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The Outcome of Abdominoplasty Performedunder Conscious Sedation: Six-YearExperience in 153 Consecutive CasesZol B. Kryger, M.D., Neil A. Fine, M.D., and Thomas A. Mustoe, M.D.Chicago, Ill.

The use of conscious sedation is rapidly gaining accep-tance and popularity in plastic surgery. At the presenttime, many procedures are performed using intravenoussedation and local anesthesia. The purpose of this articlewas to examine the safety and outcome of full abdomi-noplasties performed under conscious sedation at theauthors’ institution. Over a 6-year period from 1997 to2002, 266 abdominoplasties were performed by the twosenior authors. One hundred thirteen of these (42 per-cent) were performed under a general or regional anes-thetic because a concurrent procedure was performedthat precluded the use of conscious sedation (64 hyster-ectomies, 18 hernia repairs, six urogynecologic proce-dures, 10 breast reductions, and one laparoscopic chole-cystectomy) or because of patient and surgeon preference(14 cases). One hundred fifty-three abdominoplasties (58percent) were performed under conscious sedation usingintravenous midazolam and fentanyl along with a localanesthetic. No patients had an unplanned conversion todeep sedation or general anesthesia. Eighty percent ofthese cases were performed with a concurrent procedure(80 liposuctions, 19 breast augmentations, 20 mas-topexies, three capsulotomies, and 13 varied facial aes-thetic procedures). In addition, 12 patients had concur-rent hernia repairs (five ventral and seven umbilical)under conscious sedation. Mean follow-up was 10 months(range, 1 to 56 months). There were no intraoperativecomplications and no major postoperative complications.The minor complication rate was 11.1 percent (10 sero-mas requiring needle aspiration in the office, three su-perficial wound infections, two cases of marginal skinnecrosis, one stitch abscess, and one pseudobursa requir-ing reexcision). Seven revisions were performed for sub-optimal scars (5 percent). The results of this study dem-onstrate that abdominoplasties can be performed underconscious sedation in a safe and cost-effective manner foralmost all patients. This type of procedure is well toler-ated, has a low complication rate, and has high patientsatisfaction. Increasing experience and small modifica-tions in local anesthesia and surgical technique havestrengthened the authors’ conviction that conscious se-dation is the preferred method of anesthesia for most

patients undergoing abdominoplasty. (Plast. Reconstr.Surg. 113: 1807, 2004.)

Conscious sedation is rapidly gaining accep-tance and popularity among plastic surgeons.1For many years, it has been widely used in thefields of oral surgery, ophthalmology, gastroen-terology, pulmonary medicine, and radiology.With the growth of office-based proceduresand surgicenters, there has been a concomi-tant increase in the role of conscious sedation.2A recent task force of the American Society ofPlastic and Reconstructive Surgeons was assem-bled to deal specifically with many of the issuesrelated to conscious sedation.3 Currently, a va-riety of aesthetic procedures are performedusing a local anesthetic combined with someform of intravenous sedation. These proce-dures include breast augmentation, breast re-duction, mastopexy, abdominoplasty, rhytidec-tomy, rhinoplasty, blepharoplasty, andliposuction.4

Conscious sedation is defined as a depressedlevel of consciousness to the point that thepatient is in a state of relaxation but maintainsrespiratory drive and the ability to protect theairway. The patient is also capable of respond-ing to physical and verbal stimulation. This isin contrast to deep sedation, in which the pa-tient is unable to respond to verbal stimuli, willonly respond to painful stimulation with with-drawal, and has potential compromise of air-way protection and respiratory drive. At ourinstitution, we have found conscious sedation

From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine. Received for publication May27, 2003; revised October 9, 2003.

DOI: 10.1097/01.PRS.0000117303.63028.7D

1807

to be safe, to have high patient satisfaction, andto offer a number of advantages including costsavings. We have developed a straightforwardprotocol on the basis of selection of patientswho are in a good overall state of health thatmakes them American Society of Anesthesiol-ogists status I or II, effective local anesthesia,and incremental administration of a benzodi-azepine/narcotic combination approved byour hospital’s conscious sedation committee.

