Preoperative Respiratory Physiotherapy in Abdominoplasty Patients

Preoperative Respiratory Physiotherapy in Abdominoplasty Patients Abstract Background After abdominoplasty, patients experience decreased ventilatory function and increased intra-abdominal pressure (IAP). Breathing exercises are used during the pre- and postoperative periods of several abdominal surgeries to prevent or minimize postoperative complications. Objectives The aim of this study was to assess the effect of preoperative respiratory physiotherapy on the outcome of abdominoplasty patients. Methods Thirty-three patients were divided into 2 groups. The control group (n = 18) received no preoperative intervention. The intervention group (n = 15) performed breathing exercises during the preoperative period, including incentive spirometry, diaphragmatic breathing, shortened expiration, and sustained maximal inspiration. Respiratory physiotherapy started one week before surgery. Breathing exercises were performed daily. They were performed 3 times weekly in the presence of a physiotherapist and patients were instructed to carry on the exercises at home on days without physiotherapy sessions for three sets of 20 repetitions each. Patients were assessed by spirometry and IAP measurements. Results No significant difference in spirometry was found between groups. However, patients in the intervention group had lower IAP at the start of surgery and at all time points (P = 0.010) compared with controls. Conclusions Preoperative respiratory physiotherapy had no impact on spirometry, but may have contributed to reduce IAP intraoperatively. Level of Evidence: 2 Abdominoplasty is one of the most performed aesthetic surgeries.1,2 In most abdominoplasties, repair of musculoaponeurotic deformities is a combined procedure, with diastasis recti being the most common.3 Although abdominoplasty can improve the quality of life, self-esteem, self-image, and sexuality of patients,4,5 this procedure is still associated with a high number of medical lawsuits, and therefore complications should be prevented.6 Pulmonary embolism is fortunately uncommon but represents one of the most serious postoperative complications.3,7,8 Other postoperative pulmonary complications include atelectasis, pneumonia, bronchoconstriction, respiratory failure, and need for prolonged mechanical ventilation. These complications are associated with increased length of hospital stay, morbidity, and mortality.9,10 Ventilation and pulmonary function after abdominoplasty have been studied by some authors.2,11-14 These authors reported an initial decrease in spirometric parameters, which returned to preoperative levels at about 15 to 30 days postoperatively.2,11-14 Respiratory complications occur in about 6% of patients undergoing abdominoplasty,15 and are associated with the presence of chronic obstructive pulmonary disease, dyspnea at rest, dependent functional status, malnutrition, recurrent incarcerated hernia, concomitant intra-abdominal procedures, American Society of Anesthesiologists (ASA) physical status classification greater than III, and prolonged operative time.15 Therefore, the search for new procedures to prevent postoperative pulmonary complications is necessary, especially for patients with risk factors. Pre- and postoperative respiratory physiotherapy has been reported to prevent pulmonary complications in abdominal surgery. Grams et al16 conducted a systematic review and meta-analysis on breathing exercises in patients who underwent surgeries in the supraumbilical region and found that, despite the low number of studies involved and their poor methodological quality, breathing exercises improved respiratory muscle strength. Celli et al17 concluded that incentive spirometry was the treatment of choice for patients undergoing abdominal surgery because it led to a shorter length of hospital stay compared to the nonintervention group.17 Fagevik Olsén et al18 observed that prophylactic respiratory physiotherapy reduces the incidence of postoperative pulmonary complications and improves mobilization and oxygen saturation after abdominal surgery. Changes in spirometric parameters and increase in intra-abdominal pressure (IAP) occur in normal patients undergoing abdominoplasty.19-21 Any improvement in ventilation observed after breathing exercises indicates a possible treatment effect. This would be especially important in patients with a risk factor for developing pulmonary complications after surgery, such as smokers and patients with chronic obstructive pulmonary disease, among others. No studies were found in the literature to date, showing the efficacy of preoperative breathing exercises in patients undergoing abdominoplasty. Also, there is an increase in IAP after abdominoplasty.14 This increase in IAP leads to a decrease on the speed of blood flow at the common femoral vein by about 30% after abdominoplasty with the use of compressive garments.22 The decrease in blood flow of the femoral vein increases the risk of thromboembolic events. Therefore, the aim of this study was to evaluate the effect of preoperative respiratory physiotherapy on the outcome of abdominoplasty patients focusing on the ventilatory function as well as on the IAP. METHODS This prospective, interventional, single-center controlled clinical trial was approved by the Research Ethics Committee of the Federal University of São Paulo (UNIFESP), Brazil, (approval no. 0773/10) and performed in accordance with the Resolution 196/96 of the Brazilian National Health Council (Conselho Nacional de Saúde, CNS) and Brazilian Ethical Review System on research involving human beings and also in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all patients prior to their inclusion in the study and anonymity was ensured. The study was conducted from February 2012 to December 2015. A nonrandom sample of 33 patients who expressed a desire to undergo abdominoplasty and met study criteria were selected to participated in the study. Inclusion criteria were female gender, 18 to 50 years of age, body mass index (BMI) between 20 and 30 kg/m2, deformities of the skin and subcutaneous tissues in the abdominal region (Nahas’ type III deformity, for which resection of skin and subcutaneous tissue between the umbilicus and pubis is indicated),23,24 and musculoaponeurotic defect with laxity of the entire abdominal wall and flank region (Nahas’ type B deformity, for which plication of both the anterior rectus sheath and external oblique aponeurosis is indicated).25 Patients with obstructive and restrictive respiratory diseases, abnormal chest X-ray, smoking habit, systemic diseases, history of previous abdominal surgery, supraumbilical scars, and marked weight loss after bariatric surgery were not included in the study. Failing to attend the preoperative respiratory physiotherapy sessions or to perform the breathing exercises at home as instructed was also considered as an exclusion criterion. The 33 selected patients who met study criteria were allocated to 2 groups. The first 18 patients were allocated to the control group and received no intervention; and the next 15 patients were allocated to the intervention group and received preoperative respiratory physiotherapy. Respiratory Physiotherapy Intervention Respiratory physiotherapy, consisting of daily breathing exercises, started one week before surgery. The exercises were performed 3 times weekly in the presence of a physiotherapist and patients were instructed to carry on the exercises at home on the other 4 days of the week without physiotherapy sessions. The first physiotherapy session was administered 7 days preoperatively, the second session was carried out 4 days preoperatively, and the last session was conducted one day before surgery. Patients received written instructions for each exercise and a worksheet to complete after the daily exercises. Patients were asked to perform 3 sets of twenty repetitions of each exercise. Each preoperative respiratory physiotherapy session included: Incentive spirometry, which is a breathing exercise designed to help the patient to take long, deep breaths using an incentive spirometer (Respiron, NCS Industry and Commerce, Barueri, Brazil). The patient inhales through the device mouthpiece raising 3 balls, which encourages them to inhale as long as possible. Diaphragmatic breathing is done by contracting the diaphragm so that the abdomen expands on inspiration and contracts slightly on expiration. Shortened expiration, consisting of inspiration to total lung capacity (the maximum amount of air), expiration of a small amount of air, followed by inspiration to total lung capacity and expiration of a small amount of air, and for the last time, inspiration to total lung capacity and normal expiration to residual volume, the maximum amount of air. Sustained maximal inspiration, which is performed by inspiring to total lung capacity, holding for 3 seconds, and normally expiring to residual volume, the maximum amount of air. Surgical Procedure All patients underwent abdominoplasty performed by the same plastic surgeon (F.X.N.), using a standardized technique. The surgical procedure was conducted under general anesthesia. Pancuronium bromide was used as a muscle relaxant at a dosage of 0.3 mL/kg body weight to induce neuromuscular blockade and at 0.15 mL/kg/h for maintenance. A suprapubic incision was made and extended laterally to the anterior superior iliac spines. The dermal-fat flap was superiorly dissected from the subjacent muscles (rectus abdominis and external oblique muscles) and the umbilicus was isolated.26 Diastasis recti was corrected