A Primer on Abdominoplasty Safety

Abstract

Background: Abdominoplasty continues to be a frequently performed plastic surgery procedure. Futhermore, an increase in both surgical and medical weight loss is contributing to the procedure's increasing popularity. Technical refinements have improved surgical outcomes and safety. Despite this, it remains a procedure with one of the highest morbidity and mortality risks in aesthetic plastic surgery. Methods: A review of abdominoplasty complications and best practices was performed in order to provide a succinct review of the most prevalent safety issues in abdominoplasty surgery. Proposal: In order to mitigate the risk of complications, risk stratification, patient selection, and using evidence-based techniques are essential. In the present study, the authors provide recommendations for approaching the most common safety considerations of this procedure. Conclusion: Appropriate patient selection, surgical technique and proper protocols, ensures surgeons control the modifiable risk factors that increase complications. Implementing nonpharmacologic and pharmacologic interventions reduce the risk of venous thromboembolism. Using evidence-based techniques tailored to the specific patient's anatomy ensures the vascular territories of the abdominoplasty flap are respected and perfusion for wound healing is optimized.

Introduction

Abdominoplasty is one of the most common procedures in plastic surgery worldwide. In 2022, 161 948 abdominoplasties were performed in the United States alone, a 37% increase from pre-pandemic times, and a 50% increase among members of Generation X. ¹ The steady increase in abdominoplasty rates can be attributed to multiple factors, including increased rate of surgical weight loss, a growing popularity for GLP-1 medications leading to non-surgical weight loss, more media attention destigmatizing plastic surgery in general, and greater patient acceptance. Abdominoplasties are being performed more commonly in an office-based ambulatory setting and in combination with other cosmetic procedures—particularly liposuction.^2,3

Abdominoplasty is associated with a higher complication rate than other procedures in plastic surgery ⁴ and carries one of the highest mortality rates in aesthetic plastic surgery. Mortality rates have been reported to be 1:2415, ⁵ 1:3281, ⁶ and most recently, 1:13 000. ⁷ CosmetAssure data demonstrates an overall 4% complication rate for abdominoplasty and that patients who have a BMI greater or equal to 30, are above 55 years old, and who are of male sex have more major complications than others. ⁸ Other authors, however, have reported a much higher complication rate, ranging from 21% ² to 53%.^4,9 The most recent and long-term review of abdominoplasties by Stein et al reviewed abdominoplasty data exclusively by board certified plastic surgeons in the United States and found that complications have decreased over time. This 16-year review split into 2 chronological cohorts showed that the early cohort had a complication rate of 22%, compared to the more recent cohort of 19%. ²

A detailed consultation is critical to identify the modifiable risk factors that increase complications, as well as potential contraindications to surgery. Most surgeons consider significant cardiopulmonary disease, smoking, imminent pregnancy, or uncontrolled psychopathology (ie, body dysmorphia and borderline personality disorder) to be contraindications for abdominoplasty. Modifiable risk factors such as body mass index, hemoglobin a1c, nutritional state, and MRSA status can all be optimized before proceeding with surgery. During the consutlation the surgeon uses the information gathered to make one of three choices. First, whether to take the off-ramp (avoid surgery altogether due to unacceptable risk level), second, to enter an optimization period where modifiable risk factors are addressed to mitigate risk of complication (acceptable risk level), or third, proceed with surgery in an appropriately selected patient (low risk level). A critial appreciation for abdominoplasty complications, how to mitigate their risk, and how to manage them once they occur is necessary to optimize outcomes and safety profile of this procedure. Herein, the authors provide and introductory review to key safety issues of the abdominoplasty procedure.

