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journal homepage: www.JournalofSurgicalResearch.com

Intraoperative factors associated with

postoperative complications in body contouring
surgery

Barak Cohen, MD,a,1 Benjamin Meilik, MD,b,1 Ahuva Weiss-Meilik, MD,c

Aviv Tarrab, MD,d and Idit Matot, MDa,*
a
Division of Anesthesia, Intensive Care and Pain Medicine, Tel Aviv Medical Center affiliated with Sackler Medical
School, Tel Aviv University, Tel Aviv, Israel
b
Department of Plastic Surgery, Tel Aviv Medical Center affiliated with Sackler Medical School, Tel Aviv University,
Tel Aviv, Israel
c
Clinical Performances Research and Operational Unit, Tel Aviv Medical Center, Tel Aviv, Israel
d
Hadassah Medical School, Hebrew University, Jerusalem, Israel

article info abstract

Article history: Background: Several preoperative factors have been shown to influence outcome of body
Received 18 February 2017 contouring surgeries. The effect of intraoperative features, including fluid volume
Received in revised form administered, hemodynamic and respiratory parameters, and body temperature on post-
1 July 2017 operative complication, has not been reported to date.
Accepted 1 August 2017 Materials and methods: All subsequent patients undergoing body contouring surgery in the Tel
Aviv Medical Center between 2007 and 2012 were enrolled. Demographic and intraoperative
Keywords: data were collected and analyzed for possible associations with postoperative complications,
Hypoxemia including formation of seroma, hematoma/bleeding, other surgical site complications
Intraoperative hypothermia (infection, adhesiolysis, or need for debridement), formation of a hypertrophic scar, any
Intravenous fluids administration documented, infection or a composite outcome of any of the previously mentioned.
Postbariatric abdominoplasty Results: Data of 218 patients were assessed. Mean (standard deviation) age of patients was
Wound complications 41(14) y. Intraoperative administration of higher volumes of fluids was significantly associ-
ated with formation of seroma (P ¼ 0.01), hematoma/bleeding (P ¼ 0.03), hypertrophic scar
(P ¼ 0.01), surgical site complications (P ¼ 0.01), and a composite outcome (P < 0.001).
Development of hematoma/bleeding was associated with longer periods of low (<35.6 C)
intraoperative core temperature (72% versus 50% of surgery duration in patients who did not
develop this complication, P < 0.05). Surgical site complications were associated with longer
periods of intraoperative oxygen desaturation (saturation 92%, 4.2% versus 0.9% of surgery
duration in patients who did not develop surgical site complications, P < 0.01).
Conclusions: Intraoperative moderate hypothermia, hypoxemia, and liberal fluid administra-
tion are associated with worse surgical outcome in patients undergoing body contouring sur-
gery. Increased awareness of the potential adverse effects of these factors in body contouring
surgery will enhance interventions aimed at avoiding and promptly treating such events.
ª 2017 Elsevier Inc. All rights reserved.