To date, there have been few large series ofpatients evaluating the safety and efficacy ofabdominoplasties performed under conscioussedation.5 A previous study by the present au-thors determined that this procedure was safeand effective in a relatively small series of pa-tients.4 The objective of this article is to reviewour cumulative experience over the past 6years with performing full or complete ab-dominoplasties with the use of conscious seda-tion. With the exception of concurrent proce-dures requiring a general or regionalanesthetic, 92 percent of the abdominoplastiesperformed over this 6-year period were per-formed using conscious sedation, and therewere no unplanned conversions to general an-esthesia intraoperatively. Only 8 percent of el-igible patients chose to receive a general anes-thetic rather than conscious sedation. Theindications for performing abdominoplasty un-der conscious sedation, the adjunct proceduresperformed, the complication rate, and out-comes are evaluated, as are some improve-ments we have made in the technique of localanesthesia and conscious sedation that haveenhanced our enthusiasm for this technique.

PATIENTS AND METHODS

Patient Selection

Between January 1, 1997, and January 1,2003, 266 consecutive abdominoplasties per-formed by the authors were reviewed. Onehundred fifty-three of these patients receivedconscious sedation. The remaining patientsunderwent general or epidural anesthesia andwere excluded (Table I). All of the subjectswho underwent conscious sedation underwenta full history and physical examination beforesurgery and met the criteria of the AmericanSociety of Anesthesiologists status I or II.Therefore, they had no more than a singlehealth problem, and this problem was wellcontrolled.

Anesthetic Technique

After informed consent was obtained andbefore the start of the procedure, patients werepremedicated with intravenous diazepam (Va-lium; Hoffmann La Roche, Inc., Nutley, N.J.)administered in increments of 5 to 10 mg. Thedose administered ranged from 10 to 50 mg,with the goal being adequate preoperative sub-jective relaxation of the patient, with slurredspeech as the desired endpoint. All patientsalso received a single dose of preoperative an-tibiotics and an antiemetic, ondansetron (Zof-ran; Glaxo SmithKline, Philadelphia, Pa.). Inthe operating room, one nurse is responsiblefor continuously monitoring patient status us-ing pulse oximetry, blood pressure, and car-diac monitoring. This is performed by a nursewith appropriate experience and backgroundin continuous patient monitoring but no spe-cialized anesthesia training. It is important toemphasize that this nurse has no other dutiesto perform during the procedure. The pa-tient’s oxygen saturation, blood pressure, heartrate, level of arousal, and respiratory statuswere checked every 5 minutes. Changes in vitalsigns, level of arousal, and the oxygen satura-tion were communicated to the surgeon every5 minutes. In addition, the surgeon couldmake his own assessment of arousal on thebasis of response to verbal stimulation. On thebasis of these parameters, the patient wouldreceive 0.5 to 3 mg of midazolam (Versed;Hoffmann La Roche). In addition, fentanyl wasgiven in increments of 12.5 to 50 �g. However,after local anesthetic was infiltrated, fentanyladministration was infrequently required, ex-cept in preparation for subsequent local anes-thetic administration to a new surgical site. Thetotal dose of fentanyl never exceeded 200 �gover the course of the procedure. Toward the

TABLE IAbdominoplasties Excluded from the Study*

Concurrent Procedure No. of Patients

Hysterectomy 64Hernia repair 18Urogynecologic (e.g., pelvic sling) 6Laparoscopic cholecystectomy 1Reduction mammaplasty 10Patient/surgeon preference for general

or regional anesthesia 14Total 113 (42% of all

abdominoplasties)

* Abdominoplasties were excluded because of concurrent procedures thatrequired a general or regional anesthetic, or based on patient and surgeonpreference.