Seroma

Depending on the source reporting, seromas are often the most common complication reported after abdominoplasty. Reported rates range from 5% to 25%.^10–13 The clinical consequence of seromas vary greatly. They range from being minor (even clinically undetectable) and absorbing spontaneously, to severe, persistent collections that require intervention due to pseudobursa formation. The most common way to mitigate seroma formation is to use postoperative drains. This straightforward method has survived the test of time, and while certain techniques have come and gone out of favor, drains remain the most common method utilized by board certified plastic surgeons in the United States. ² Other strategies include preservation of the Scarpa fascia, ¹⁴ avoiding flap dissection with cautery, ¹⁵ using tissue sealants/glue,^16–18 and the use of progressive tension sutures.^19,20 Despite evidence for and against such interventions, ultimately, a surgeon's preference and surgical technique will dictate the chosen intervention. For instance, a meta-analysis demonstrated that placement of progressive tension sutures reduced the incidence of seroma. Despite this, a 2024 study of board-certified plastic surgeons demonstrated that 89% of surgeons still use drains. ² Some authors specifically argue against drainless techniques due to the increase in operative time, longer recovery, and inability to entirely prevent seromas with progressive tension sutures. ⁹

Author Recommendations: When raising the abdominoplasty flap we prefer to cut up on the fat as apposed to the junction of the fascia and subscarpal fat. This serves to both leave a thin layer of fat on the fascia and decrease thermal injury to the fascia, both of which are thought to increase seroma rates. We use 2 19-French drains placed at a remote site, lateral and inferior to the incision line. While placement within the incision line or centrally within the pubic hair has been employed by some surgeons, we do not do that. Placing drains within the incision sometimes leads to prolonged healing of the abdominoplasty scar at that site and inferior long-term scarring in that area compared to the incisional scar. With respect to central drain placement, evolving fashion over the years has led to a much smaller percentage of patients with pubic hair so the notion that the central scar will be hidden in the pubic hair line is no longer applicable.

Hematoma

Hematomas occur in approximately 2% of abdominoplasties.^2,22 The clinical significance of bleeding, however, cannot be understated. The large potential space under the abdominoplasty flap and the compliance of both the abdominoplasty flap and underlying fascial layer facilitates a large potential space for blood to accumulate. This can eventually lead to delayed diagnosis, hemodynamic instability, and the need for transfusions. ²⁵ The management of clinically significant bleeding requires re-exploration in the operating room, and opening of the entire surgical field. Unlike other surgeries where beside management of hematomas can be performed, local treatments of abdominoplasty hematomas are typically not recommended. Copious irrigation, meticulous hemostasis, and new drains placement is required to expedite healing, decompress tension on the abdominal incision, and remove a potential nidus for future infection. Risk factors for hematoma include hypertension, high BMI, ²⁴ the use of blood thinners, prior liposuction, and products that impeded coagulation.

Author Recommendations: We only perform abdominoplasties on patients with a hemoglobin and hematocrit within the normal range. If there is suspicion of hematoma we recommend admission with prompt exploration in the operating room. Admission for conservative monitoring of hematoma progression is often not recommended. Whether a bleeding vessel requires ligation or not- cleaning out a clot expedites healing and reduces the incidence of future complication, such as skin necrosis, infection and delayed wound healing.

Infection

Surgical site infections remain the second most common complication after abdominoplasty surgery. The CosmetAssure database reports an infection rate of 1.63% based on insured patients who returned for surgery within 30 days of surgery. Others report a range from 1% to 4%.^21,22 A detailed medical history and laboratory investigation is necessary to screen for infection risk factors. Obesity, elevated hemoglobin a1c, malnutrition, smoking history, and an immunosuppressed state all increase infection rate post abdominoplasty.^23,24

Infections post abdominoplasty typically present as localized erythema, swelling or spontaneous drainage. Over time a collection may develop followed by discharge of purulent fluid. Systemically, a patient may present with pain, fever, chills. Laboratory investigations may demonstrate elevated inflammatory markers. Diagnosis is made clinically, and a CT scan is seldom necessary to make a diagnosis. For localized infections, oral antimicrobial coverage, removal of drains and local drainage of collections are suggested. Wounds should be cultured (aerobic, anaerobic, and mycobacterium) and antimicrobial coverage tailored appropriately. For more significant infections or systemic symptoms, patients should be admitted to hospital, started on intravenous antibiotics, and depending on the wound presentation, explored in the operating room.