and an L-shaped plication of the external oblique aponeurosis was performed. Excess skin and subcutaneous tissue of the abdominal flap were excised, the umbilicus was transposed, and the skin was closed in layers. Evaluation of Intervention Outcomes Spirometry and measurements of IAP were used to evaluate the intervention outcomes. Spirometry Spirometry was performed one week before surgery and at 2, 7, and 15 days postoperatively, using a portable handheld spirometer (Koko model, nSpire Health Inc., Longmont, CO). The postoperative day 15 was considered the endpoint of the study. The test was conducted in a quiet environment, under the guidance of a physiotherapist (M.A.R.). The patients were instructed to rest for a period prior to spirometry. They remained seated during the test, using a nose clip to prevent air leakage. The test was explained in detail so that the patients could make the forced expiratory maneuvers followed by deep inspiration and normal breathing. Spirometric measurements included:27,28 FVC—Forced vital capacity, which is the volume of air (in liters) that is exhaled during a forced expiration, starting from total lung capacity and ending at complete expiration. FEV1—Forced expiratory volume in one second, which is the volume of air that is exhaled in one second during forced expiration. FEF25-75%—Forced expiratory flow between 25% and 75% of forced vital capacity, which is measured from the FVC curve. EVC—Slow or expiratory vital capacity, which is the volume of air exhaled after a maximum inspiration. IVC—Inspiratory vital capacity, which is the volume of air inhaled after normal expiration (tidal volume). FEV1/FVC—is the ratio of FEV1 to FVC. Intra-Abdominal Pressure (IAP) The IAP was measured intraoperatively at five time points: 1) before and 2) after plication of the anterior rectus sheath; 3) after the L-shaped plication of the external oblique aponeurosis; 4) at the end of surgery; and 5) after placement of the compression garment. The method for the measurement of IAP was described by Kron.29 All IAP measurements were performed intraoperatively with the operating table still in the horizontal position; the table was flexed only after the last measurement. It consists in connecting a system of a saline solution column and a scale in centimeters to a three-way tube to inject 50 mL of the solution in the empty bladder in order to determine the intra-abdominal pressure in cm H2O.29 Statistical Analysis Data were entered into an Excel spreadsheet (Microsoft Corporation, Redwood, WA) and the Statistical Package for the Social Sciences 19.0 for Windows (SPSS Inc., Chicago, IL) was used for data analysis. The Mann-Whitney test was performed to compare patient characteristics (age, BMI, and interrecti distance) between groups. Repeated measures analysis of variance (ANOVA) was carried out for between-group comparisons of spirometric measurements (FVC, FEV1, FEV1/FVC, FEF25-75%, IVC, and EVC) and IAP measurements, followed by Bonferroni’s test, when necessary. All statistical tests were performed at a significance level α of 0.05 (P < 0.05). Data are expressed as mean ± standard deviation (SD). RESULTS No patient dropped out of the postoperative follow up. No significant differences in the main patient characteristics were found between the intervention and control groups. The mean patient age was 32 ± 4.9 years (range, 24-42 years) in the control group and 34 ± 8.8 years (range, 21-50 years) in the intervention group; and the mean BMI was 24.5 ± 0.7 kg/m2 (range, 18.9-25.59 kg/m2) in the control group and 26.0 ± 6.7 7 kg/m2 (range, 20.63-28.3 kg/m2) in the intervention group (Table 1). Table 1. Mean Values of the Main Patient Characteristics in Both Groups Characteristics  Control group (n = 18)  Intervention group (n = 15)  P value  Mean  SD  Mean  SD  BMI (kg/m2)  24.5 (18.9-25.6)  0.7  26.0 (20.6-28.3)  6.7  0.509  Age (yr)  32 (24-42)  4.9  34 (21-50)  8.8  0.486  Interrecti distance (cm)  3 cm above the umbilicus  2.0  0.91  2.25  1.26  0.929  2 cm above the umbilicus  2.0  1.37  2.5  1.17  0.845  2 cm below the umbilicus  2.0  1.22  2.0  1.12  0.762  Characteristics  Control group (n = 18)  Intervention group (n = 15)  P value  Mean  SD  Mean  SD  BMI (kg/m2)  24.5 (18.9-25.6)  0.7  26.0 (20.6-28.3)  6.7  0.509  Age (yr)  32 (24-42)  4.9  34 (21-50)  8.8  0.486  Interrecti distance (cm)  3 cm above the umbilicus  2.0  0.91  2.25  1.26  0.929  2 cm above the umbilicus  2.0  1.37  2.5  1.17  0.845  2 cm below the umbilicus  2.0  1.22  2.0  1.12  0.762  Mann-Whitney test (P ≤ 0.05). View Large There were also no significant between-group differences in spirometric measurements (EVC, FEV1, FVC, FEV1/FVC, FEF25-75%, and IVC) at the 4 time points. Both groups showed similar variations in spirometric measurements over time (Figures 1-6 and Table 2). The comparisons of EVC, FEV1, FVC, FEV1/FVC, FEF25-75%, and IVC between groups at all time points are shown in Figures 1-6. Figure 1. View largeDownload slide Comparison of expiratory vital capacity (EVC) measurements between the control and intervention groups at the 4 time points (P = 0.365, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 1. View largeDownload slide Comparison of expiratory vital capacity (EVC) measurements between the control and intervention groups at the 4 time points (P = 0.365, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 2. View largeDownload slide Comparison of forced expiratory volume in one second (FEV1) measurements between the control and intervention groups at the 4 time points (P = 0.789, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 2. View largeDownload slide Comparison of forced expiratory volume in one second (FEV1) measurements between the control and intervention groups at the 4 time points (P = 0.789, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 3. View largeDownload slide Comparison of forced vital capacity (FVC) measurements between the control and intervention groups at the 4 time points (P = 0.403, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 3. View largeDownload slide Comparison of forced vital capacity (FVC) measurements between the control and intervention groups at the 4 time points (P = 0.403, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 4. View largeDownload slide Comparison of the ratio FEV1/FVC between the control and intervention groups at the 4 time points (P = 0.198, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2 ; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 4. View largeDownload slide Comparison of the ratio FEV1/FVC between the control and intervention groups at the 4 time points (P = 0.198, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2 ; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 5. View largeDownload slide Comparison of FEF25-75% between the control and intervention groups at the 4 time points (P = 0.379, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 5. View largeDownload slide Comparison of FEF25-75% between the control and intervention groups at the 4 time points (P = 0.379, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 6. View largeDownload slide Comparison of IVC between the control and intervention groups at the 4 time points (P = 0.890, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 6. View largeDownload slide Comparison of IVC between the control and intervention groups at the 4 time points (P = 0.890, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Table 2. Comparison of Spirometry Measurements Over Time EVC  P value  IVC  P value  Baseline > PO2  <0.001*  Baseline > PO2  <0.001*  Baseline > PO7  <0.001*  Baseline = PO7  0.185  Baseline > PO15  <0.001*  Baseline = PO15  1.000  PO2 < PO7  <0.001*  PO2 < PO7  0.002*  PO2 < PO15  <0.001*  PO2 < PO15  <0.001*  PO7 < PO15  0.006*  PO7 = PO15  0.179  FEV1    FVC    Baseline > PO2  <0.001*  Baseline > PO2  <0.001*  Baseline > PO7  0.001*  Baseline > PO7  <0.001*  Baseline > PO15  0.004*  Baseline > PO15  0.010*  PO2 < PO7  <0.001*  PO2 < PO7  <0.001*  PO2 < PO15  <0.001*  PO2 < PO15  <0.001*  PO7 = PO15  0.128  PO7 = PO15  0.103  FEV1/FVC    FEF25-75%    Baseline = PO2  0.732  Baseline > PO2  <0.001*  Baseline = PO7  1.000  Baseline > PO7  0.024*  Baseline = PO15  1.000  Baseline = PO15  0.093  PO2 = PO7  0.079  PO2 < PO7  <0.001*  PO2 = PO15  0.881  PO2 < PO15  <0.001*  PO7 = PO15  1.000  PO7 = PO15  0.217  EVC  P value  IVC  P value  Baseline > PO2  <0.001*  Baseline > PO2  <0.001*  Baseline > PO7  <0.001*  Baseline = PO7  0.185  Baseline > PO15  <0.001*  Baseline = PO15  1.000  PO2 < PO7  <0.001*  PO2 < PO7  0.002*  PO2 < PO15  <0.001*  PO2 < PO15  <0.001*  PO7 < PO15  0.006*  PO7 = PO15  0.179  FEV1    FVC    Baseline > PO2  <0.001*  Baseline > PO2  <0.001*  Baseline > PO7  0.001*  Baseline > PO7  <0.001*  Baseline > PO15  0.004*  Baseline > PO15  0.010*  PO2 < PO7  <0.001*  PO2 < PO7  <0.001*  PO2 < PO15  <0.001*  PO2 < PO15  <0.001*  PO7 = PO15  0.128  PO7 = PO15  0.103  FEV1/FVC    FEF25-75%    Baseline = PO2  0.732  Baseline > PO2  <0.001*  Baseline = PO7  1.000  Baseline > PO7  0.024*  Baseline = PO15  1.000  Baseline = PO15  0.093  PO2 = PO7  0.079  PO2 < PO7  <0.001*  PO2 = PO15  0.881  PO2 < PO15  <0.001*  PO7 = PO15  1.000  PO7 = PO15  0.217  EVC, slow or expiratory vital capacity; FEF25-75%, forced expiratory flow between 25% and 75% of forced vital capacity; FEV1, forced expiratory volume in one second; FVC, forced vital capacity; IVC, inspiratory vital capacity; PO, postoperative day. *Statistical significance (P < 0.05, Bonferroni’s test) View Large IAP was significantly lower (P = 0.010) in the intervention group