1808 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2004

end of the case, the amount of sedation wasdecreased to allow the patient to slowly returnto a normal state of arousal and awareness.Early in our series, a few patients received sup-plemental oxygen, but with increasing experi-ence and with lower doses of fentanyl, wefound this to be unnecessary except as a poten-tial backup. Foley catheters or sequential com-pression devices have not been used, theformer because of the short duration of theprocedures (4 hours or less) and the latterbecause of the light level of sedation, allowingfor spontaneous shifting in position and con-traction of the leg muscles during the proce-dure in which the patient alternated betweenlight sleep and consciousness. Most patientsusually had no memory of the procedure andno recollection of pain.4

Surgical Technique

The surgical approach used for abdomino-plasties performed under conscious sedationdoes not differ significantly from those per-formed under general anesthesia, but it hasevolved with increasing experience. After ini-tial administration of intravenous sedation, lo-cal anesthesia is achieved along the incisionsites initially with approximately 20 cc of 0.5%lidocaine (Xylocaine; Astra-Zeneca, Wilming-ton, Del.), with 1:100,000 epinephrine alongthe incision sites. Using a standard liposuctionwetting solution (50 cc of 1% lidocaine andone ampule of 1:1000 epinephrine mixed in 1liter of lactated Ringer’s solution), the lowerabdominal incision is infiltrated to achieve tu-mescence, allowing immediate achievement ofa bloodless field. Next, the initial skin incisionis made down to the abdominal fascia. At thistime, the local anesthetic can be directed be-neath Scarpa’s fascia immediately over the ab-dominal fascia using approximately 2 liters oftumescent solution for the entire abdomen.Fifteen to 20 minutes should elapse betweeninfusing the tumescent solution and beginningthe abdominal dissection to allow for the fulleffect of the local anesthetic. Planned concur-rent procedures, typically suction-assisted li-pectomy to the hips, waist, and mons pubis, areperformed during this waiting period, afterthese areas are infiltrated. The patient isturned into a lateral position for the liposuc-tion, which is quite easy to perform under con-scious sedation, as the patient can assist inturning himself or herself.

To minimize patient discomfort, the entire

dissection is performed using a scalpel, andhemostasis is achieved using bipolar cautery,thus minimizing pain from muscle and nervestimulation. The hydrodissection obtained bytumescent infiltration allows for easy identifi-cation of the perforating nerve and vessels, andthe dissection is essentially bloodless. The ab-dominal flap is elevated at the level of theanterior rectus fascia and undermined up tothe level of the costal margins and xiphoid,with limited lateral dissection, as described byLockwood.6 Occasional injections of 0.5% lido-caine with epinephrine are infiltrated directlyinto nerves as they perforate the rectus fascia ifthere is pain during cauterization of the ac-companying vessels. However, if the tumescentinfiltrate is effective, this is usually not neces-sary. Fascial imbrication is then performed asdescribed elsewhere.6 There is no pain with theimbrication when using this technique of anes-thesia because of the diffusion of the lidocainethrough the fascia.

Supplemental Infiltration of Local Anesthetic beneaththe Fascia Is Not Required

In 12 patients, a ventral or umbilical herniawas repaired, in 10 patients primarily and intwo patients with Prolene mesh (Ethicon, Inc.,Somerville, N.J.). The patients are then placedin a flexed position and the skin flap is pulledcaudally, using variation of a lateral tensiontechnique.6 An important modification hasbeen to remove the dermis, including hair fol-licles, from a portion of the hair-bearing monspubis to avoid the pubic hair being pulledsuperiorly. This allows for an appropriately lowscar, overlap of the skin flaps to avoid scardepression, and minimization of concern overminor wound-healing problems at the “T” ifthe umbilical vertical scar cannot be totallyexcised. Scarpa’s fascia is closed as a separatelayer laterally to avoid scar depression. Scarwidening is prevented by placement of a sub-cuticular polypropylene suture left in place forseveral months. The excess skin is removedand, before skin closure, the umbilicus is repo-sitioned as previously described by one of theauthors.7 At the end of the procedure, twosuction drains are placed just inferior to theabdominoplasty incision.

