5 Patient Consultation and Instructions
for Abdominoplasty
Melvin A. Shiffman
5.1 History
The patient must have a sufficient history taken to es- tablish the problem of which the patient complains.
Past history, review of systems, and family history should include all information that may impact on the proposed surgical procedure and its outcome such as prior abdominal surgeries. There must be an attempt to rule out cardiac or pulmonary problems, allergies, bleeding problems, diabetes mellitus, medications be- ing taken such as aspirin, ibuprofen, herbals, antihy- pertensives, anticoagulants, and estrogens. Prior thrombophlebitis or pulmonary embolus is important to elicit. Family history should include questions about bleeding tendencies or thromboembolism.
5.2 Physical
The physical examination should not be cursory. The systems examined should include the heart and lungs as well as the area(s) of the body involved in the pa- tient’s complaint(s). There should be a careful evalua- tion for possible abdominal wall or umbilical hernias.
The medical record should contain all of the appropri- ate information for another physician, who may exam- ine the record, to come to the same conclusions and de- cisions as the operating surgeon. Preoperative and postoperative photos are essential.
5.3
Medical Record
The content of the medical record should be sufficient to show that an informed consent has been given through explanation of the proposed procedure, possi- ble viable alternatives, and the risks and complications.
This does not mean only forms signed by the patient containing the information. The patient must make a knowledgeable decision about the proposed procedure and the physician should take an active part in making
sure this is achieved even if some other healthcare pro- vider has explained the procedure and risks.
The physical must be recorded with enough perti- nent information that would allow another physician to come to the same conclusions as to the diagnosis and the treatment. This includes pertinent negative find- ings.
The record should contain the recommendations and the reasons for the recommended procedure or treatment. The physician’s thinking is an important as- pect of the medical record and will substantiate any proposed or advised therapy.
5.4 Consent
To obtain consent for a surgical procedure all that is necessary is for the patient to sign a consent form stat- ing what the procedure is in lay terms. To obtain a legal- ly valid informed consent requires much more. The pa- tient should not only know the name of the procedure in lay terms but also what is being done in the proce- dure in simple language. The material risks and com- plications must be explained to the patient as well as any viable alternatives of treatment and their material risks and complications. The patient must make a knowledgeable decision concerning the surgery.
Preoperative and postoperative instructions proba- bly should be made available not only in writing but by oral instruction as well. The patient should be made aware as to what to expect after surgery.
5.5
Explanation of Abdominoplasty (Abdominal Lift)
Abdominoplasty (abdominal lift) is a procedure to re- move excess fat and skin from the lower abdomen by lifting the skin and fat off the underlying muscles from the pubis to the ribs, tightening the underlying mus- cles, and tightening the skin by removal of the excess.
Drainage tubes (one on each side) are left in place after surgery for approximately 3 days or until the drainage Chapter 5
from the tubes has significantly decreased (usually no more than 50 ml from each tube over a 24-h period of time). The operation gives a flatter appearance to the abdomen, but leaves a scar around the umbilicus and across the lower abdomen.
5.6
Risks and Complications of Abdominoplasty
Explaining the possible risks and complications to the patient may be done by the office staff or through the use of an audiovisual recording. The physician has to be involved in the discussion in order to establish rap- port with the patient and to be available to answer questions.
If scars are present from prior abdominal surgical pro- cedures, those in the lower abdominal wall will usually be completely resected with the abdominoplasty. If there are upper abdominal scars, the risk of necrosis of the flap is increased and variations on the usual abdominoplasty in- cision may be necessary. If the skin cannot be totally re- sected from above the umbilicus down to the lower ab- dominal incision, there may be a vertical scar from the umbilicus to the transverse lower abdominal scar.
A list of complications with the patient’s initialing each paragraph, by itself, is not adequate in and of it- self. Someone must discuss these with the patient to make sure that each risk is understood.