than in the control group at all time points (Figure 7). Figure 7. View largeDownload slide Intra-abdominal pressure (IAP) in the intervention and control groups measured intraoperatively at the 5 time points (P1 to P5), with significant between-group difference over time (P = 0.010, repeated measures ANOVA). P1 = before plication of the anterior rectus sheath; P2 = after plication of the anterior rectus sheath; P3 = after the L-shaped plication of the external oblique aponeurosis; P4 = after skin closure; and P5 = after placement of the compression garment. Figure 7. View largeDownload slide Intra-abdominal pressure (IAP) in the intervention and control groups measured intraoperatively at the 5 time points (P1 to P5), with significant between-group difference over time (P = 0.010, repeated measures ANOVA). P1 = before plication of the anterior rectus sheath; P2 = after plication of the anterior rectus sheath; P3 = after the L-shaped plication of the external oblique aponeurosis; P4 = after skin closure; and P5 = after placement of the compression garment. None of the patients in this series experienced any complication. DISCUSSION Abdominoplasty is the fourth most commonly performed plastic surgery procedure in Brazil, the fifth in the United States, and the sixth worldwide. Brazil is the country where this procedure is the most performed, accounting for 15.4% of the total plastic surgery procedures.1,2,30 Several studies have shown that ventilatory function decreases11-14 and intra-abdominal pressure increases after abdominoplasty,11,14,19-21 and that these changes may lead to postoperative pulmonary complications.21 In addition to the most common postoperative complications associated with abdominoplasty, such as seroma,30,31 hematoma, surgical wound dehiscence, unsightly scars,31,32 and reduced sensitivity of the infraumbilical region,33 some pulmonary complications may occur due to increased intra-abdominal pressure. These are secondary complications to the diaphragmatic movement restriction, including pulmonary atelectasis, pneumonia, respiratory failure, and the need for prolonged mechanical ventilation. This is the first study to postoperatively address the effects of preoperative breathing exercises in abdominoplasty patients. Preoperative exercises were used in an attempt to increase pulmonary expansion, muscular strength, and prevent an increase in IAP. It was difficult to establish an exercise routine, including frequency, number of repetitions, duration and type of exercise, since no gold standard is available in the literature. Respiratory therapy techniques are commonly used in the postoperative period to increase lung reexpansion, decreasing the risk of pulmonary complications resulting from surgery.34-40 No studies were found to date evaluating the prevention of possible pulmonary complications using preoperative breathing exercises in abdominoplasty patients. The study population had a mean interrecti distance of 2 cm. Although this is a common characteristic of patients who seek abdominoplasty and correction of diastasis recti secondary to pregnancy in our institution, it might not be the case in other countries. It is important to note that, even with a small diastasis, a reduction in all spirometry parameters was observed in the control group after surgery. Thus, abdominoplasty combined with plication of the rectus abdominis muscles for interrecti distances of approximately 2 cm leads to ventilatory restriction. This makes this group of patients an ideal model to assess improvement in ventilatory function with the use of an exercise program. After abdominoplasty, the diaphragm requires a force greater than normal during inspiration due to a reduction in abdominal wall compliance and marked increase in diaphragmatic contraction during abdominal motion. This may lead to a decrease in vital capacity due to an increase in residual volume. Correction of diastasis recti and reduction of abdominal fat during abdominoplasty may help improve pulmonary function in the late postoperative period but not in the early postoperative period.12 All patients selected for this study were women and had the same type of abdominal deformity, contributing to the homogeneity of the sample. Women are the most common candidates for abdominoplasty in the nonmassive weight loss patient. Their BMI ranged from 20 to 30 kg/m2 to avoid any pulmonary dysfunction associated with changes in respiratory mechanics due to obesity.7,8 Smokers and patients with obstructive and restrictive respiratory diseases, abnormal chest X-ray, systemic diseases, history of previous abdominal surgery, supraumbilical scars, and marked weight loss after bariatric surgery were not included in the study because these factors may be associated with changes in the ventilatory function, which may impact spirometry. In this study, the exercise program used only basic, evidence-based techniques similar to those described in previous studies on abdominal and thoracic surgeries to prevent postoperative pulmonary complications and contained breathing exercises commonly used in respiratory physiotherapy.17 The exercises were simple and easily understood and performed by the patients. Patient adherence to a respiratory physiotherapy program requires guidance and follow up. The patient may not comply with the exercise regimen or may not perform the exercises correctly. Thus, the patient should to be monitored by a specialist when performing the exercises. Incentive spirometry and exercises such as deep breathing are intended to increase alveolar ventilation, reducing the respiratory dysfunction in the postoperative period.41 It was found that the breathing exercises had no significant impact on spirometry. Perhaps the duration of the exercise program (one week before surgery) may have been insufficient to produce significant improvement. Soares et al42 evaluated the effect of respiratory and global exercises performed 2 to 3 weeks before surgery and found no significant differences in IVC and EVC between intervention and control groups in the postoperative period. However, these authors reported significant between-group differences in maximal inspiratory pressure, indicating a higher inspiratory strength and respiratory muscle endurance in the intervention group than in the control group.42 Thus, further studies are necessary to investigate if 2 or more weeks of preoperative respiratory physiotherapy would improve ventilatory function in patients undergoing abdominoplasty. A systematic review by Pouwels et al43 indicated that preoperative pulmonary physiotherapy prior to major abdominal surgeries seem to be effective in reducing postoperative pulmonary complications. Carneiro et al37 observed that sustained deep inspiration therapy performed 24 hours before surgery and 24 and 48 hours postoperatively tends to decrease FEV1 and FEF25-75% in the postoperative period, but without statistical significance. Cattaneo et al44 found that the preoperative use of incentive spirometry does not prevent postoperative decrease in pulmonary function in bariatric patients. Fagevik Olsén et al18 reported that respiratory physiotherapy before major abdominal surgery decreased the incidence of postoperative pulmonary complications and improved oxygen saturation. A systematic review evaluating the effects of exercise therapy performed before and after upper abdominal surgery concluded that breathing exercises may improve respiratory muscle strength, preventing postoperative pulmonary complication, but also that good quality studies are still necessary.16 There is still no consensus about the efficacy of postoperative breathing exercises in abdominal surgery patients. No evidence has been found to date that the exclusive use of incentive spirometry after upper abdominal surgery prevents pulmonary complications, and there are few scientifically rigorous studies on this topic.45,46 Thomas and McIntosh47 conducted a review to evaluate the efficacy of deep breathing and incentive spirometry after upper abdominal surgery and found that they are indicated to prevent postoperative pulmonary complications such as atelectasis. Thus, it seems that there is no consensus in the literature regarding the use of breathing exercises and incentive spirometry in abdominal surgery in either the pre- or postoperative periods. After abdominoplasty, there is a decrease in ventilatory function and an increase in IAP. The passive stretching of the diaphragm in the cranial direction allows the transmission of the increased IAP to the pleural cavity, reducing the static and dynamic pulmonary compliance.48,49 Thus, an increase in IAP levels results in an increase in inspiratory pressure or decrease in tidal volume.49 In the present study, IAP was significantly lower in the intervention group than in the control group at all time points, from the beginning of surgery to the placement of the compression garment. This may be explained by the fact that breathing exercises increase respiratory compliance, reducing IAP, or by the individual aponeurotic characteristics of patients.50 This finding suggests that it may be possible to reduce the risk of postoperative pulmonary complications in abdominoplasty patients by decreasing the stretching of the diaphragm caused by increased IAP through a preoperative breathing exercise program. Some studies have described a correlation between IAP and pulmonary function parameters.49,51,52 Thus, a complete pulmonary function evaluation, including measurements of lung volumes, should be performed to increase the knowledge about the mechanical behavior of the respiratory