Postoperative Care

At the conclusion of the procedure, patientsare able to bypass the recovery room and pro-ceed directly to the outpatient day surgery

Vol. 113, No. 6 / ABDOMINOPLASTY UNDER CONSCIOUS SEDATION 1809

area. Until they are ready for discharge, theyare monitored according to routine for con-scious sedation procedures. Some of the pa-tients are admitted overnight for observation,largely on the basis of the patient’s personalpreference and the extent of the accompany-ing procedures performed. Occasionally, over-night admission is required because of postop-erative nausea. Those who choose to go homeon the day of surgery are required to meetcriteria for discharge (e.g., ability to ambulateto a chair and the bathroom, maintain bladdercontrol, and tolerate oral intake withoutemesis).

RESULTS

Over the 6-year period, 266 patients under-went an abdominoplasty by the authors. Onehundred thirteen of these (42 percent) wereperformed under general or epidural anesthe-sia and were excluded from the study. This wasprimarily because of the performance of a con-current procedure that required a general orregional anesthetic, as summarized in Table I.This included hysterectomy (n � 64), herniarepair (n � 18), urogynecologic procedures (n� 6), reduction mammaplasty (n � 10), andlaparoscopic cholecystectomy (n � 1). In addi-tion, 14 abdominoplasties were performed un-der general anesthetic and hence excludedfrom the data because of either patient or sur-geon preference.

One hundred fifty-three abdominoplasties(58 percent) were performed under conscioussedation. Table II summarizes the patient data.All but five of the patients were women (96.7percent). Patient age ranged from 25 to 70years (mean, 43 years). Follow-up ranged from3 to 56 months (mean, 10 months). Most of the

cases involved the performance of additionalaesthetic procedures (Fig. 1). These includedsuction-assisted lipectomy (n � 80), breast aug-mentation (n � 19), mastopexy (n � 20), cap-sulotomy (n � 3), blepharoplasty (n � 5),rhytidectomy (n � 2), fat injection (n � 2),neck lift (n � 1), brow lift (n � 1), dermabra-sion (n � 1), and chin implant (n � 1). Figures2 through 5 show two patients who underwentabdominoplasty with supplemental liposuctionto the hips and flanks.

In addition, 12 patients underwent simulta-neous hernia repair by one of the authors. Fiveof these were ventral hernias and seven wereumbilical hernias. Prolene mesh was used intwo of the ventral hernias to reinforce a largerdefect. All 12 of the patients who underwentsimultaneous hernia repair under conscioussedation tolerated the procedure well withoutany additional difficulty; however, with ventralhernia repair, the patients were all observedovernight in the hospital. In total, 41 of the 153patients (27 percent) were admitted for obser-vation, and only three patients required admis-sion beyond the 23-hour observation period.Of these 41 patients, 38 were planned admis-sions according to patient preference. This wasoften determined by the extent of accompany-ing procedures. For example, patients under-going breast augmentation and mastopexy inaddition to the abdominoplasty typicallyplanned on spending one night in the hospital.In addition, some of the anticipated admis-sions were for cases that were scheduled to endvery late in the day. Only three patients (2percent) from our series had to be admittedfor observation because of postoperative nau-sea and vomiting not relieved by the adminis-tration of Zofran and other antiemetics. It alsomust be noted that patients were only observedfor 2 to 3 hours before the decision was madeto admit them. If these cases were performedin an outpatient facility with longer observa-tion periods, we do not believe any of thesepatients would have required admission. How-ever, the option of admission was reassuring tothe patients.