Author Recommendation: We follow abdominoplasty patients at least once a week for the first month after surgery to monitor for early signs of infection and seroma, and treat them promptly if they arise. Frank abscess or systemic infection can be prevented by managing early erythema appropriately. Prophylactic antibiotics are unnecessary and contributes to antimicrobial resistance. We encourage targeted antimicrobial therapy when cultures are available and early treatment of a suspected infection with a cephalosporin covering Strep and Staph Aureus, the primary culprit in most abdominoplasty infections.

Skin Necrosis

From a surgical standpoint, elevation of an abdominoplasty flap is done with an understanding of Hugers vascular perfusion territories.^26,27 Supraumbilical elevation of the abdominoplasty flap is limited to a narrow tunnel up to the xiphoid, referred to as Huger zone 1. ²⁸ Due to the continuous undermining of this area it is more prone to vascular complications so if liposuction is performed here, it should remain limited. The most at-risk area of tissue is between the umbilicus and the incision (the so called “terrible abdominoplasty triangle”). This area not only has the greatest tension, but it also is the furthest area from the axial blood flow of the abdominoplasty flap.

The popularity of energy-based devices further threatens flap vascularity and mobility due to scarring. Surgeons should take this into account when counseling their patients about the chances of having a vertical scar from their native umbilicus due to the potential inability to get the old umbilical site removed with the portion of the flap excised. Paradoxical adipose hyperplasia (PAH) secondary to cryolypolysis of the abdomen is also thought to be on the rise, and it is plausible that subcutaneous scarring caused by PAH can similarly alter flap vascularity and mobility. ²⁹

Author Recommendations: We do not perform abdominoplasties on smokers. All patients must stop smoking (cigarettes, vaping and marijuana) or cocaine use at least a month before an abdominoplasty. If threatened or frank necrosis occurs, external and internal offloading of the flap is encouraged to maximize perfusion. Binders are removed, collections are drained, and wound tension reversed by body position or even suture removal to leave the wound open. Adjunct therapies such as hyperbaric oxygen, ³⁰ nitropaste and dimethylsulfoxide can also be used. Traditional dressings with iodine gauze can be used to dry out the wound and promote eschar formation while providing some microbial resistance. At times, local wound debridement and VAC placement can help contract the wound, either as a primary technique of secondary wound closure or as a bridge to surgical revision.

Wound Healing Complications

Wound complications are a common minor complication following abdominoplasty and is particularly prevalent in obese and massive weight loss patients (up to 50%). ³¹ Smokers and diabetics similarly are at high risk. As with any complication, preoperative patient optimization is critical to mitigate the chance of wound complication. From a technical standpoint, the closure type and suture type is variable, but most advise a closure of Scarpas layer, in addition to at least one more layer of closure including the dermis. Incisional vacuum dressings have also showed promise in decreasing JP fluid output and facilitating early drain removal. ³² Whether this results in less wound healing complications is still unknown.

Author Recommendations: The authors recommend approaching pannus resection on a case-by-case basis and consider age, skin quality and whether the abdomen was treated concomitantly or in the past with either surgery or energy-based devices. A more aggressive skin resection may lead to improved final contour but increases tension and decreases vascularity on the abdominoplasty flap. The authors therefore approach closure of 30-year-old patient with virgin abdomen differently than, say, a 60-year-old patient with inferior skin quality who has a history of past liposuction and cryolipolysis.

Venous Thromboembolism

Venous thromboembolism (VTE) remains the most serious and common major complication in abdominoplasty.

Incidence rates have been reported between 0.35% ³³ and 1.21%. ⁹ In circumferential abdominoplasty reported rates are as high as 9.4%.^33,34 Plastic surgery inpatients have a VTE risk ten times greater than aesthetic patients (0.09% vs 1.2%).^35,36 VTE risk is variable and dependent on patient and procedure-specific risks. When liposuction is combined with abdominoplasty, for instance, the incidence rate is higher, or if the patient is obese or on hormone replacement therapy. ³³ Combined hormonal contraceptives are associated with a 2-3 fold higher risk of VTE compared with females off OCP,^37,38 and the effect and size of this relationship depends both on the progestogen used and the dose of estradiol. ³⁷ Some OCP manufacturers specifically outline that these medications should be stopped at least a month before surgery.^39,40 Smoking is also thought to be a risk factor for VTE.^41–43 In fact, nonsmoker status in patients undergoing aesthetic surgery is protective against symptomatic VTE (OR 0.63). ⁴⁴