system after abdominoplasty. A high IAP leads to an increase venous stasis in the lower limbs, which increases risk of thromboembolic events.52 A low IAP at the beginning of surgery may reduce this risk, as there is a tendency for the IAP to remain low along the procedures, as noted by the results of this study. Berjeaut et al22 showed that an increase in IAP caused by the use of compressive garments may reduce the blood flow by 30% in the common femoral vein. Thus, high IAP may increase the risk of deep vein thrombosis, as stasis is a risk factor for this complication. A larger study to look at the actual reduction in DVT would be very interesting, but it would need a very large number of patients indeed. A further study should be designed to investigate this subject. This study is the first attempt to reduce respiratory complications, which occur in about 6% of patients undergoing abdominoplasty,15 using of preoperative breathing exercises. It is necessary to test other respiratory interventions and to investigate the influence of respiratory mechanics on IAP. One of the limitations of this study is that one cannot state that the reduced intraoperative IAP levels found in the intervention group should be fully attributed to the breathing exercise program, because IAP was not measured before the beginning of the exercise therapy. Such measurement is not feasible to perform on an outpatient basis, because it would be necessary to insert a vesical catheter with the patient under sedation at least once before surgery. It is important to note that a sedate patient has higher muscle tone than an anesthetized patient, which would affect preoperative IAP measurements. Thus, it would be difficult to compare preintervention IAP levels with intraoperative IAP measurements. Other measures should be used to assess IAP levels in future studies, such as a manometry. Some indirectly assessment can also be performed to evaluate IAP levels, such as respirometry, and oxygen saturation among others. Those measurements can be performed on an outpatient basis. In a future study, the preoperative exercises should be done with a binder on. During the design of the present study, we did not consider that IAP would increase just after the placement of a compression garment. IAP is a factor that should always be considered, especially in patients with a large diastasis requiring major intervention through musculoaponeurotic repair, because restriction of diaphragmatic movement with respiratory failure may occur in these cases. The assessment of patients with a normal pulmonary condition was a key point in this study. If an improvement could be detected in such patients, it would suggest testing these exercises in patients with respiratory problems and smokers. Further research in populations requiring more extensive plication or other procedures in the musculoaponeurotic plane should also be carried out. Patients with other respiratory conditions, such as smokers or those with chronic obstructive pulmonary diseases, who wish to undergo abdominoplasty should also be studied. This model should be tested using different breathing exercises, different number of repetitions, postoperative interventions, other types of therapy for the strengthening of respiratory muscles, and positive pressure in an attempt to improve patient ventilation following abdominoplasty, with a consequent reduction in respiratory complications. CONCLUSION The 1 week respiratory physiotherapy program used in this study performed before abdominoplasty had no impact on spirometric parameters, but may have reduced IAP levels measured intraoperatively. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Cosmetic surgery national data bank statistics. Aesthet Surg J . 2016; 36( Suppl 1): 1- 29. 2. International Society of Aesthetic Plastic Surgery (ISAPS). ISAPS International survey on aesthetic/cosmetic: Procedures performed in 2014 . Hanover, NH: ISAPS; 2015. https://www.isaps.org/Media/Default/global-statistics/2015%20ISAPS%20Results.pdf. Accessed April 25, 2017. 3. Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. Plast Reconstr Surg . 2006; 117( 6): 1797- 1808. Google Scholar CrossRef Search ADS PubMed  4. de Brito MJ, Nahas FX, Barbosa MVet al.   Abdominoplasty and its effect on body image, self-esteem, and mental health. Ann Plast Surg . 2010; 65( 1): 5- 10. Google Scholar CrossRef Search ADS PubMed  5. de Brito MJ, Nahas FX, Bussolaro RA, Shinmyo LM, Barbosa MV, Ferreira LM. Effects of abdominoplasty on female sexuality: a pilot study. J Sex Med . 2012; 9( 3): 918- 926. Google Scholar CrossRef Search ADS PubMed  6. da Silva DB, Nahas FX, Bussolaro RA, de Brito MJ, Ferreira LM. The increasing growth of plastic surgery lawsuits in Brazil. Aesthetic Plast Surg . 2010; 34( 4): 541- 542. Google Scholar CrossRef Search ADS PubMed  7. Momeni A, Heier M, Bannasch H, Stark GB. Complications in abdominoplasty: a risk factor analysis. J Plast Reconstr Aesthet Surg . 2009; 62( 10): 1250- 1254. Google Scholar CrossRef Search ADS PubMed  8. Neaman KC, Hansen JE. Analysis of complications from abdominoplasty: a review of 206 cases at a university hospital. Ann Plast Surg . 2007; 58( 3): 292- 298. Google Scholar CrossRef Search ADS PubMed  9. Rock P, Rich PB. Postoperative pulmonary complications. Curr Opin Anaesthesiol . 2003; 16( 2): 123- 131. Google Scholar CrossRef Search ADS PubMed  10. Khan MA, Hussain SF. Pre-operative pulmonary evaluation. J Ayub Med Coll Abbottabad . 2005; 17( 4): 82- 86. Google Scholar PubMed  11. Helene AJr, Saad RJr, Stirbulov R. Respiratory evaluation in patients submitted to abdominoplasty. Rev Col Bras Cir . 2006; 33: 45- 50. Google Scholar CrossRef Search ADS   12. Vaca Escobar B, Gerra Navarrete D, Manzano Manzano R. Postabdominoplasty respiratory changes. Cir Plast Iberolatinoam . 2007; 33: 69- 72. 13. Tercan M, Bekerecioglu M, Dikensoy Oet al.   Effects of abdominoplasty on respiratory functions: a prospective study. Ann Plast Surg . 2002; 49( 6): 617- 620. Google Scholar CrossRef Search ADS PubMed  14. Rodrigues MA, Nahas FX, Gomes HC, Ferreira LM. Ventilatory function and intra-abdominal pressure in patients who underwent abdominoplasty with plication of the external oblique aponeurosis. Aesthetic Plast Surg . 2013; 37( 5): 993- 999. Google Scholar CrossRef Search ADS PubMed  15. Fischer JP, Wes AM, Serletti JM, Kovach SJ. Complications in body contouring procedures: an analysis of 1797 patients from the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program databases. Plast Reconstr Surg . 2013; 132( 6): 1411- 1420. Google Scholar PubMed  16. Grams ST, Ono LM, Noronha MA, Schivinski CI, Paulin E. Breathing exercises in upper abdominal surgery: a systematic review and meta-analysis. Rev Bras Fisioter . 2012; 16( 5): 345- 353. Google Scholar CrossRef Search ADS PubMed  17. Celli BR, Rodriguez KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Am Rev Respir Dis . 1984; 130( 1): 12- 15. Google Scholar PubMed  18. Fagevik Olsén M, Hahn I, Nordgren S, Lönroth H, Lundholm K. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery. Br J Surg . 1997; 84( 11): 1535- 1538. Google Scholar CrossRef Search ADS PubMed  19. Huang GJ, Bajaj AK, Gupta S, Petersen F, Miles DA. Increased intraabdominal pressure in abdominoplasty: delineation of risk factors. Plast Reconstr Surg . 2007; 119( 4): 1319- 1325. Google Scholar CrossRef Search ADS PubMed  20. Graça Neto L, Araújo LR, Rudy MR, Auersvald LA, Graf R. Intraabdominal pressure in abdominoplasty patients. Aesthetic Plast Surg . 2006; 30( 6): 655- 658. Google Scholar CrossRef Search ADS PubMed  21. Talisman R, Kaplan B, Haik J, Aronov S, Shraga A, Orenstein A. Measuring alterations in intra-abdominal pressure during abdominoplasty as a predictive value for possible postoperative complications. Aesthetic Plast Surg . 2002; 26( 3): 189- 192. Google Scholar CrossRef Search ADS PubMed  22. Berjeaut RH, Nahas FX, Dos Santos LK, Filho JD, Ferreira LM. Does the use of compression garments increase venous stasis in the common femoral vein? Plast Reconstr Surg . 2015; 135( 1): 85e- 91e. Google Scholar CrossRef Search ADS PubMed  23. Nahas FX, Ferreira LM. Concepts on correction of the musculoaponeurotic layer in abdominoplasty. Clin Plast Surg . 2010; 37( 3): 527- 538. Google Scholar CrossRef Search ADS PubMed  24. Nahas FX. An aesthetic classification of the abdomen based on the myoaponeurotic layer. Plast Reconstr Surg . 2001; 108( 6): 1787- 1795; discussion 1796. Google Scholar CrossRef Search ADS PubMed  25. Nahas FX. A pragmatic way to treat abdominal deformities based on skin and subcutaneous excess. Aesthetic Plast Surg . 2001; 25( 5): 365- 371. Google Scholar CrossRef Search ADS PubMed  26. Nahas FX. How to deal with the umbilical stalk during abdominoplasty. Plast Reconstr Surg . 2000; 106( 5): 1220- 1221. Google Scholar CrossRef Search ADS PubMed  27. Pereira CAC. I Consenso brasileiro de espirometria [I Brazilian Consensus on Spirometry]. J Pneumol . 1996; 22: 105- 164. http://jornaldepneumologia.com.br/PDF/Suple_179_57_I%20CONSENSO%20BRASILEIRO% 20SOBRE%20ESPIROMETRIA%201996.pdf. Accessed October 15, 2015. 28. Pereira CAC, Neder JA. Diretrizes para testes de função pulmonar [Guidelines for pulmonary function tests]. J Pneumol . 2002; 28: S1- S238. http://www.jornaldepneumologia.com.br/detalhe_suplemento.asp?id=45. Accessed October 15, 2015. 29. Kron IL, Harman PK, Nolan SP. The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg . 1984; 199( 1): 28- 30. Google Scholar CrossRef Search ADS PubMed  30. Di Martino M, Nahas FX, Barbosa MVet al.   