There were no significant intraoperativecomplications, including electrocardiographicchanges, cardiac arrhythmias, respiratory de-pression requiring narcotic reversal, and acutehypertension or hypotension. Furthermore, nocases were aborted and none were converted togeneral anesthesia or deep sedation. The inter-vention of an anesthesiologist was never re-

TABLE IIData for All Patients Undergoing Abdominoplasties

Performed under Conscious Sedation from January 1,1997, to January 1, 2003*

YearNo. of

Patients

1997 71998 301999 332000 222001 322002 29

Total 153

* Sex: female 148 (96.7%); male, 5 (3.3%); all were American Society ofAnesthesiologists status I or II; patient age ranged from 25 to 70 years (mean43 years); and follow-up ranged from 1 to 56 months (mean, 10 mo).


quired, although one was always immediatelyavailable. There were no major postoperativecomplications. The minor complication ratewas 11.1 percent (Table III). These includedseroma formation requiring one to two aspira-tions (6.5 percent), superficial wound infec-tion (2.0 percent), skin necrosis (1.3 percent),a single case of stitch abscess (0.65 percent),and a single case of reoperation for excision ofa pseudobursa (0.65 percent). Furthermore,the revision rate for a suboptimal scar was 5percent, or seven cases.

In a follow-up survey previously reported bythe authors, the majority of the patients de-scribed having total or near-total amnesia ofthe surgery. Ninety percent considered the ex-perience to be either satisfactory, good, or ex-cellent and stated that they would likely un-dergo conscious sedation again if the choicearose.4 This latter statement has been con-firmed by the fact that among the 67 patientswho underwent a cosmetic procedure at a laterdate, 62 (93 percent) chose to do so underconscious sedation when this was an option.No patient has expressed dissatisfaction withthe technique, and many patients have specif-

ically sought out this technique for its per-ceived safety (versus general anesthesia).

DISCUSSION

During this 6-year period, 153 full abdomi-noplasties under conscious sedation were per-formed, the majority of which involved one ormore concurrent aesthetic procedures, lipo-suction being the most common. Of particularinterest, 12 patients underwent simultaneoushernia repair (five ventral and seven umbili-cal), all of which were well-tolerated. Overall,there were no intraoperative complications,and the minor postoperative complication ratewas 11.1 percent, slightly less than the averagereported rate of 15 percent (range, 6 to 33percent).8–11 The scar revision rate reported inthis review was 5 percent, which is also withinthe lower limits reported in the literature.11,12

When we compared both our minor complica-tion and scar revision rates to that of abdomi-noplasties performed under general or re-gional anesthesia by the same surgeons, wefound no significant difference. The resultssupport the use of local anesthesia combinedwith intravenous sedation as a routine method

FIG. 1. A graphic representation of all abdominoplasties and the concurrentprocedures performed under conscious sedation over a 6-year period. Note thatsome patients underwent more than a single concurrent procedure. �The facialaesthetic category includes five blepharoplasties, two face lifts, two fat injections,one brow lift, one neck lift, one dermabrasion, and one chin implant.


of anesthesia for abdominoplasties using thedescribed protocol.

The most important consideration facing asurgeon contemplating the use of conscioussedation is the issue of patient safety. None ofthe patients in this 6-year review suffered anymorbidity or mortality related to the use ofconscious sedation. The main risk associated

with conscious sedation is respiratory depres-sion. We have never had a case of respiratorydepression that was not resolved by simplestimulation of the patient. Supplemental oxy-gen is rarely necessary, and we find the abilityof the patient to maintain an oxygen saturationover 95 percent without supplemental oxygento be a useful guideline for avoiding overseda-

FIG. 2. Preoperative photographs of a 49-year-old patient who underwent abdominoplasty under conscious sedation withsupplemental liposuction to the hips and flanks.


