When I was trained to do abdominoplasty, it was absolutely unthinkable that the procedure could be done on an outpatient basis. Patients were expected to stay in bed-with no movement whatsoever-for 24 hours after the procedure. They were log-rolled from side-to-side by the nurses in order to have the sheets on the bed changed. The belief was that if they moved at all, they might break their stitches. The average post-op hospital stay was five to six days. When they were discharged, they were instructed as general surgery patients were-for example, as a precaution, they were told not to walk the steps for six weeks. Recuperation was often complicated by lengthy periods of inactivity, which contributed to pulmonary problems and vascular problems such as phlebitis.

Times changed and medicine improved. By the late 1970s, hospital stays had been cut down to a couple of days. However, it was still not possible to do outpatient abdominoplasty, because, over the first 24 hours postoperatively, the patient was still kept totally immobilized in bed. Eventually, even those barriers came down, and patients started to be discharged much more quickly. It became possible to begin thinking about doing abdominoplasty on an outpatient basis.

I have been doing outpatient abdominoplasties for the last 15 years, and we do several a month at the SurgiCenter of Baltimore. In this article, I'll share our guidelines and procedures for accepting and performing these cases.

The typical patient profile
Most patients are women (especially those who have had children), but many men have the procedure as well. Patients who seek this procedure have hanging skin and fat that can't be tightened with any amount of exercise. This can be caused by repeated weight gain and loss, genetics, or pregnancy.

The "average" abdominoplasty patient is a woman who has had a couple of children. Quite possibly, she has lost some weight to try to get back in shape. The skin and remaining fat then sag and hang. During pregnancy, these patients get a diastasis (separation) of the rectus muscles. Since the muscles are no longer pulling vertically, the lower abdomen begins to bulge outward, creating a "pot belly" appearance.

Another group of patients who commonly seek abdominoplasty are women who have what you might call "crumple tummy," which is also caused by pregnancy. Although we can't get rid of the stretch marks, abdominoplasty can help remove much of the redundancy of skin around the abdomen, stretching the marks further downward, so that they can be more easily concealed. It can also help present less of a "wrinkled" appearance when sitting down. These patients are often among the easiest to work with because the surgeon is only dealing with a thin layer of excess skin and very little fat. The surgery usually goes very quickly and produces excellent results.

Screening Candidates
Abdominoplasty should only be done on an outpatient basis with patients who are fairly young (about 30 to 50 years of age), reasonably healthy (i.e., no serious medical illnesses and have moderate physical dimensions), and who meet anesthesia requirements.

Certain patients would not be optimal candidates for abdominoplasty, even if they are otherwise healthy. They include:

Women who plan future pregnancies. The stresses of pregnancy and childbirth will destroy the vertical muscle tightening done during the procedure; essentially, they will "undo" the procedure. Given the expense, time, and discomfort involved, patients should be encouraged to wait until they do not plan to have more children.

Patients who have had extreme scarring from previous abdominal surgeries. The scar tissue may hamper the surgical team's efforts and lead to vascular problems.

Pre-op instruction and education
All of our abdominoplasty patients meet with a nurse about three weeks before the procedure. The nurse instructs them about pre- and post-op care (for example, she shows them the proper way to get out of bed) and gives them a written checklist of instructions .

One of our requirements for abdominoplasty patients is that they have a friend or family member drive them home and stay with them during the first 48 hours post-op. This person also attends the pre-op meeting to learn about the responsibilities he or she will have, including emptying the drains.

About a week before surgery, patients must undergo a physical from their family physician. Patients who are over 50 must have an EKG and patients who are on diuretics or heart medications must have bloodwork, including electrolytes, as part of the physical. Female patients of childbearing age also receive a pregnancy test.

We do not require a chest x-ray unless there are pulmonary indications. Patients lose very little blood during the procedure, making it unnecessary to donate blood in advance. We do ask patients to temporarily discontinue taking non-steroidal anti-inflammatory drugs, because they can interfere with clotting.

The Day of Surgery
An abdominoplasty patient arrives about an hour before the procedure and undergoes several pre-op interviews.

First, a PACU nurse meets the patient and ensures that she is NPO for surgery and asks whether she has taken her medications. Next, the anesthesia provider assesses the patient. Finally, the OR circulating nurse asks her a checklist of questions (this is shorter than the first interview, but some of the questions from the first interview are repeated, such as when the patient last ate and affirming that she is not pregnant).

At each step along the way, the staff explains to the patient what will happen during various phases of her stay and strives to put the patient's mind at ease.

Depending upon how extensive the procedure will be, you can expect OR time to take two and a half to four hours. These are some crucial facets to keep in mind.