* Corresponding author. Division of Anesthesia, Intensive Care and Pain Medicine, Tel Aviv Medical Center, Tel Aviv, 6 Weizmann Street,
Tel Aviv 6423906, Israel. Tel.: þ972 3 6974758; fax: þ972 3 6973026.
E-mail address: iditm@tlvmc.gov.il (I. Matot).
1
These first co-authors equally contributed to the formation of this study.
0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jss.2017.08.004
 cohen et al  intraoperative factors and outcome
Introduction
Availability of bariatric surgery for extreme obesity has
improved in recent years, making super morbid obesity pa-
tients legitimate candidates for weight reduction operations.1-
4
This has raised the need for body contouring surgery for
patients after massive weight loss. Body contouring surgeries
are fairly extensive, might be prolonged, and can possibly
involve several different regions of the body. The reported
morbidity is relatively high, approaching 50%, mostly related
to various wound healing complications which can be
managed conservatively and rarely require return to the
operating room.5-8 Recent studies reported higher complica-
tion rates in patients who have body contouring surgery after
bariatric surgery.5-8 Identification of controllable variables
associated with increased risk of postoperative wound com-
plications will help reduce morbidity in this vulnerable patient
population.
Several patient’s risk factors and surgical aspects have
been shown to affect postoperative outcome in body con-
touring surgery. These include the initial body mass index
(BMI), smoking, and the amount of tissue removed during
surgery.6,7,9 A recent review concludes that carefully moni-
toring operating room temperature and fluids status can help
avoid complications; however, scarce data are presented to
support this comment.10 Thus, the present study aimed to
evaluate the influence of various intraoperative factors on
postoperative wound healing complication rate in body con-
touring surgery.
Material and methods
This single-center retrospective cohort study was approved by
the Tel Aviv Medical Center (TLVMC) Institutional Review
Board (IRB no. 0089-11-TLV) that waived the need for informed
consent.
All consecutive adult patients undergoing post bariatric
abdominoplasty under general anesthesia for massive weight
loss in the TLVMC from January 2007 till May 2012 were
included. TLVMC is a referral center for such operations. Pa-
tients were admitted to the hospital the night before surgery
to meet the anesthesiologist and have a blood workup. Pa-
tients received a standardized thromboembolic prevention
protocol (subcutaneous enoxaparin [Clexane], 40 mg preop-
eratively, which is continued throughout the hospital stay and
for 2 wk after hospital discharge) and immediate preoperative
intravenous antibiotics. Temperatures were measured by
mean of esophageal probe.
The relevant perioperative data were extracted from the
computerized medical records at TLVMC.
1. Demographic and anthropometric data: age, gender, BMI,
American Society of Anesthesiologists (ASA) physical sta-
tus score, smoking habits
2. Duration of surgery
3. Preoperative and postoperative complete blood count
4. Fluid volume administration during surgery as well as the
volume of administered blood products, if any
25
5. Intraoperative hemodynamic and respiratory parameters
(intraoperative heart rate, respiratory rate, blood pressure,
oxygen saturation, temperature, respiratory pressures,
inspired oxygen concentration, end-tidal CO2 concentra-
tion). Hypothermia was defined as core temperature below
35.6 C. Oxygen desaturation was defined as oxygen satu-
ration 92%.
6. Intraoperative administration of vasopressors.
Postoperatively, all patients were examined and inter-
viewed daily as part of the departmental routine medical care
by an attending physician. Most patients were discharged
with the drains and returned to the outpatient clinic to have
those removed. The drains were removed systematically in all
patients when fluid output was <30 mL/d. After hospital
discharge, patients were seen in the outpatient surgical clinic,
weekly for 1 mo and then at 3 mo. Complications detected by
the attending physician during patients’ hospital stay and 30 d
follow-up were recorded.
Primary endpoint
The primary endpoint was occurrence of any of the listed
postoperative (30 d) surgical site morbidities: seroma for-
mation (detected clinically or radiologically irrespective of
the need for evacuation), hematoma (including documented
postoperative bleeding), hypertrophic scar, and other surgi-
cal site complications (infection, wound dehiscence, or need
for debridement) and a composite outcome of these
complications.
Secondary endpoints
Postoperative anemia (hemoglobin concentration <12 g/dL or
a drop >1.5 g/dL compared with the preoperative level), the
occurrence till 30 d postoperatively of systemic infection, deep
venous thrombosis, and pulmonary embolism.
Any association between demographic or hemodynamic/
respiratory/temperature parameters and the defined out-
comes was evaluated.
Statistical analysis was performed using SPSS software
(SPSS for windows version 21.0; IBM corp, Armonk, NY). Cate-
gorical data were analyzed by logistic regression models and
compared by squared Chi test. Continuous variables were
compared using the Student’s t-test for unpaired samples
when normal deviation was assumed. When the data were not
assumed to deviate normally, the nonparametric Wilcoxon
test was used. Significance level was set to a P value <0.05.
Results
The records of 218 consecutive adult patients undergoing
abdominoplasty for massive weight loss (50% loss of the
excess weight, weight loss between 45 and 73 kg in this cohort)