Seroma in lipoabdominoplasty and abdominoplasty: a comparative study using ultrasound. Plast Reconstr Surg . 2010; 126( 5): 1742- 1751. Google Scholar CrossRef Search ADS PubMed  31. Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture prevent seroma in abdominoplasty? Plast Reconstr Surg . 2007; 119( 3): 1060- 1064; discussion 1065. Google Scholar CrossRef Search ADS PubMed  32. Nahas FX, Solia D, Ferreira LM, Novo NF. The use of tissue adhesive for skin closure in body contouring surgery. Aesthetic Plast Surg . 2004; 28( 3): 165- 169. Google Scholar CrossRef Search ADS PubMed  33. Farah AB, Nahas FX, Ferreira LM, Mendes Jde A, Juliano Y. Sensibility of the abdomen after abdominoplasty. Plast Reconstr Surg . 2004; 114( 2): 577- 582; discussion 583. Google Scholar CrossRef Search ADS PubMed  34. Hall JC, Tarala R, Harris J, Tapper J, Christiansen K. Incentive spirometry versus routine chest physiotherapy for prevention of pulmonary complications after abdominal surgery. Lancet . 1991; 337( 8747): 953- 956. Google Scholar CrossRef Search ADS PubMed  35. Rezaiguia S, Jayr C. Prevention of respiratory complications after abdominal surgery. Ann Fr Anesth Reanim . 1996; 15( 5): 623- 646. Google Scholar CrossRef Search ADS PubMed  36. Tomich GM, França DC, Diniz MT, Britto RR, Sampaio RF, Parreira VF. Effects of breathing exercises on breathing pattern and thoracoabdominal motion after gastroplasty. J Bras Pneumol . 2010; 36( 2): 197- 204. Google Scholar CrossRef Search ADS PubMed  37. Carneiro EM, Ramos Mde C, Terra GA, Rodrigues Júnior V, Matos D, Crema E. Evaluation of breathing exercise in hormonal and immunological responses in patients undergoing abdominal surgery. Acta Cir Bras . 2013; 28( 5): 385- 390. Google Scholar CrossRef Search ADS PubMed  38. Denehy L, Carroll S, Ntoumenopoulos G, Jenkins S. A randomized controlled trial comparing periodic mask CPAP with physiotherapy after abdominal surgery. Physiother Res Int . 2001; 6( 4): 236- 250. Google Scholar CrossRef Search ADS PubMed  39. Mackay MR, Ellis E, Johnston C. Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients. Aust J Physiother . 2005; 51( 3): 151- 159. Google Scholar CrossRef Search ADS PubMed  40. Manzano RM, Carvalho CR, Saraiva-Romanholo BM, Vieira JE. Chest physiotherapy during immediate postoperative period among patients undergoing upper abdominal surgery: randomized clinical trial. Sao Paulo Med J . 2008; 126( 5): 269- 273. Google Scholar CrossRef Search ADS PubMed  41. Celli B. Respiratory muscle strength after upper abdominal surgery. Thorax . 1993; 48( 7): 683- 684. Google Scholar CrossRef Search ADS PubMed  42. Soares SM, Nucci LB, da Silva MM, Campacci TC. Pulmonary function and physical performance outcomes with preoperative physical therapy in upper abdominal surgery: a randomized controlled trial. Clin Rehabil . 2013; 27( 7): 616- 627. Google Scholar CrossRef Search ADS PubMed  43. Pouwels S, Stokmans RA, Willigendael EMet al.   Preoperative exercise therapy for elective major abdominal surgery: a systematic review. Int J Surg . 2014; 12( 2): 134- 140. Google Scholar CrossRef Search ADS PubMed  44. Cattano D, Altamirano A, Vannucci A, Melnikov V, Cone C, Hagberg CA. Preoperative use of incentive spirometry does not affect postoperative lung function in bariatric surgery. Transl Res . 2010; 156( 5): 265- 272. Google Scholar CrossRef Search ADS PubMed  45. do Nascimento Junior P, Módolo NS, Andrade Set al.   Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database Syst Rev . 2014; 2: CD006058. 46. Overend TJ, Anderson CM, Lucy SD, Bhatia C, Jonsson BI, Timmermans C. The effect of incentive spirometry on postoperative pulmonary complications: a systematic review. Chest . 2001; 120( 3): 971- 978. Google Scholar CrossRef Search ADS PubMed  47. Thomas JA, McIntosh JM. Are incentive spirometry, intermittent positive pressure breathing, and deep breathing exercises effective in the prevention of postoperative pulmonary complications after upper abdominal surgery? A systematic overview and meta-analysis. Phys Ther . 1994; 74( 1): 3- 10; discussion 10. Google Scholar CrossRef Search ADS PubMed  48. Vegar-Brozovic V, Brezak J, Brozovic I. Intra-abdominal hypertension: pulmonary and cerebral complications. Transplant Proc . 2008; 40( 4): 1190- 1192. Google Scholar CrossRef Search ADS PubMed  49. De Waele JJ, De Laet I, Kirkpatrick AW, Hoste E. Intra-abdominal hypertension and abdominal compartment syndrome. Am J Kidney Dis . 2011; 57( 1): 159- 169. Google Scholar CrossRef Search ADS PubMed  50. Nahas FX, Barbosa MV, Ferreira LM. Factors that may influence failure of the correction of the musculoaponeurotic deformities of the abdomen. Plast Reconstr Surg . 2009; 124( 1): 334; author reply 334-334; author reply 335. Google Scholar CrossRef Search ADS PubMed  51. Struck MF, Reske AW, Schmidt T, Hilbert P, Steen M, Wrigge H. Respiratory functions of burn patients undergoing decompressive laparotomy due to secondary abdominal compartment syndrome. Burns . 2014; 40( 1): 120- 126. Google Scholar CrossRef Search ADS PubMed  52. Gaidukov KM, Raibuzhis EN, Hussain Aet al.   Effect of intra-abdominal pressure on respiratory function in patients undergoing ventral hernia repair. World J Crit Care Med . 2013; 2( 2): 9- 16. Google Scholar CrossRef Search ADS PubMed  © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

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Abstract

Abstract Background After abdominoplasty, patients experience decreased ventilatory function and increased intra-abdominal pressure (IAP). Breathing exercises are used during the pre- and postoperative periods of several abdominal surgeries to prevent or minimize postoperative complications. Objectives The aim of this study was to assess the effect of preoperative respiratory physiotherapy on the outcome of abdominoplasty patients. Methods Thirty-three patients were divided into 2 groups. The control group (n = 18) received no preoperative intervention. The intervention group (n = 15) performed breathing exercises during the preoperative period, including incentive spirometry, diaphragmatic breathing, shortened expiration, and sustained maximal inspiration. Respiratory physiotherapy started one week before surgery. Breathing exercises were performed daily. They were performed 3 times weekly in the presence of a physiotherapist and patients were instructed to carry on the exercises at home on days without physiotherapy sessions for three sets of 20 repetitions each. Patients were assessed by spirometry and IAP measurements. Results No significant difference in spirometry was found between groups. However, patients in the intervention group had lower IAP at the start of surgery and at all time points (P = 0.010) compared with controls. Conclusions Preoperative respiratory physiotherapy had no impact on spirometry, but may have contributed to reduce IAP intraoperatively. Level of Evidence: 2 Abdominoplasty is one of the most performed aesthetic surgeries.1,2 In most abdominoplasties, repair of musculoaponeurotic deformities is a combined procedure, with diastasis recti being the most common.3 Although abdominoplasty can improve the quality of life, self-esteem, self-image, and sexuality of patients,4,5 this procedure is still associated with a high number of medical lawsuits, and therefore complications should be prevented.6 Pulmonary embolism is fortunately uncommon but represents one of the most serious postoperative complications.3,7,8 Other postoperative pulmonary complications include atelectasis, pneumonia, bronchoconstriction, respiratory failure, and need for prolonged mechanical ventilation. These complications are associated with increased length of hospital stay, morbidity, and mortality.9,10 Ventilation and pulmonary function after abdominoplasty have been studied by some authors.2,11-14 These authors reported an initial decrease in spirometric parameters, which returned to preoperative levels at about 15 to 30 days postoperatively.2,11-14 Respiratory complications occur in about 6% of patients undergoing abdominoplasty,15 and are associated with the presence of chronic obstructive pulmonary disease, dyspnea at rest, dependent functional status, malnutrition, recurrent incarcerated hernia, concomitant intra-abdominal procedures, American Society of Anesthesiologists (ASA) physical status classification greater than III, and prolonged operative time.15 Therefore, the search for new procedures to prevent postoperative pulmonary complications is necessary, especially for patients with risk factors. Pre- and postoperative respiratory physiotherapy has been reported to prevent pulmonary complications in abdominal surgery. Grams et al16 conducted a systematic review and meta-analysis on breathing exercises in patients who underwent surgeries in the supraumbilical region and found that, despite the low number of studies involved and their poor methodological quality, breathing exercises improved respiratory muscle strength. Celli et al17 concluded that incentive spirometry was the treatment of choice for patients undergoing abdominal surgery because it led to a shorter length of hospital stay compared to the nonintervention group.17 Fagevik Olsén et al18 observed that prophylactic respiratory physiotherapy reduces the incidence of postoperative pulmonary complications and improves mobilization and oxygen saturation after abdominal surgery. Changes in spirometric parameters and increase in intra-abdominal pressure (IAP) occur in normal patients undergoing abdominoplasty.19-21 Any improvement in ventilation observed after breathing exercises indicates a possible treatment effect. This would be especially