tion (crossing from conscious to deep seda-tion). The responsible surgeon and monitor-ing nurse or nurse anesthetist should be able toidentify and handle patients who briefly slipinto deep sedation with stimulation or whorequire supplemental oxygen, jaw thrust, maskventilation, or narcotic reversal. In practice,with small incremental doses of midazolam,limited use of narcotics, and effective local an-esthesia, brief stimulation and very rarely jaw

thrust or supplemental oxygen have been allthat have been necessary. With short-actingagents, the occasional periods of deep sedationhave only lasted a few minutes at most. In ourseries, there were no intraoperative complica-tions such as cardiac arrhythmias, respiratorydepression, acute hypertension or hypoten-sion, or the need for narcotic reversal withnaloxone. Nevertheless, as a safety measure,the capability to convert to general anesthesia

FIG. 3. Three-month postoperative photographs of the same patient shown in Figure 2.


or immediate anesthesia assistance is alwaysavailable at our institution.

There are a few other key points to considerwhen using conscious sedation. First, patientselection is important.13 Patients with moder-ate to significant cardiopulmonary disease arenot good candidates. We recommend that pa-tients with comorbid conditions who do notmeet the criteria for American Society of An-

esthesiologists status I or II (see Patients andMethods section) receive monitored anesthe-sia care by an anesthesiologist. Patients withanxiety disorders and extreme fear of the op-erating room may benefit from monitored an-esthesia care or a general anesthetic.

A second safety point is the importance ofsurgeon familiarity with the medications usedfor conscious sedation. There are a variety of

FIG. 4. Preoperative photographs of a 44-year-old patient who underwent abdominoplasty under conscious sedation withsupplemental liposuction to the thighs, hips, and flanks.


intravenous sedation regimens. At our institu-tion, we use a combination of midazolam andfentanyl. The advantage of using this combina-tion is that midazolam has excellent anxiolyticand amnestic effects, whereas fentanyl is anexcellent, short-acting analgesic. A recent mul-ticenter, randomized study demonstrated thatthe combination of fentanyl and midazolam issuperior to midazolam alone in decreasing the

patient’s subjective report of pain andanxiety.14

The main drawback of fentanyl is respiratorydepression; however, it does have a very shorthalf-life. Midazolam, in contrast, has minimaleffects on the respiratory system except insome older patients, in which lower doses mustbe used. We recommend continuous oxygensaturation monitoring and checking the pa-

FIG. 5. Three-month postoperative photographs of the same patient shown in Figure 4.


tient’s respiratory status and other vital signsevery 5 minutes. Medications are only admin-istered in small doses at each 5-minute interval(no more than 50 �g of fentanyl and 2 mg ofmidazolam at a time). This helps achieve asteady-state effect. Both of these medicationshave antagonists that are able to reverse theireffects. Flumazenil (Mazicon; Roche, Nutley,N.J.) and naloxone (Narcan; DuPont Pharma-ceuticals Company, Wilmington, Del.), the an-tagonists of midazolam and fentanyl, respec-tively, should be readily available in theoperating room. The surgeon should be famil-iar with their dosage and administration. Thesemedications are discussed in greater lengthelsewhere.3,4 Finally, at our institution, an an-esthesiologist is always available in case ofemergency. An excellent summary of some rec-ommended guidelines for safe use of conscioussedation can be found in the report of the taskforce of the American Society of Anesthesiolo-gists for guidelines on sedation and analgesiaby nonanesthesiologists.13

It is worthwhile to note that there are otherpopular methods of intravenous sedation, suchas the use of propofol in combination with anopiate and benzodiazepine. The disadvantageof this combination is the higher risk of respi-ratory depression and the lack of a reversingagent for propofol. However, the fact that adeeper level of sedation can be maintainedmakes this technique preferable for selectedpatients who are very anxious. We feel stronglythat this necessitates a higher degree of expe-rience and training in anesthetic technique,including the ability to intubate the patient. Arecently published series of abdominoplastywith sedation using propofol used monitoredanesthesia care by an anesthesiologist or nurseanesthetist.5