under general anesthesia in TLVMC from January 2007 till May
2012 were reviewed. These were mainly female patients
(n ¼ 152, 70%), mean (standard deviation [SD]) age of 41(14) y,
average BMI of 29.6 kg/m2 (3.1), and the vast majority of
26 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 1 8 ( 2 2 1 ) 2 4 e2 9
patients had an ASA physical status score of I or II. More than
80% (n ¼ 184) were none or previous smokers. Only eight
patients were diagnosed with diabetes mellitus at the time of
operation. Demographic data are shown in Table 1. Mean (SD)
operative time (minute) was 122.11
Primary endpoint
The most common wound healingerelated complication was
hematoma (20%) followed by seroma which developed in 10%
of cases. None of the patients developed skin necrosis or an
abscess. Rate of the composite outcome was 45% (Table 2).
Patients who suffered hematoma formation were hypo-
thermic (core temperature <35.6 C) for a significantly longer
intraoperative duration compared with those who did not
develop hematoma: 72% versus 50% of operative time,
respectively, P < 0.05. In addition, the average temperatures
measured were marginally lower in this group (with and
without hematoma 35.2 C versus 35.5 C, respectively,
P ¼ 0.075).
Patients who developed surgical site complications were
found to be exposed to significantly longer periods of intra-
operative desaturation (oxygen saturation 92%, excluding
extubation period) when compared with patients without this
complication (4.2% versus 0.9% of surgery duration, respec-
tively, P < 0.01). To refine this finding to the pure intra-
operative period and eliminate possible airway management
problems, the same analysis was done excluding the first
15 min of anesthesia. The correlation between intraoperative
desaturation and surgical site complications was found to be
even stronger (5.5% versus 0.9% of surgery duration in patients
with surgical site complications versus no complications,
respectively, P < 0.001).
Mean (SD) volume of fluids administered was 1762 (948)
cc, and none of the patients received blood products. Higher
volumes of intraoperative fluid administration were
significantly associated with formation of seroma (P ¼ 0.01),
hematoma/bleeding (P ¼ 0.03), hypertrophic scar (P ¼ 0.01),
surgical site complications (P ¼ 0.01), and a composite
Table 1 e Demographic data.
Total, N 218
Age, y, mean (SD) 41 (14)
Gender, N (%)
Male 66 (30)
Female 152 (70)
ASA, N (%)
I or II 96%
III 4%
BMI, mean (SD) 29.6 (3.1)
Smoking status, N (%)
Current 29 (13.3)
Previous 42 (19.3)
Never 142 (65.1)
Unknown 5 (2.3)
Table 2 e Overall complication rates.
Outcome N (%)
Seroma 21 (9.6)
Hematoma/bleeding 44 (20.2)
Hypertrophic scar 11 (5.0)
Surgical site complication* 41 (18.8)
Postoperative anemia 112 (51.4)
Composite outcomey 98 (45.0)
*
Surgical site complication: infection, wound dehiscence or need
for debridement.
y
Composite outcome: any of the previously mentioned complica-
tions excluding postoperative anemia.
outcome (P < 0.001) as shown in Table 3. Significance was
also achieved when a multiple regression model taking into
account duration of surgery was performed (P ¼ 0.04; odds
ratio 1.63; 95% confidence interval 1.02-2.54).
All other measured factors (ASA score, BMI, smoking
status, hemoglobin, intraoperative hemodynamics, and
operation time) were not found to significantly influence
outcome.
Secondary endpoint
Approximately half of the patients suffered from post-
operative anemia. Higher volumes of intraoperative fluid
administration were significantly associated with post-
operative anemia (P < 0.001). None of the patients developed
systemic complications in need of pharmacologic or other
intervention (deep vein thrombosis/pulmonary emboli/sys-
temic infection).
Discussion
Previous studies reported an effect of intraoperative factors on
postoperative outcome. All these studies involved patients
with significant comorbidities.12-25 The present study dem-
onstrates several associations of that kind in a unique popu-
lation of patients undergoing postbariatric abdominoplasty.
These patients are usually young with little comorbidity,
mainly related to their previous extreme obesity. Neverthe-
less, several influences of intraoperative management have
been found to be significantly associated with specific
important outcomes distinctive to this kind of operation.
Hypothermia is frequent during surgical procedures, more
so when extensive body parts are exposed, despite several
routine measures that the anesthesiologist implements with
the aim to avoid such an adverse event.26 Patients undergoing
large body contouring procedures are at risk for hypothermia.10
Indeed, both groups of patients in the present study (those who
developed complications and those who did not) were hypo-
thermic (core temperature <35.6 C). A strong correlation was
found, however, between the duration of intraoperative hypo-
thermia and the formation of surgical site hematoma or
bleeding. This finding is in agreement with several previous
studies demonstrating increased morbidity and mortality in
 cohen et al  intraoperative factors and outcome
Table 3 e Complication rates and intraoperative fluid administration.
Complication Present, mean (SD)
volume administered, cc
Seroma 2275 (1329)
Hematoma/bleeding 2075 (887)
Hypertrophic scar 2568 (1061)
Surgical site complication* 2150 (1205)
Postoperative anemia 2032 (1082)
Composite outcomey 2060 (1029)
*
Surgical site complication: infection, adhesiolysis, or need for debridement.
y
Composite outcome: any of the previously mentioned complications excluding postoperative anemia.
patients suffering intraoperative hypothermia,12,13 a problem
more common in longer and more extensive operations.