important in patients with a risk factor for developing pulmonary complications after surgery, such as smokers and patients with chronic obstructive pulmonary disease, among others. No studies were found in the literature to date, showing the efficacy of preoperative breathing exercises in patients undergoing abdominoplasty. Also, there is an increase in IAP after abdominoplasty.14 This increase in IAP leads to a decrease on the speed of blood flow at the common femoral vein by about 30% after abdominoplasty with the use of compressive garments.22 The decrease in blood flow of the femoral vein increases the risk of thromboembolic events. Therefore, the aim of this study was to evaluate the effect of preoperative respiratory physiotherapy on the outcome of abdominoplasty patients focusing on the ventilatory function as well as on the IAP. METHODS This prospective, interventional, single-center controlled clinical trial was approved by the Research Ethics Committee of the Federal University of São Paulo (UNIFESP), Brazil, (approval no. 0773/10) and performed in accordance with the Resolution 196/96 of the Brazilian National Health Council (Conselho Nacional de Saúde, CNS) and Brazilian Ethical Review System on research involving human beings and also in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all patients prior to their inclusion in the study and anonymity was ensured. The study was conducted from February 2012 to December 2015. A nonrandom sample of 33 patients who expressed a desire to undergo abdominoplasty and met study criteria were selected to participated in the study. Inclusion criteria were female gender, 18 to 50 years of age, body mass index (BMI) between 20 and 30 kg/m2, deformities of the skin and subcutaneous tissues in the abdominal region (Nahas’ type III deformity, for which resection of skin and subcutaneous tissue between the umbilicus and pubis is indicated),23,24 and musculoaponeurotic defect with laxity of the entire abdominal wall and flank region (Nahas’ type B deformity, for which plication of both the anterior rectus sheath and external oblique aponeurosis is indicated).25 Patients with obstructive and restrictive respiratory diseases, abnormal chest X-ray, smoking habit, systemic diseases, history of previous abdominal surgery, supraumbilical scars, and marked weight loss after bariatric surgery were not included in the study. Failing to attend the preoperative respiratory physiotherapy sessions or to perform the breathing exercises at home as instructed was also considered as an exclusion criterion. The 33 selected patients who met study criteria were allocated to 2 groups. The first 18 patients were allocated to the control group and received no intervention; and the next 15 patients were allocated to the intervention group and received preoperative respiratory physiotherapy. Respiratory Physiotherapy Intervention Respiratory physiotherapy, consisting of daily breathing exercises, started one week before surgery. The exercises were performed 3 times weekly in the presence of a physiotherapist and patients were instructed to carry on the exercises at home on the other 4 days of the week without physiotherapy sessions. The first physiotherapy session was administered 7 days preoperatively, the second session was carried out 4 days preoperatively, and the last session was conducted one day before surgery. Patients received written instructions for each exercise and a worksheet to complete after the daily exercises. Patients were asked to perform 3 sets of twenty repetitions of each exercise. Each preoperative respiratory physiotherapy session included: Incentive spirometry, which is a breathing exercise designed to help the patient to take long, deep breaths using an incentive spirometer (Respiron, NCS Industry and Commerce, Barueri, Brazil). The patient inhales through the device mouthpiece raising 3 balls, which encourages them to inhale as long as possible. Diaphragmatic breathing is done by contracting the diaphragm so that the abdomen expands on inspiration and contracts slightly on expiration. Shortened expiration, consisting of inspiration to total lung capacity (the maximum amount of air), expiration of a small amount of air, followed by inspiration to total lung capacity and expiration of a small amount of air, and for the last time, inspiration to total lung capacity and normal expiration to residual volume, the maximum amount of air. Sustained maximal inspiration, which is performed by inspiring to total lung capacity, holding for 3 seconds, and normally expiring to residual volume, the maximum amount of air. Surgical Procedure All patients underwent abdominoplasty performed by the same plastic surgeon (F.X.N.), using a standardized technique. The surgical procedure was conducted under general anesthesia. Pancuronium bromide was used as a muscle relaxant at a dosage of 0.3 mL/kg body weight to induce neuromuscular blockade and at 0.15 mL/kg/h for maintenance. A suprapubic incision was made and extended laterally to the anterior superior iliac spines. The dermal-fat flap was superiorly dissected from the subjacent muscles (rectus abdominis and external oblique muscles) and the umbilicus was isolated.26 Diastasis recti was corrected and an L-shaped plication of the external oblique aponeurosis was performed. Excess skin and subcutaneous tissue of the abdominal flap were excised, the umbilicus was transposed, and the skin was closed in layers. Evaluation of Intervention Outcomes Spirometry and measurements of IAP were used to evaluate the intervention outcomes. Spirometry Spirometry was performed one week before surgery and at 2, 7, and 15 days postoperatively, using a portable handheld spirometer (Koko model, nSpire Health Inc., Longmont, CO). The postoperative day 15 was considered the endpoint of the study. The test was conducted in a quiet environment, under the guidance of a physiotherapist (M.A.R.). The patients were instructed to rest for a period prior to spirometry. They remained seated during the test, using a nose clip to prevent air leakage. The test was explained in detail so that the patients could make the forced expiratory maneuvers followed by deep inspiration and normal breathing. Spirometric measurements included:27,28 FVC—Forced vital capacity, which is the volume of air (in liters) that is exhaled during a forced expiration, starting from total lung capacity and ending at complete expiration. FEV1—Forced expiratory volume in one second, which is the volume of air that is exhaled in one second during forced expiration. FEF25-75%—Forced expiratory flow between 25% and 75% of forced vital capacity, which is measured from the FVC curve. EVC—Slow or expiratory vital capacity, which is the volume of air exhaled after a maximum inspiration. IVC—Inspiratory vital capacity, which is the volume of air inhaled after normal expiration (tidal volume). FEV1/FVC—is the ratio of FEV1 to FVC. Intra-Abdominal Pressure (IAP) The IAP was measured intraoperatively at five time points: 1) before and 2) after plication of the anterior rectus sheath; 3) after the L-shaped plication of the external oblique aponeurosis; 4) at the end of surgery; and 5) after placement of the compression garment. The method for the measurement of IAP was described by Kron.29 All IAP measurements were performed intraoperatively with the operating table still in the horizontal position; the table was flexed only after the last measurement. It consists in connecting a system of a saline solution column and a scale in centimeters to a three-way tube to inject 50 mL of the solution in the empty bladder in order to determine the intra-abdominal pressure in cm H2O.29 Statistical Analysis Data were entered into an Excel spreadsheet (Microsoft Corporation, Redwood, WA) and the Statistical Package for the Social Sciences 19.0 for Windows (SPSS Inc., Chicago, IL) was used for data analysis. The Mann-Whitney test was performed to compare patient characteristics (age, BMI, and interrecti distance) between groups. Repeated measures analysis of variance (ANOVA) was carried out for between-group comparisons of spirometric measurements (FVC, FEV1, FEV1/FVC, FEF25-75%, IVC, and EVC) and IAP measurements, followed by Bonferroni’s test, when necessary. All statistical tests were performed at a significance level α of 0.05 (P < 0.05). Data are expressed as mean ± standard deviation (SD). RESULTS No patient dropped out of the postoperative follow up. No significant differences in the main patient characteristics were found between the intervention and control groups. The mean patient age was 32 ± 4.9 years (range, 24-42 years) in the control group and 34 ± 8.8 years (range, 21-50 years) in the intervention group; and the mean BMI was 24.5 ± 0.7 kg/m2 (range, 18.9-25.59 kg/m2) in the control group and 26.0 ± 6.7 7 kg/m2 (range, 20.63-28.3 kg/m2) in the intervention group (Table 1). Table 1. Mean Values of the Main Patient Characteristics in Both Groups Characteristics  Control group (n = 18)  Intervention group (n = 15)  P value  Mean  SD  Mean  SD  BMI (kg/m2)  24.5 (18.9-25.6)  0.7  26.0 (20.6-28.3)  6.7  0.509  Age (yr)  32 (24-42)  4.9  34 (21-50)  8.8  0.486  Interrecti distance (cm)  3 cm above the umbilicus  2.0  0.91  2.25  1.26  0.929  2 cm above the umbilicus  2.0  1.37  2.5  1.17  0.845  2 cm below the umbilicus  2.0  1.22  2.0  1.12  0.762  Characteristics  Control group (n = 18)  Intervention group (n = 15)  P value  Mean  SD  Mean  SD  BMI (kg/m2)  24.5 (18.9-25.6)  0.7  26.0 (20.6-28.3)  6.7  0.509  Age (yr)  32 (24-42)  4.9  34 (21-50)  8.8  0.486  Interrecti distance (cm)  3 cm above the