1. Bleeding, hematoma, bruising
2. Seroma (fluid collection), chronic pseudocyst 3. Infection, sepsis
4. Sensory loss
5. Skin necrosis with delayed healing (weeks to months)
6. Dehiscence (wide opening of wound) with prolonged period of healing (weeks to months) 7. Scarring: wide, hypertrophic, or keloid 8. Asymmetry
9. Persistent edema (swelling)
10. Umbilicus off center or loss of umbilicus 11. Dog ears
12. Need for further surgery
13. Thromboembolic disorder, fat emboli 14. Anesthesia risks, i.e., drug reactions, cardiac
arrhythmias, pulmonary problems
5.7
Alternatives to Abdominoplasty
5.7.1 Liposuction
Liposuction alone or in combination (before, during, or after) with abdominoplasty should be discussed if any of these appear to be a viable alternative. The risks
and expected results must be explained as well as the reasons for preferring abdominoplasty alone.
5.7.2
Limited Abdominoplasty
If there is loose skin mainly in the lower abdomen but not enough to remove skin from the pubis to the umbi- licus, alternatives include a limited resection in the lower abdomen without moving the umbilicus or a more aggressive resection leaving a vertical midline lower abdominal scar (Fig. 5.1). The limitations as well as the advantages of each procedure should be dis- cussed if there appear to be viable alternatives.
Fig. 5.1. More extensive minimized abdominoplasty without enough skin to resect in the lower abdomen to allow a low transverse scar. This results in an acceptable midline and transverse scar if the patient is forewarned prior to surgery
5.8
Preoperative Instructions
A careful history must be taken to include at least prior abdominal surgical procedures, present medication be- ing used, allergies, intake of steroids within the previ- ous 12 months, blood dyscrasia or bruising problems (including family members), smoking, drug or alcohol abuse, or any other problem that might interfere with normal healing or increase anesthesia risk (heart or lung disease).
No aspirin or product containing aspirin is to be tak- en within 2 weeks prior to and following surgery. This includes prescription medications or over-the-counter products. Vitamins and herbals should be avoided for 2 weeks prior to and 2 weeks after surgery while estro- gens (birth control pills or hormone replacement ther- apy) should be stopped for at least 3 weeks preopera- tively and 2 weeks postoperatively. Hormones may be a problem to avoid in certain patients but the increased 68 5 Patient Consultation and Instructions for Abdominoplasty
risk of thromboembolic disease must be explained. The surgeon may wish to avoid operating at a time when the menstrual period is expected, especially the first 5 days of menstrual bleeding, although I personally have nev- er seen a bleeding problem in an abdominoplasty done during menses.
Many physicians request skin cleansing by shower- ing with Hibiclens or Phisohex for 3 days prior to sur- gery and in the morning of the day of surgery.
5.9
Postoperative Instructions
Drainage tubes are used following abdominoplasty for approximately 3 days or when the amount of daily drainage has been reduced sufficiently. The patient and/or the family must be made completely familiar with the methods of emptying and reestablishing vacu- um in the reservoir. Pain will tend to decrease substan- tially after the drains are removed.
The patient or caretaker should be instructed to call the doctor if there is bleeding through the dressings, drainage of pus, increasing pain, or other unusual symptoms (shortness of breath, chest pain, mental con- fusion, etc.)
Prescriptions for pain medication and an antibiotic are given to the patient, making sure there is no allergy to either drug.
Usually, the dressings are not changed for the first 3 days (until such time as the drains are ready to be re- moved). The patient should be instructed to call the surgeon if there appears to be excessive bleeding into the dressings, increasing pain, drainage of pus, or an unusual foul smell from the wound or dressing.
The patient should be instructed in diet and limita- tions of activities. The author usually limits the length of time of sitting for 3 weeks postoperatively.
5.10 Conclusions
A properly instructed patient is essential to obtain an informed consent for a surgical procedure. Not only must the contemplated surgical procedure with its ma- terial risks and complications be explained, but also any viable alternatives and their material risks. The pa- tient must be informed about preoperative as well as postoperative care. Adequate time should be spent with the patient to make sure that the patient understands all that is said and has the opportunity to have all ques- tions answered. These discussions must be adequately entered into the medical record since the record is the physician’s best defense (see Chapter 26).
5.10 Conclusions 69