There are a number of obvious benefits to

the use of conscious sedation instead of gen-eral anesthesia or deep sedation. First, thecomplications associated directly with the ad-ministration of a general anesthetic areavoided. These are not negligible, and includeadverse cardiopulmonary effects, airway injury,postoperative nausea and vomiting, and posi-tional nerve injuries. Such complications occurin approximately 1 to 2 percent of abdomino-plasties under general anesthesia.11,12 Second,the risk of developing deep vein thrombosis asa result of blood pooling in the lower extrem-ities during general anesthesia is substantiallyreduced. At our institution, there has neverbeen a diagnosed case of deep vein thrombosiswith symptoms to date as a result of a proce-dure performed under conscious sedation. Al-though we cannot rule out an asymptomaticcase of subclinical deep vein thrombosis, wefeel the risk is so much smaller because ofspontaneous shifting of the patient during theprocedure with leg muscle activity. We at-tribute the benefit to avoiding the immobilityand muscle relaxation seen with general anes-thesia and, to a lesser extent, with deepsedation.

Patient satisfaction is a critical issue for plas-tic surgery procedures. Since first performingabdominoplasty under conscious sedation inthe mid 1990s, our annual volume has in-creased and reached a steady state over thepast few years. We feel that this indicates con-tinued patient satisfaction with this procedure.At our institution, 90 percent of patients didnot consider the experience to be unpleasant,and rated it as satisfactory, good, or excellent.4In fact, most had complete or near-total amne-sia of anything related to the actual surgery,primarily because of the excellent amnesticeffects of midazolam. Furthermore, 62 of 67patients (93 percent) who underwent subse-quent cosmetic procedures chose to do so un-der conscious sedation. We believe that formost abdominoplasty patients, conscious seda-tion is very well tolerated and should always beaddressed in the preoperative discussion.

One of the most unpleasant parts of any sur-gical experience for patients is postoperative nau-sea and vomiting. We routinely administer pro-phylaxis with the antiemetic ondansetron(Zofran), on the basis of a randomized, prospec-tive study demonstrating its efficacy in reducingthe incidence of postoperative nausea and vom-iting.15 Controlling postoperative nausea and

TABLE IIIPostoperative Complication Rate for AbdominoplastiesPerformed under Conscious Sedation (n � 153; mean

follow-up, 10 mo)*

Complication No. of Patients %

Seroma requiring aspiration 10 6.5Superficial skin infection 3 2.0Skin necrosis 2 1.3Stich abscess 1 0.65Pseudobursa excision 1 0.65

Overall complication rate 17 11.1

* All of the complications listed refer only to the abdominoplasty and notto other concurrent procedures; seven scar revisions are not included.


vomiting has been shown to help eliminate manyunintended postoperative admissions.16 In ourseries, only three patients (2 percent) requiredan overnight stay in the hospital because of post-operative nausea and vomiting that resolvedwithin 24 hours of the procedure. Unintentionaladmission postoperatively is also related togreater procedure length and a higher total dos-age of intraoperative midazolam/fentanyl.5

Therefore, patients undergoing lengthier com-bined procedures such as abdominoplasty alongwith breast augmentation and mastopexy oftenplanned on spending the night in the hospitalfor observation and were warned about that pos-sibility. The decision to admit the patient wasmade after 2 to 3 hours of observation in cases ofunplanned admission, and it is highly likely thatlonger periods of observation could have avertedthose admissions, but that was not our goal.

CONCLUSIONS

Our enthusiasm for conscious sedation withfull abdominoplasty has increased because ofour enhanced ability to achieve effective localanesthesia. This has been the result of in-creased care to place the local anesthetic at thefascia-fat interface under direct vision, and al-lowing a full 15 to 20 minutes to elapse beforecutting major perforators that have accompa-nying nerves. We perform liposuction duringthis time period along the hips and waist, mostoften while the patient is in a lateral position.The small increase in time required for localanesthetic infiltration is balanced by the sav-ings in time for induction and extubation un-der general anesthesia. The results of thepresent study support the routine use of con-scious sedation for abdominoplasty, even incases when a concurrent cosmetic procedure isplanned. This series showed no intraoperativecomplications related to the use of conscioussedation at our institution. The postoperativecomplication rate was no higher than that ofabdominoplasties performed by the authorsunder general anesthesia. Careful patient se-lection, a comprehensive understanding of themedications, and close intraoperative monitor-ing can make conscious sedation a safe, well-tolerated, and cost-effective method of anes-thesia for abdominoplasty.