umbilicus  2.0  0.91  2.25  1.26  0.929  2 cm above the umbilicus  2.0  1.37  2.5  1.17  0.845  2 cm below the umbilicus  2.0  1.22  2.0  1.12  0.762  Mann-Whitney test (P ≤ 0.05). View Large There were also no significant between-group differences in spirometric measurements (EVC, FEV1, FVC, FEV1/FVC, FEF25-75%, and IVC) at the 4 time points. Both groups showed similar variations in spirometric measurements over time (Figures 1-6 and Table 2). The comparisons of EVC, FEV1, FVC, FEV1/FVC, FEF25-75%, and IVC between groups at all time points are shown in Figures 1-6. Figure 1. View largeDownload slide Comparison of expiratory vital capacity (EVC) measurements between the control and intervention groups at the 4 time points (P = 0.365, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 1. View largeDownload slide Comparison of expiratory vital capacity (EVC) measurements between the control and intervention groups at the 4 time points (P = 0.365, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 2. View largeDownload slide Comparison of forced expiratory volume in one second (FEV1) measurements between the control and intervention groups at the 4 time points (P = 0.789, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 2. View largeDownload slide Comparison of forced expiratory volume in one second (FEV1) measurements between the control and intervention groups at the 4 time points (P = 0.789, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 3. View largeDownload slide Comparison of forced vital capacity (FVC) measurements between the control and intervention groups at the 4 time points (P = 0.403, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 3. View largeDownload slide Comparison of forced vital capacity (FVC) measurements between the control and intervention groups at the 4 time points (P = 0.403, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 4. View largeDownload slide Comparison of the ratio FEV1/FVC between the control and intervention groups at the 4 time points (P = 0.198, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2 ; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 4. View largeDownload slide Comparison of the ratio FEV1/FVC between the control and intervention groups at the 4 time points (P = 0.198, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2 ; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 5. View largeDownload slide Comparison of FEF25-75% between the control and intervention groups at the 4 time points (P = 0.379, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 5. View largeDownload slide Comparison of FEF25-75% between the control and intervention groups at the 4 time points (P = 0.379, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 6. View largeDownload slide Comparison of IVC between the control and intervention groups at the 4 time points (P = 0.890, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Figure 6. View largeDownload slide Comparison of IVC between the control and intervention groups at the 4 time points (P = 0.890, repeated measures ANOVA). Baseline = preoperative assessment; PO2 = postoperative day 2; PO7 = postoperative day 7; PO15 = postoperative day 15. Table 2. Comparison of Spirometry Measurements Over Time EVC  P value  IVC  P value  Baseline > PO2  <0.001*  Baseline > PO2  <0.001*  Baseline > PO7  <0.001*  Baseline = PO7  0.185  Baseline > PO15  <0.001*  Baseline = PO15  1.000  PO2 < PO7  <0.001*  PO2 < PO7  0.002*  PO2 < PO15  <0.001*  PO2 < PO15  <0.001*  PO7 < PO15  0.006*  PO7 = PO15  0.179  FEV1    FVC    Baseline > PO2  <0.001*  Baseline > PO2  <0.001*  Baseline > PO7  0.001*  Baseline > PO7  <0.001*  Baseline > PO15  0.004*  Baseline > PO15  0.010*  PO2 < PO7  <0.001*  PO2 < PO7  <0.001*  PO2 < PO15  <0.001*  PO2 < PO15  <0.001*  PO7 = PO15  0.128  PO7 = PO15  0.103  FEV1/FVC    FEF25-75%    Baseline = PO2  0.732  Baseline > PO2  <0.001*  Baseline = PO7  1.000  Baseline > PO7  0.024*  Baseline = PO15  1.000  Baseline = PO15  0.093  PO2 = PO7  0.079  PO2 < PO7  <0.001*  PO2 = PO15  0.881  PO2 < PO15  <0.001*  PO7 = PO15  1.000  PO7 = PO15  0.217  EVC  P value  IVC  P value  Baseline > PO2  <0.001*  Baseline > PO2  <0.001*  Baseline > PO7  <0.001*  Baseline = PO7  0.185  Baseline > PO15  <0.001*  Baseline = PO15  1.000  PO2 < PO7  <0.001*  PO2 < PO7  0.002*  PO2 < PO15  <0.001*  PO2 < PO15  <0.001*  PO7 < PO15  0.006*  PO7 = PO15  0.179  FEV1    FVC    Baseline > PO2  <0.001*  Baseline > PO2  <0.001*  Baseline > PO7  0.001*  Baseline > PO7  <0.001*  Baseline > PO15  0.004*  Baseline > PO15  0.010*  PO2 < PO7  <0.001*  PO2 < PO7  <0.001*  PO2 < PO15  <0.001*  PO2 < PO15  <0.001*  PO7 = PO15  0.128  PO7 = PO15  0.103  FEV1/FVC    FEF25-75%    Baseline = PO2  0.732  Baseline > PO2  <0.001*  Baseline = PO7  1.000  Baseline > PO7  0.024*  Baseline = PO15  1.000  Baseline = PO15  0.093  PO2 = PO7  0.079  PO2 < PO7  <0.001*  PO2 = PO15  0.881  PO2 < PO15  <0.001*  PO7 = PO15  1.000  PO7 = PO15  0.217  EVC, slow or expiratory vital capacity; FEF25-75%, forced expiratory flow between 25% and 75% of forced vital capacity; FEV1, forced expiratory volume in one second; FVC, forced vital capacity; IVC, inspiratory vital capacity; PO, postoperative day. *Statistical significance (P < 0.05, Bonferroni’s test) View Large IAP was significantly lower (P = 0.010) in the intervention group than in the control group at all time points (Figure 7). Figure 7. View largeDownload slide Intra-abdominal pressure (IAP) in the intervention and control groups measured intraoperatively at the 5 time points (P1 to P5), with significant between-group difference over time (P = 0.010, repeated measures ANOVA). P1 = before plication of the anterior rectus sheath; P2 = after plication of the anterior rectus sheath; P3 = after the L-shaped plication of the external oblique aponeurosis; P4 = after skin closure; and P5 = after placement of the compression garment. Figure 7. View largeDownload slide Intra-abdominal pressure (IAP) in the intervention and control groups measured intraoperatively at the 5 time points (P1 to P5), with significant between-group difference over time (P = 0.010, repeated measures ANOVA). P1 = before plication of the anterior rectus sheath; P2 = after plication of the anterior rectus sheath; P3 = after the L-shaped plication of the external oblique aponeurosis; P4 = after skin closure; and P5 = after placement of the compression garment. None of the patients in this series experienced any complication. DISCUSSION Abdominoplasty is the fourth most commonly performed plastic surgery procedure in Brazil, the fifth in the United States, and the sixth worldwide. Brazil is the country where this procedure is the most performed, accounting for 15.4% of the total plastic surgery procedures.1,2,30 Several studies have shown that ventilatory function decreases11-14 and intra-abdominal pressure increases after abdominoplasty,11,14,19-21 and that these changes may lead to postoperative pulmonary complications.21 In addition to the most common postoperative complications associated with abdominoplasty, such as seroma,30,31 hematoma, surgical wound dehiscence, unsightly scars,31,32 and reduced sensitivity of the infraumbilical region,33 some pulmonary complications may occur due to increased intra-abdominal pressure. These are secondary complications to the diaphragmatic movement restriction, including pulmonary atelectasis, pneumonia, respiratory failure, and the need for prolonged mechanical ventilation. This is the first study to postoperatively address the effects of preoperative breathing exercises in abdominoplasty patients. Preoperative exercises were used in an attempt to increase pulmonary expansion, muscular strength, and prevent an increase in IAP. It was difficult to establish an exercise routine, including frequency, number of repetitions, duration and type of exercise, since no gold standard is available in the literature. Respiratory therapy techniques are commonly used in the postoperative period to increase lung reexpansion, decreasing the risk of pulmonary complications resulting from surgery.34-40 No studies were found to date evaluating the prevention of possible pulmonary complications using preoperative breathing exercises in abdominoplasty patients. The study population had a mean interrecti distance of 2 cm. Although this is a common characteristic of patients who seek abdominoplasty and correction of diastasis recti secondary to pregnancy in our institution, it might not be the case in other countries. It is important to note that, even with a small diastasis, a reduction in all spirometry parameters was observed in the control group after surgery. Thus, abdominoplasty combined with plication of the rectus abdominis muscles for interrecti distances of approximately 2 cm leads to ventilatory restriction. This makes this group of patients an ideal model to assess improvement in ventilatory function with the use of an exercise program. After abdominoplasty, the diaphragm requires a force greater than normal during inspiration due to a reduction in abdominal wall compliance and marked increase in diaphragmatic contraction during abdominal motion. This may lead to a decrease in vital capacity due to an increase in residual volume. Correction of diastasis recti and reduction of abdominal fat during abdominoplasty may help improve pulmonary function in the late postoperative period but not in the early postoperative period.12 All patients selected for this study were women and had the same type of abdominal deformity, contributing to the homogeneity of the sample. Women are the most common candidates for abdominoplasty