Anesthesia
We do most abdominoplasties under general anesthesia. The average abdominoplasty surgical field extends from the pelvic area to the ribcage. Thus, it's difficult-and risky-to administer a spinal block. The procedure is not conducive to IV anesthesia because muscle relaxation may be needed.

In a handful of cases where a "lesser" partial tuck is being done, it may be possible to do the case under local. In partial abdominoplasty, only the lower part of the abdomen is being operated on. Most of these cases still require general anesthesia but in a small minority of these cases-cases in which no muscle work is being done and the incisions are very narrow-local anesthesia may be appropriate.

Positioning and Pressure Relief
During the procedure, the patient lies supine; there should be a slight break in the bed to take strain off the patient's back and a slight break at the knees to take pressure off the legs. The heels and arms should be padded on soft rubberized foam. We use alternating pressure stockings to maintain circulation in the legs. Once the patient is under anesthesia, we also use warming blankets to maintain body temperature.

The Procedure
The reason abdominoplasty is such a long procedure is that it covers a wide field of surgery. Briefly, this is what a surgeon does in a full abdominoplasty. He makes an incision around the pubis and up the groin on both sides. He then extends the incision as far laterally as is necessary to pull the skin down and out to the side to get rid of the appearance of "dog ears" and redundant skin. He also pulls the rectus muscles together with rows of sutures, repairing any diastasis. Finally, he repositions the umbilicus. That means he must cut the skin loose from around the umbilicus, pull the "flap" down, make a new opening and bring the umbilicus out to a new location.

In partial abdominoplasty, the surgeon is only working in the lower area, so the incisions are not as wide and the surgeon does not have to remove as much skin. Thus, it is often not necessary to re-position the umbilicus. If the patient has had pregnancies, the surgeon still has to tighten the rectus muscles with sutures. If not, even that step may be unnecessary.

After closing the wounds with sutures, a binder is applied to keep gentle pressure on the area. Also, while the patient is still asleep, the anesthesiologist administers medication to control PONV; this is especially important because we don't want patients with an abdominal muscle repair vomiting when they wake up.

Recovery room and discharge
Before the patient is released from the recovery room, she is checked out by the attending doctor and/or nurse. Every patient must stay a minimum of an hour in the recovery room after the procedure. On average, most patients remain considerably longer-at least two or three hours. During the patient's stay in PACU, we gradually move her through the process of sitting up-she goes from a stretcher, to a semi-sitting position in the lounger, to a sitting position. Finally, when she is ready, we move her to a standing position and allow her to use the bathroom. It should be noted that we do not catheterize men who undergo the procedure (we have them empty their bladder right before the surgery) but we do routinely put a urinary catheter in female patients. Before discharge, we open the binder, take down the dressings and examine the wounds to make sure that no hematomas have built up.

Patients are ready to go home with their caretaker when their vital signs are stable, their bleeding has ceased, and their post-op pain is under control.

Post-op pain control and followup
All patients receive post-op pain prescriptions during their pre-op meeting. I usually prescribe 10 mg of lortab (an oxycodone-based opioid) to be used for the first 48 hours postoperatively. Beyond that, few patients will need anything other than acetaminophen. Patients can expect to be very sore the first post-operative day and less so the day after. They usually begin to improve rapidly after the third day.

We have all abdominoplasty patients return to the facility the day after surgery (this is standard for all major cosmetic procedures) to take down the dressings and examine the incisions. We have them stand and look in the mirror to see for themselves how their abdominal area now looks.

After the second day, patients slowly begin to resume normal activities. We do ask, though, that they be very cautious while walking the steps.

Some doctors like to do abdominoplasty procedures on a Friday and then give the patient a weekend to recover before re-examining them. I don't believe in doing this. I want to see them before the weekend. For that reason, I will not schedule the procedure for later than a Thursday.

Profitability outlook
Although it is a very time-consuming procedure, abdominoplasty is a relatively profitable one. It is in many ways an "old-fashioned" surgery in that it does not require high-tech equipment and involves relatively few supplies. Our physician fee ranges from $4000 to $6000 for full abdominoplasty and $2500 to $3500 for a mini-tuck. The facility fee at our surgicenter is estimated at around $1275 for a 2 1/2 hour surgical procedure to $1950 for four hours (this includes the anesthesiologist fee).

We're proud to have developed a procedure for abdominoplasty that works for our surgeons, staff, and most of all, our patients. We look forward to building our satisfied patient population for many years to come.

Lawrence Pinkner, MD, is the president of the AAASC and of the SurgiCenter of Baltimore.