Thomas A. Mustoe, M.D.Division of Plastic and Reconstructive SurgeryNorthwestern University Medical CenterGalter 19-250675 North St. Clair StreetChicago, Ill. [email protected]

REFERENCES

1. Mottura, A. A. Local anesthesia for abdominoplasty,liposuction and combined operations. Aesthetic Plast.Surg. 17: 117, 1993.

2. Abramson, D. Tumescent abdominoplasty: An ambula-tory office procedure. Aesthetic Plast. Surg. 22: 404,1998.

3. Iverson, R. E. Sedation and analgesia in ambulatorysettings: American Society of Plastic and Reconstruc-tive Surgeons Task Force on Sedation and Analgesiain Ambulatory Settings. Plast. Reconstr. Surg. 104: 1559,1999.

4. Byun, M. Y., Fine, N. A., Lee, J. Y., and Mustoe, T. A. Theclinical outcome of abdominoplasty performed underconscious sedation: Increased use of fentanyl corre-lated with longer stay in outpatient unit. Plast. Reconstr.Surg. 103: 1260, 1999.

5. Rosenberg, M. H., Palaia, D. A., and Bonanno, P. C.Abdominoplasty with procedural sedation and anal-gesia. Ann. Plast. Surg. 46: 485, 2001.

6. Lockwood, T. High lateral tension abdominoplasty withsuperficial fascial system suspension. Plast. Reconstr.Surg. 96: 603, 1995.

7. Lee, M. J., and Mustoe, T. A. Simplified technique forcreating a youthful umbilicus in abdominoplasty.Plast. Reconstr. Surg. 109: 2136, 2002.

8. Grazer, F. M., and Goldwyn, R. M. Abdominoplasty as-sessed by survey, with emphasis on complications.Plast. Reconstr. Surg. 59: 513, 1977.

9. Pollack, H., and Pollack, T. Progressive tension sutures:A technique to reduce local complications in abdomi-noplasty. Plast. Reconstr. Surg. 105: 2583, 2000.

10. Baxter, R. A. Controlled results with abdominoplasty.Aesthetic Plast. Surg. 25: 357, 2001.

11. Dillerud, E. Abdominoplasty combined with suction li-poplasty: A case study of complications, revisions, andrisk factors in 487 cases. Ann. Plast. Surg. 27: 182, 1991.

12. Van Uchelen, J. H., Werker, P. M., and Kon, M. Com-plications of abdominoplasty in 86 patients. Plast. Re-constr. Surg. 107: 1869, 2001.

13. American Society of Anesthesiologists Task Force on Se-dation and Analgesia by Non-anesthesiologists. Prac-tice Guidelines for Sedation and Analgesia by Non-anesthesiologists. Anesthesiology 84: 459, 1996.

14. Dionne, R. A., Yagiela, J. A., Moore, P. A., et al. Com-paring efficacy and safety of four intravenous sedationregimens in dental outpatients. J. Am. Dent. Assoc. 132:740, 2001.

15. Marcus, J. R., Few, J. W., Chao, J. D., et al. The preven-tion of emesis in plastic surgery: A randomized, pro-spective study. Plast. Reconstr. Surg. 109: 2487, 2002.

16. Marcus, J. R., Tyrone, J. W., Few, J. W., et al. Optimi-zation of conscious sedation in plastic surgery. Plast.Reconstr. Surg. 104: 1338, 1999.


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