in the nonmassive weight loss patient. Their BMI ranged from 20 to 30 kg/m2 to avoid any pulmonary dysfunction associated with changes in respiratory mechanics due to obesity.7,8 Smokers and patients with obstructive and restrictive respiratory diseases, abnormal chest X-ray, systemic diseases, history of previous abdominal surgery, supraumbilical scars, and marked weight loss after bariatric surgery were not included in the study because these factors may be associated with changes in the ventilatory function, which may impact spirometry. In this study, the exercise program used only basic, evidence-based techniques similar to those described in previous studies on abdominal and thoracic surgeries to prevent postoperative pulmonary complications and contained breathing exercises commonly used in respiratory physiotherapy.17 The exercises were simple and easily understood and performed by the patients. Patient adherence to a respiratory physiotherapy program requires guidance and follow up. The patient may not comply with the exercise regimen or may not perform the exercises correctly. Thus, the patient should to be monitored by a specialist when performing the exercises. Incentive spirometry and exercises such as deep breathing are intended to increase alveolar ventilation, reducing the respiratory dysfunction in the postoperative period.41 It was found that the breathing exercises had no significant impact on spirometry. Perhaps the duration of the exercise program (one week before surgery) may have been insufficient to produce significant improvement. Soares et al42 evaluated the effect of respiratory and global exercises performed 2 to 3 weeks before surgery and found no significant differences in IVC and EVC between intervention and control groups in the postoperative period. However, these authors reported significant between-group differences in maximal inspiratory pressure, indicating a higher inspiratory strength and respiratory muscle endurance in the intervention group than in the control group.42 Thus, further studies are necessary to investigate if 2 or more weeks of preoperative respiratory physiotherapy would improve ventilatory function in patients undergoing abdominoplasty. A systematic review by Pouwels et al43 indicated that preoperative pulmonary physiotherapy prior to major abdominal surgeries seem to be effective in reducing postoperative pulmonary complications. Carneiro et al37 observed that sustained deep inspiration therapy performed 24 hours before surgery and 24 and 48 hours postoperatively tends to decrease FEV1 and FEF25-75% in the postoperative period, but without statistical significance. Cattaneo et al44 found that the preoperative use of incentive spirometry does not prevent postoperative decrease in pulmonary function in bariatric patients. Fagevik Olsén et al18 reported that respiratory physiotherapy before major abdominal surgery decreased the incidence of postoperative pulmonary complications and improved oxygen saturation. A systematic review evaluating the effects of exercise therapy performed before and after upper abdominal surgery concluded that breathing exercises may improve respiratory muscle strength, preventing postoperative pulmonary complication, but also that good quality studies are still necessary.16 There is still no consensus about the efficacy of postoperative breathing exercises in abdominal surgery patients. No evidence has been found to date that the exclusive use of incentive spirometry after upper abdominal surgery prevents pulmonary complications, and there are few scientifically rigorous studies on this topic.45,46 Thomas and McIntosh47 conducted a review to evaluate the efficacy of deep breathing and incentive spirometry after upper abdominal surgery and found that they are indicated to prevent postoperative pulmonary complications such as atelectasis. Thus, it seems that there is no consensus in the literature regarding the use of breathing exercises and incentive spirometry in abdominal surgery in either the pre- or postoperative periods. After abdominoplasty, there is a decrease in ventilatory function and an increase in IAP. The passive stretching of the diaphragm in the cranial direction allows the transmission of the increased IAP to the pleural cavity, reducing the static and dynamic pulmonary compliance.48,49 Thus, an increase in IAP levels results in an increase in inspiratory pressure or decrease in tidal volume.49 In the present study, IAP was significantly lower in the intervention group than in the control group at all time points, from the beginning of surgery to the placement of the compression garment. This may be explained by the fact that breathing exercises increase respiratory compliance, reducing IAP, or by the individual aponeurotic characteristics of patients.50 This finding suggests that it may be possible to reduce the risk of postoperative pulmonary complications in abdominoplasty patients by decreasing the stretching of the diaphragm caused by increased IAP through a preoperative breathing exercise program. Some studies have described a correlation between IAP and pulmonary function parameters.49,51,52 Thus, a complete pulmonary function evaluation, including measurements of lung volumes, should be performed to increase the knowledge about the mechanical behavior of the respiratory system after abdominoplasty. A high IAP leads to an increase venous stasis in the lower limbs, which increases risk of thromboembolic events.52 A low IAP at the beginning of surgery may reduce this risk, as there is a tendency for the IAP to remain low along the procedures, as noted by the results of this study. Berjeaut et al22 showed that an increase in IAP caused by the use of compressive garments may reduce the blood flow by 30% in the common femoral vein. Thus, high IAP may increase the risk of deep vein thrombosis, as stasis is a risk factor for this complication. A larger study to look at the actual reduction in DVT would be very interesting, but it would need a very large number of patients indeed. A further study should be designed to investigate this subject. This study is the first attempt to reduce respiratory complications, which occur in about 6% of patients undergoing abdominoplasty,15 using of preoperative breathing exercises. It is necessary to test other respiratory interventions and to investigate the influence of respiratory mechanics on IAP. One of the limitations of this study is that one cannot state that the reduced intraoperative IAP levels found in the intervention group should be fully attributed to the breathing exercise program, because IAP was not measured before the beginning of the exercise therapy. Such measurement is not feasible to perform on an outpatient basis, because it would be necessary to insert a vesical catheter with the patient under sedation at least once before surgery. It is important to note that a sedate patient has higher muscle tone than an anesthetized patient, which would affect preoperative IAP measurements. Thus, it would be difficult to compare preintervention IAP levels with intraoperative IAP measurements. Other measures should be used to assess IAP levels in future studies, such as a manometry. Some indirectly assessment can also be performed to evaluate IAP levels, such as respirometry, and oxygen saturation among others. Those measurements can be performed on an outpatient basis. In a future study, the preoperative exercises should be done with a binder on. During the design of the present study, we did not consider that IAP would increase just after the placement of a compression garment. IAP is a factor that should always be considered, especially in patients with a large diastasis requiring major intervention through musculoaponeurotic repair, because restriction of diaphragmatic movement with respiratory failure may occur in these cases. The assessment of patients with a normal pulmonary condition was a key point in this study. If an improvement could be detected in such patients, it would suggest testing these exercises in patients with respiratory problems and smokers. Further research in populations requiring more extensive plication or other procedures in the musculoaponeurotic plane should also be carried out. Patients with other respiratory conditions, such as smokers or those with chronic obstructive pulmonary diseases, who wish to undergo abdominoplasty should also be studied. This model should be tested using different breathing exercises, different number of repetitions, postoperative interventions, other types of therapy for the strengthening of respiratory muscles, and positive pressure in an attempt to improve patient ventilation following abdominoplasty, with a consequent reduction in respiratory complications. CONCLUSION The 1 week respiratory physiotherapy program used in this study performed before abdominoplasty had no impact on spirometric parameters, but may have reduced IAP levels measured intraoperatively. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Cosmetic surgery national data bank statistics. Aesthet Surg J . 2016; 36( Suppl 1): 1- 29. 2. International Society of Aesthetic Plastic Surgery (ISAPS). ISAPS International survey on aesthetic/cosmetic: Procedures performed in 2014 . Hanover, NH: ISAPS; 2015. https://www.isaps.org/Media/Default/global-statistics/2015%20ISAPS%20Results.pdf. Accessed April 25, 2017. 3. Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. 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Aesthetic Surgery JournalOxford University Press

Published: Mar 1, 2018

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