**2. Surgical and analgesic considerations and methods in abdominoplasty**

Abdominoplasty is the third most frequent form of body contouring surgery after breast augmentation and liposuction. In 2019, based on the American Society of Plastic Surgery (ASPS) analysis, there were a total of 123,427 cases in the USA. In all, 34 patients underwent abdominoplasty at the Bagatin Polyclinic in 2019. It is one of the most common and demanding procedures requiring significant recovery where patients are absent from work for 2–3 weeks and sometimes even longer. The age of patients varies from 19 all the way to 75 years of age. The oldest female patient who underwent abdominoplasty at our clinic was 75 years of age for a series of procedures that included breast augmentation and thigh tightening around the groin area. Age is not a limit factor in undergoing these procedures, but patient safety is always an important factor, and caution should be taken.

Among all the procedures covering everyday esthetic surgery, liposuction is statistically the most frequent procedure, which is frequently done in combination with abdominoplasty. It has developed through the years and stems from the eternal search for finding ways of achieving the ideal body dimensions, long-term vitality as well as slowing down and delaying the aging process. This surgical method permanently reduces fatty tissue from a specific part of the body which cannot be done or is very difficult using other methods for removing fat and body contouring. Parts of the body where fat accumulates and is difficult to remove through specific exercises are the abdominal part, the segment above the gluteus, thighs, and sections around the knees and upper arm.

The most often myth relating to this surgical procedure is the opinion that it is a method for treating obesity because the disproportionate deposits of fatty tissue are often visible in persons whose body mass index is within normal limits.

Besides removing fatty tissue, this surgical procedure also offers the following positive results:

*Fan-Shaped Application of Local Abdominal Wall Analgesia in Abdominoplasty Patients… DOI: http://dx.doi.org/10.5772/intechopen.100235*


Modern liposuction can also be done under local anesthesia, which in turn enables communicating with the patient throughout the entire surgical procedure and an adequate evaluation of pain. The procedure is ordinarily limited to suctioning up to 3 liters of fat, and the patient is able to quickly return home after the procedure. This form of anesthesia enables abdominoplasty to be performed without plication of the abdominal muscles.

Liposuction has undergone a significant evolution from its beginnings to current mass use. The third generation of ultrasound technology based on VASER® (vibration amplification of sound energy at resonance) [1, 2] offers safer liposuction and satisfactory results, especially when wanting to achieve better definition using surface liposuction (**Figure 1**).

The abdominoplasty procedure ordinarily comprises VASER liposuction [1, 2] of the lower or more often lower and middle section of the back and VASER liposuction of the lower chest area, hips, and abdominal wall, most often plication of the abdominal wall longitudinally and the removal of excess skin in a lateral direction in the area of the lower section of the abdominal wall [3, 4]. It is relatively a significant and long operation often accompanied by intense pain and difficult recovery. This can be most evident in the first days following the operation. Hence, attempts are being directed to devising a specific type of analgesic, which will provide patients with the fastest and least painful recovery, as well as a quick return to daily activities and work.

The abdominoplasty procedure begins with infiltration of the abdominal wall with a tumescent fluid: normal saline solution (0.9% NaCl) containing adrenaline (1 mg), bupivacaine (12,5 ml of 5 mg/ml), and sodium bicarbonate (10 mL of

**Figure 1.** *VASER device and surgical instrument setup.*

8.4% w/v), for each liter used [5]. It is then necessary to wait 10–15 min for the vasoconstriction and fat breakdown to take effect. The VASER used operates on an ultrasound principle which reduces larger segments of fat into smaller pieces, which in turn facilitates its removal. VASER technology provides a more sparing liposuction method that preserves blood vessels, nerves, and connective tissue, and consequently protects vascularization and sensitivity, while, on the other hand, acts specifically on fat and causes bloating and fragmenting of fatty tissue, facilitating the removal of fatty tissue into a less dense form. This reduces mechanical damage to tissue because the fat is more easily taken out using liposuction (**Figure 2**).

After a thorough liposuction, preserving vascularization and innervation of transitional structures and skin, the strengthening of the abdominal wall can commence, most often in terms of plication of the straight abdominal muscles (**Figure 3**).

In addition to the vertical strengthening of the abdominal wall, a horizontal or central plication is performed. This provides contours to the abdominal wall. Indeed, the BMI is always taken into consideration and should ideally be below 30. This is important, given that the internal abdominal content should be as minimally distended, as possible.

In this phase, a long-acting local anesthetic is administered [6, 7] to the plication area, the horizontal incision, and in the oblique radial direction, across the area of the abdominal wall, toward the hips. This is done to reduce pain in the initial phase, after the operation, and to achieve maximum recovery and mobilization. Optimally, this reduces more serious complications, such as deep vein thrombosis and pulmonary embolism, due to faster postoperative mobilization.

The next step is a fixation of the lower horizontal incision. Freeing the umbilicus and removing excess skin and subcutaneous tissue in the lower area of the abdominal wall are performed. Care is always taken to remove a similar amount of tissue on both sides (**Figure 4**).

#### **Figure 2.**

*A: First part of the procedure is the infiltration of the abdominal wall, B: VASER probe with three rings for ultrasound application on the abdominal wall, C: VASER liposuction with VentX cannula, and D: Result immediately after VASER liposuction.*

*Fan-Shaped Application of Local Abdominal Wall Analgesia in Abdominoplasty Patients… DOI: http://dx.doi.org/10.5772/intechopen.100235*

#### **Figure 3.**

*A: Markings for plication of straight abdominal wall muscles, B: Result after plication of abdominal wall muscles, C: Markings for application of long-lasting infiltration analgesia, and D: Markings for fixation of lower abdominal wall straight scar.*

#### **Figure 4.**

*A. Excess of skin and subcutaneous tissue in abdominoplasty patient. B. Removed tissue in abdominoplasty patient. C. Appearance at the end of abdominal wall surgery (abdominoplasty), and D. position in bed after abdominoplasty.*

Within this phase involves the further mobilization of skin and subcutaneous tissue, as required. The fixation of skin and subcutaneous tissue is performed horizontally and if necessary, vertically to a lesser extent, to achieve the desired results. The final phase involves further freeing of the navel, within the mobilized skin and subcutaneous lobe centrally and this is then fixed into a position just above the hips. Pressurized drains are placed to drain excess fluids. All the wounds are closed off in layers. Sterile surgical bandages and compression garments are applied. The bed should be with an elevated head position, the patient lying comfortably on

#### **Figure 5.**

*Final presentation and straight position of the patient day after surgery. This shows that patient can straight up without pain immediately after surgery. This is very important for overall recovery.*

their back, legs bent at the knees, to provide support, and careful not to stretch the freshly operated abdominal site (**Figure 5**).
