hereditary thrombophilia, and these conditions can dramatically
increase the risk of VTE.Those homozygous for
factor V Leiden mutations, for instance, have a
relative risk for VTE of 79. This value increases
to 100 with oral contraceptive use [80].
History of previous infection, as noted by
Beran, is another potential warning sign for
adverse outcomes [1]. We routinely utilize nostril
mupirocin ointment (GlaxoSmithKline, Research
Triangle Park, NC) in the perioperative period, as
well as oral and intravenous antibiotics and antimicrobial body scrubs. At the time of surgery,
alcohol-based prep solutions are used.
Table 9.2 Risk factors to consider in routine screening
for thrombophilia. Reproduced with permission from
Friedman etal. [80]
Personal history of VTE (including during pregnancy
or while taking oral contraceptives). Unusual site of
thrombosis (mesenteric, splenic, portal, hepatic,
cerebral) also increases suspicion.
Personal history of idiopathic, migratory, or recurrent
SVT in the absence of varicose veins.
Personal or family history of skin necrosis when
receiving warfarin. Warfarin decreases the level of
natural anticoagulants, rendering the patient
temporarily hypercoagulable. Development of skin
necrosis is suggestive of preexisting protein C or S
deciency.
Personal history of adverse pregnancy outcomes,
including consecutive spontaneous abortions later than
10 weeks of gestation, three nonconsecutive
spontaneous abortions, severe unexplained intrauterine
growth restriction, intrauterine fetal death, placental
abruption, or severe preeclampsia.
First-degree relative who had a VTE, especially at a
young age.
First-degree relative with known hereditary
coagulopathy.
First-degree relative of a neonate with purpura
fulminans without sepsis. This suggests a homozygous
state of protein C and S deciencies.
VTE Venous thromboembolism, SVT supercial venous
thrombosis
An important concern of combining breast
surgery and abdominoplasty is an increased risk
of systemic morbidity. VTE is extremely dangerous and occurs at a signicant rate. While the
data is still open to interpretation with regard to
VTE prophylaxis, the operating surgeon should
be well versed with the available literature so as
to be able to make patient-specic decisions
using metrics such as the Davison-Caprini model
or equivalent systems prior to any surgery [41,
42, 48, 49]. Our patients discontinue the use of all
female hormones (including drug-eluting
patches, intravaginal devices [81], and intrauterine contraceptive devices) in the preoperative
period. Nicotine usage, from any source [82], is
also stopped. We offer our patients prothrombogenic blood test screening and postoperative
venous Doppler testing. Capella has found evidence of VTE on ultrasound the morning after
circumferential body lifts in up to 2% of cases
[83]. Additionally, we liberally hydrate our
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patients and use compressive stockings and
sequential pneumatic compression devices prior
to the induction of anesthesia.
To be a medically appropriate candidate for a
combined procedure, medical “clearance” for
each individual procedure must be obtained.
Aesthetic surgery patients (especially those
undergoing a combined procedure) should be
healthy, low-risk (e.g., ASA I) patients.
Precautions must also be taken to maximize the
safety of each individual procedure. For example,
if indicated prior to breast surgery, a mammogram must be obtained. Similarly, if clinical concern exists prior to implant cases, a screen for
autoimmune issues is obtained. After all, the
entire case may be compromised if there is a
problem with one portion of a combined procedure. Preoperative planning for the massive
weight loss patient demands special vigilance.
The importance of patient selection, management
of expectations, maintenance of intraoperative
normothermia, and VTE prophylaxis in this population is highlighted by Rubin’s group [84].
in the supine position. We continue injecting in
the prone position when indicated and then perform any prone procedures (e.g., back and ank
liposuction) so that the patient does not have to
be ipped to the prone position after other procedures. We next perform any facial and breast procedures. This allows for extended monitoring for
any signs of hematoma. Consequently, the
abdominoplasty is done last as the “Miami Beach
Chair Position” places the patient in extreme
exion that makes other procedures awkward.
While as mentioned earlier there is no “absolute cutoff” for safe operative time, we aim to
limit total operative time in combined procedures
to approximately 4h. According to the DavisonCaprini model, VTE risk increases after only
45min [41, 42]. We have found that in appropriately selected patients, this framework provides a
reasonable amount of time in which to complete
combination abdominoplasty and breast surgery
or other procedures.
9.4.3 Postoperative Management
9.4.2 Intraoperative Considerations
The foundation of a complex combined procedure is an experienced, coordinated operative
team. This includes perioperative personnel,
nurses, scrub techs, assistants, and anesthesiologists. A 1903 Wall Street Journal editorial
expresses the long-recognized importance of a
cohesive, skilled group dedicated to the successful achievement of a common goal quite effectively: “A ‘scrub’ team which has thoroughly
mastered the theory of co-operation will at football or baseball frequently beat a team of men
who are far better players, individually, but do
not understand how to work together” [85]. A
team that has “mastered the theory of co-operation” may not, unfortunately, be the default in an
operating room.
The surgeon must design a precise operative
plan and convey that plan clearly to the surgical
team. We regularly work with an anesthesiologist
familiar with the logistics of combined cases. We
inject superwet solution sequentially, beginning
A “tectonic shift” has occurred in inpatient hospital admissions over the past decade. While in
the past one-third of our patients were admitted
for an overnight stay, we now perform all cases as
outpatient procedures. The patients are then
observed overnight by an experienced nurse.
While the ultimate responsibility for safety rests
with the surgeon, this new model has shared the
burden of detecting postoperative problems with
the patient and caregiver. This change has made
patient and caregiver education even more critical so that they are adequately prepared to recognize problems. We additionally advise checking
key areas several hours after completion of all
procedures and prior to discharge (e.g., assessing
the nipple-areola complex after breast reduction
and the suprapubic region after abdominoplasty
for ischemia). Liberal uid intake is encouraged
if medically appropriate, and a Foley catheter is
used to assist with close tracking of uid status.
An abdominal binder is placed on postoperative
day 3. We occasionally screen for DVT and offer
patients a venous Doppler study postoperatively.
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While it is true that most VTEs are subclinical,
any cardiopulmonary symptoms or leg pain or
swelling warrant a prompt evaluation. After
suture removal, patient follow-up continues
weekly to surveil for seroma or pseudobursa formation and to assess the overall quality of
healing.
9.5 Conclusion
Abdominoplasty is a frequently performed procedure, and requests to combine this operation
with other aesthetic procedures are becoming
more popular. The tendency towards multiple
births, later pregnancies, patients’ desires to
retain their youthful prepregnancy appearance,
and the fact that nonsurgical alternatives do not
provide the same degree of benet have driven
increasing demand for these procedures.
Combined abdominal and breast procedures have
become so popular—these body areas are often
subject to the most recognizable alterations following pregnancy—that the term “mommy
makeover” has been born.
When planning a combined procedure, local
factors, systemic factors, and perioperative issues
should be optimized so as to ensure that the safety
and success of the combined procedure are comparable to those metrics for the individual procedures. The primary concern in combined
procedures is systemic risk, particularly VTE.
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