Moreover, a recent study by Coon et al.27 showed that lower
intraoperative temperature was associated with an increased
risk of seroma formation and transfusion. Hypothermia im-
pairs coagulation and immune function by inhibition of diverse
enzymatic processes, as well as platelet function.28 It was
shown to increase the incidence of hemorrhagic complications
and blood products administration.11 In a recent study that
included nearly 60,000 patients undergoing noncardiac surgery,
mild hypothermia was associated with increased transfusion
requirements.29 This may explain, in part, the correlation be-
tween intraoperative hypothermia and increased incidence of
bleeding complications as demonstrated in our cohort.
While fluid administration is the rule during surgery,
importance of the actual volume administered intra-
operatively was recognized only in the last two decades. In
the present study, large volumes of intravenous fluids
administered during surgery were found to increase the risk
of various detrimental outcomes, including surgical site
complications and anemia. Data from previous studies, the
majority of which in patients undergoing intra-abdominal
surgery, pulmonary resection, or in critically ill patients,
similarly reported an association between liberal intrave-
nous fluid administration and increased morbidity and
mortality.15-17,19,20 Excess fluid administration might cause
either clinical or subclinical pulmonary congestion and
impair oxygenation,16,30 in addition to tissue edema at the
site of the already traumatized surgical site. This, in turn,
might harm blood flow and oxygenation of the tissue, impair
wound healing, and increase the incidence of postoperative
complications.31
The effect of supplemental oxygen on surgical wound heal-
ing is controversial. It was first described as beneficial in
reducing surgical site infection rate, as well as ameliorating
postoperative nausea and vomiting,32-35 but these evidences
were later challenged.36-39 Anesthesia providers usually prefer
to avoid administration of O2 concentrations higher than
necessary for various reasons, such as prevention of absorption
atelectasis and the ability to promptly detect oxygenation
problems. Our results show a clear association between intra-
operative desaturation and the development of surgical site
complications. This is in line with the scientific literature
showing the importance of adequate oxygen supply to tissues in
27
Absent, mean (SD) P value
volume administered, cc
1700 (876) 0.01
1680 (950) 0.03
1723 (929) 0.01
1671 (858) 0.01
1527 (744) <0.001
1509 (796) <0.001
the process of wound healing.40,41 It may be argued that hyp-
oxemia might have been related to comorbid disease of the pa-
tients; however, this possibility is remote as only very few
patients (n ¼ 9) have had any significant disease (mostly diabetes
mellitus) and none suffered from lung disease or congestive
heart failure. Short duration of hypoxemia, as evidenced in the
current study, was most probably the result of atelectasis as it
promptly responded to recruitment maneuvers.
Data from the present study do not show correlation be-
tween decreased blood pressure or tachycardia and worse
outcome. This is in contrast to previous studies that demon-
strated increased cardiac, neurologic, and renal morbidity
associated with decreased blood pressure or tachycardia.21-
24,42
This might reflect a selection bias of relatively young
patients that had lost a significant portion of their weight and
who seem healthy enough to undergo body contouring sur-
gery. Indeed, ASA physical status score of study patients was I
or II, and none of the patients had any cardiovascular or renal
disease. Patients with significant comorbidities who might be
prone to the detrimental effects of hypotension or tachycardia
probably were not considered as appropriate candidates for
elective and extensive surgery.
The present study has several limitations. First, it is a
single center study. Second, the retrospective nature of the
study does not allow us to take into account hemodynamic
and respiratory parameters recorded in the recovery room as
well as accumulated fluid drainage volume. Finally, because of
the retrospective nature of the study, the exact nature of the
hypertrophic scar is not reported (e.g., tension on the wound,
exact location, and so on).
In conclusion, results from the present study in healthy
patients undergoing postbariatric abdominoplasty show that
several intraoperative parameters, although moderate in na-
ture, are associated with early complications, mainly related
to surgical site. These factors include duration of hypother-
mia, hypoxemia, and liberal fluid administration. Increased
awareness of the potential adverse effects of these aspects in
this type of surgery may enhance interventions aimed at
avoiding such events. Thus, a protocol involving patient pre-
warming, a higher operating room temperature and the
routine use of warmed fluids is recommended. In addition,
restrictive fluid approach should be considered and measures
to avoid/treat hypoxemia such as recruitment maneuvers
should be embraced.
28 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 1 8 ( 2 2 1 ) 2 4 e2 9
Acknowledgment
None.
Authors’ contribution: B.M., A.T., and I.M. contributed to the
formulation of the research concept. B.M., B.C., A.T., A.W.M.,
and I.M. contributed to data acquisition and statistical analysis.
B.C., A.T., I.M., A.W.M., and B.M. wrote and revised the article.
Disclosure
The authors report no proprietary or commercial interest in
any product mentioned or concept discussed in this article.
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