Tumescent Abdominoplasty: An Ambulatory Office Procedure

David L. Abramson, M.D. New York, New York, USA

Abstract: Abdominoplasty has traditionally been a procedure that has been performed in a hospital setting, usually with an overnight stay, particularly when full rectus plication has been part of the operative procedure. With the development of of­fice-based operating rooms and improved office anesthesia, the ability to perform more extensive surgery outside the hospital is now possible. Additionally, the cost savings of office-based surgery compared with noncontrolled hospital charges makes it much easier for patients to plan the exact charges that they will encounter. Experience with the tumescent technique for lipo-suction has demonstrated to the plastic surgeon that extensive surgery can be performed with minimal postoperative discom­fort. The tumescent technique has also been used to perform miniabdominoplasty [1]. By using this technique in patients undergoing full abdominoplasty, this procedure can be per­formed in the office with minimal blood loss and almost no need for pain management in the early postoperative period, ind the patients can be discharged home within 3 h of the completion of the procedure.

Key words: Abdominoplasty—Office-based surgery—Tumes­cent technique

All patients undergoing abdominoplasty were having the procedure performed for strictly aesthetic concerns. Patients could have additional cosmetic surgery procedures performed simultaneously. The procedures were per­formed either with monitored anesthesia care or under general anesthesia with endotracheal intubation. The pa­tients were all marked preoperatively while standing, and all patients had excess skin extending from the pubis to just above the umbilicus removed so that no vertical scar would be present.

Once the patient was anaesthetized, prepped, and draped, between 1500 and 2000 ml of tumescent fluid was injected into the abdominal area and flanks. This fluid consisted of 25 ml of 2% lidocaine and 1 mg of epinephrine in 1000 ml of lactated Ringer's. Following completion of the tumescent infusion, liposuction of the flanks and lower flap is performed when necessary. Once the liposuction is finished the incisions are made with a No. 10 blade. The entire skin paddle to be removed is incised and then dissection carried down to the fascia laterally and inferiorly first, then proceeding superomedially toward the umbilicus. The umbilicus and its stalk are dissected free from the abdominal pannus, which is then removed.

The upper flap is then elevated in the midline toward the xiphoid to allow for rectus plication as well as skin closure. Once the abdominal flap is elevated the rectus plication is performed with either No. 1 prolene or No. 1 PDS. Additionally, external oblique plication is performed when necessary. Ten milliliters of 0.5% marcaine with epinephrine is then injected into the fascia just lat­eral to the plication. The bed is then flexed 30° to ease the tension during skin closure. Initial skin closure is performed with three vertical mattress 3-0 nylon sutures. Scarpa's fascia is approximated with 3-0 vicryl and the skin closed with inverted dermal sutures of 3-0 monocryl followed by a running intracuticular 4-0 monocryl. Prior to skin closure, the exit site for the um­bilicus is marked and a 7-mm flat Jackson-Pratt drain is placed under the abdominal flap through a separate in­cision. The umbilicus is then sutured in place with 4-0 chromic suture. Steri-strips are placed on the incision and xeroform on the umbilicus. The wounds are then covered with gauze and an abdominal binder. Any additional pro­cedures such as liposuction are performed prior to the abdominoplasty, and if any facial work is required, it is performed at the completion of the abdominoplasty.

The patient is then extubated on the operating room table and transferred to the recovery area. Postoperative pain management is performed with oral narcotics if necessary. After approximately 1.5 h the patient is taken to the restroom to void, dressed, and placed in an upright recliner for an additional hour prior to discharge. All patients are discharged home with a prescription for Vicoden ES and instructed to take 1-2 tablets every 4-6 hours if necessary.

Results

A total of six patients underwent tumescent abdominoplasty over a 6-month period. No patients required a change in plans and subsequent overnight stay. The pa­tient charts were analyzed with regard to operative time, estimated blood loss, and amount of postoperative pain medication required, as well as the amount of pain medi­cation taken home during the first 24 h (reported by patient).

Six patients, five female and one male, ranging in age from 23 to 52, underwent tumescent abdominoplasty. The male patient had fleur de lis pattern of skin excision (Figs. 1A and B), while the five female patients all had an elliptical pattern (Figs. 2A and B). Three of these patients also had liposuction of additional areas including knees and arms as well as inner and outer thighs. The surgical procedure was performed under local anesthesia with sedation. With the patient under sedation, 1500-2000 ml of warmed tumescent fluid consisting of 25 ml of 2% lidocaine and 1 mg of epinephrine were instilled with the use of a pressurized infusion device. The lipo­suction of other areas was performed first, followed by the abdominoplasty. Liposuction of the lateral portion of the abdominal flap and flanks was done in five of the six patients prior to the surgical dissection. All surgical dis­section is done with the scalpel, and electrocautery used only for homeostasis in the bipolar mode. Once the ab­dominal panniculus is removed the fascia is plicated with two running sutures, one above the umbilicus and one below. Two patients also required plication of the exter­nal oblique. Following plication 10 ml of 0.5% marcaine is injected into the fascia lateral to the plication to aid in postoperative pain relief. The operating table is then flexed and three nylon mattress sutures are placed to approximate the flaps. The wounds are then closed in three layers, vicryl in Scarpa's fascia and a combination of inverted dermal and a running intracuticular monocryl suture in the dermis. Prior to closure a single, flat closed suction drain is placed under the abdominal flap. The total operative time ranges from 80 to 140 min, with an average of 115 min. The operative time of the procedure includes the time necessary to perform the additional procedures. Estimated blood loss for all procedures was less than 50 ml for all of the abdominoplasties. Postoperatively pain management ranged from no postopera­tive pain medication to a maximum of two percosett tablets 1 h following surgery. All patients were able to ambulate home within 2 h of the completion of the pro­cedure. The total dosage of Vicodin ES during the first 24 h at home ranged from 1 to five tablets. The patients complained of moderate discomfort but not severe pain during both the first 24 h and the ensuing few days. The Jackson-Pratt drain was removed between day 3 and day 7, depending on the drainage. The three nylon mattress sutures were removed 14 days after surgery. Two pa­tients developed seromas after the drain was removed which required drainage.

Discussion

The ability to perform cosmetic surgery in the office setting provides a more comfortable environment for the patient, ease of scheduling for the physician, and decreased cost to the patient. If more extensive surgery that would traditionally be performed in the hospital or re­quire an overnight stay can be performed with decreased blood loss and ease of pain control, more procedures can be performed in an office/ambulatory setting. The use of tumescent technique has greatly increased the amount of liposuction that can be performed safely in the ambula­tory setting [2,3]. Additionally, blood loss, bruising, edema, and postoperative pain can all be reduced with tumescent techniques [4,5]. The use of endoscopic tech­niques has also helped to revolutionize how this proce­dure is performed [6-8]. Mottura described using 400 ml of a solution with epinephrine, bipuvicaine, and lido-caine to perform liposuction and abdominoplasties under local anesthesia [9]. Additionally, Worland [10] de­scribed using the tumescent technique alone to perform full abdominoplasty in a letter but did not comment on the location of the procedure or the use of rectus plica­tion.

The use of the tumescent technique combined with intrafascial marcaine has enabled us to perform full abdominoplasties in the office operating room with mini­mal blood loss, no placement of a Foley catheter, and only minimal postoperative pain medication, which can easily be administered exclusively through the oral route. I feel that the technique is safe, can produce excellent results, and will enable the patient to save a significant amount of money compared to performing this procedure in the hospital or an ambulatory surgical center.

References

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