Author Recommendations: VTE prophylaxis should be approached from both nonpharmacologic and pharmacologic perspectives. In Pannuci and Stein's 2024 review of nonpharmacologic prophylaxis, they outline the paradigm of risk identification, risk modification, and risk reduction. ⁴⁵ In this model, patients and surgeons work together in the preoperative period to mitigate VTE risk based on the available evidence. Risk elimination is impossible, but this paradigm is helpful in guiding surgeons to take all nonpharmacologic evidence-based measures possible. Intraoperative risk reducing maneuvers include preoperative warming, decreasing intraoperative time, staging procedures, using regional nerve blocks, sequential compression devices, and limiting full muscle paralysis during surgery. ³³ The use of ultrasound to detect VTEs post-operation in high-risk patients is also supported. ⁴⁶ Specific to abdominoplasty, plication, bed flexion, and compression garments all work synergistically to increase intraabdominal pressure, which can lead to venous stasis and potentially increase VTE risk.^47,48 The authors calculate a Caprini score^49,50 for every patient undergoing abdominoplasty. This identifies variation in VTE risk among plastic surgery inpatients. Scores greater than 7 are associated with significantly elevated VTE risk. ⁵⁰ Anticoagulation for patients with scores greater than 7 is recommended, albeit it is a multifaceted decision done on a case-by-case basis.

Liposuction Risks: Lidocaine Toxicity, Fluid Overload, Intraabdominal Perforation

Liposuction has become an integral component of abdominoplasty.^51,52 Indeed, the term, “Lipoabdominoplasty”^53,54 has become synonymous with abdominoplasty due to its omnipresence as an adjunct and its ability to aid in contouring. While enhancing aesthetic outcomes, it may alter the complication rate. In general, it increases the surgical time, inflammation, and recovery time. Tumescent infiltration introduces a risk of both lidocaine toxicity and fluid overload, both of which can be life threatening complications of an abdominoplasty. Abdominal perforation is another possible rare, and potentially underreported, life-threating complication of liposuction and tumescent solution infiltration.

One minor issues that may occur from the incorporation of liposuction in abdominoplasty is contour irregularities of the abdominoplasty flap. Liposuction is typically performed before the abdominoplasty. The umbilicus is a distinct aesthetic unit of the abdomen, and there can be tendency to leave a donut shaped area of fat around the umbilicus. High-definition liposuction has also become much more common, particularly in the male abdominoplasty.^55,56 This involves superficial etching of the dermis to promote subcutaneous scarring and controlled contour deformities to extenuate shadows. If performing this technique in conjunction with an abdominoplasty, surgeons must anticipate the medialization of the abdominoplasty flap during skin closure. Etching the linea semilunaris prior to rectus plication, and flap medialization to prevent dog ear formation can lead to inappropriate medialization of high definitionl liposuction zones, and an unnatural apperance.

Author Recommendations: The amount and location of liposuction is patient specific. A young patient with good skin quality can have unrestricted liposuction of all vascular territories, while an older patient with poor skin quality, or a patient who has a history of cryolipolysis would have more conservative zone III liposuction. Preoperatively, we recommend all surgeons use the patients weight to calculate the safe amount of tumescent the patient can receive, as well as communicate with the anesthesiologist preoperatively how much IV fluid is appropriate for replacement needs and to prevent fluid overload.

Conclusion

Abdominoplasty surgery has evolved over time. Decades of technical refinement have improved surgical outcome and safety profile. Careful patient selection ensures surgeons control the modifiable risk factors that increase complications. Implementing nonpharmacologic and pharmacologic interventions reduce the risk of VTE. Using evidence-based techniques tailored to the specific patient's anatomy ensures the vascular territories of the abdominoplasty flap are respected and perfusion for wound healing is optimized.