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Abdominoplasty-Related Nerve Injuries: Systematic Review and Treatment Options Ivica Ducic, Hesham M. Zakaria, John M. Felder III and Sarah Arnspiger Aesthetic Surgery Journal 2014 34: 284 originally published online 16 January 2014 DOI: 10.1177/1090820X13516341 The online version of this article can be found at: http://aes.sagepub.com/content/34/2/284
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research-article2014
AESXXX10.1177/1090820X13516341Aesthetic Surgery JournalDucic et al
Body Contouring
Abdominoplasty-Related Nerve Injuries: Systematic Review and Treatment Options
Aesthetic Surgery Journal 2014, Vol. 34(2) 284– 297 © 2014 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www. sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X13516341 www.aestheticsurgeryjournal.com
Ivica Ducic, MD, PhD; Hesham M. Zakaria, MD; John M. Felder III, MD; and Sarah Arnspiger, BA
Abstract Background: Abdominoplasty is a common cosmetic procedure; nerve injury is an underexplored risk of the procedure. Objective: The authors review existing literature to examine the incidence and treatment of nerve injuries after abdominoplasty procedures and provide a treatment algorithm based on their results. Methods: A search of the literature on MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews was undertaken. After full-text review, 23 articles met our criteria. Any mentions of nerve injury, including references to a lack of nerve injury, were documented. All data were pooled for analysis. From our combined data, we calculated the risks of postabdominoplasty nerve injury by dividing the total number of nerve injuries by the total number of patients. Results: Pooled data showed that 1.94% of patients sustained specific nerve injury, and 1.02% of patients sustained permanent injury after abdominoplasty. In addition, 7.67% experienced decreased sensation, 1.07% reported chronic pain, and 0.44% reported temporary weakness or paralysis. Nerves directly injured were the lateral femoral cutaneous (1.36% of patients) and iliohypogastric (0.10%) nerves. Nerves injured from surgical positioning were the brachial plexus (0.10%), musculocutaneous (0.10%), radial (0.05%), sciatic (0.19%), and common peroneal (0.05%) nerves. Conclusions: Although our results showed a low incidence of postabdominoplasty nerve injury, the lasting impact on affected patients’ quality of life can be significant. Appropriate and timely treatment by a multidisciplinary team is critical to optimize patient outcomes. Better reporting of nerve injuries in future studies of abdominoplasty will provide more accurate information about the incidence and consequences of these injuries. Level of Evidence: 4 Keywords abdominoplasty, body contouring, aesthetic surgery, cosmetic surgery, chronic pain, nerve injury, surgical complications Accepted for publication July 9, 2013.
Abdominoplasty is one of the most common cosmetic procedures, with 144 929 completed in the United States in 2010. This number represents an increase of over 300% since 1997.1 The procedure’s popularity is expected to continue to rise due to a growing demand for post–massive weight loss contouring procedures, an increase in the overall number of aesthetic surgery procedures, and an aging “baby boomer” population. Given the growing number of abdominoplasties being performed, it is increasingly important for surgeons and patients to understand the risks and morbidity of this procedure.2-4
The most common complications of abdominoplasties can be divided into 3 categories: immediate, early, and late complications. Immediate complications, which are also From the Departments of Neurosurgery and Plastic Surgery, Georgetown University Hospital, Washington, DC.
Corresponding Author: Dr Ivica Ducic, Departments of Plastic Surgery and Neurosurgery, Peripheral Nerve Surgery Institute, Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007, USA. E-mail: [email protected]
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Table 1. Inclusion and Exclusion Criteria for Systematic Review Inclusion Criteria
Exclusion Criteria
• English language • Patient age 13 years or older • Study type: randomized controlled trials; cohorts; case series; case reports; cross-sectional studies; meta-analyses; systematic reviews • Procedure was abdominoplasty • Procedure was surgical • Procedure was cosmetic (not reconstructive or revisional)
the most life-threatening and least common, are deep vein thrombosis,5-7 pulmonary emboli,8-10 and fat emboli. Early complications are seroma, hematoma, infection, and skin necrosis/dehiscence.11-15 Late complications include asymmetry of abdominal contour, recurrent diastasis, and scar hypertrophy.3 The risk of these complications is increased in patients who are obese,16-19 patients who smoke,20-22 and patients who have diabetes mellitus.13,23 A lesser-discussed, underexplored risk of abdominoplasty procedures is nerve injury. The standard abdominoplasty technique requires an incision along the lower aspect of the abdomen, where nerves such as the femoral, lateral femoral cutaneous, iliohypogastric, and ilioinguinal are potentially within the surgical field. Damage to these nerves is associated with chronic pain, numbness, and paralysis and can drastically affect a patient’s quality of life.24-26 Articles exist that specifically characterize skin sensitivity changes after abdominoplasty,27-30 but most studies only briefly mention nerve injury as a potential complication. We sought to determine the incidence of nerve injury after abdominoplasty by performing a systematic review of the literature with pooled analysis of results from the existing literature. Secondarily, we present a comprehensive treatment algorithm for patients who do experience nerve injury. This information can further patients’ understanding of abdominoplasty’s risks and raise plastic surgeons’ awareness of the incidence and treatment of postabdominoplasty nerve injury.
Methods Search Strategy We conducted a search of the literature on MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews. The strategy was to use the “and” function to combine terms identifying procedures with terms identifying nerve injury. Key search terms for abdominoplasty included abdominoplast*, body contour*, and liposuction. Key search terms for nerve injury included hypesthesia, nerve damage, nerve injur*, neuralg*, neuroma, neuropath*, numb*, pain, paraly*, paresis, paresthesia, sens*, and weak*. Subject headings were incorporated wherever possible. The search was deliberately broad in order to capture the
• • • • • • •
Non-English language Patient age younger than 13 years Study type: narrative review; editorial; letter; commentary; erratum No mention of rate of nerve injury Procedure was not abdominoplasty Procedure was not surgical Procedure was reconstructive or revisional (not cosmetic)
greatest number of articles. It was not limited by date of publication but was limited to the English language. With the exception of narrative reviews, editorials, letters, commentaries, and erratum, all study types were included. Additional studies were identified by reviewing the reference lists of relevant articles from our search results and by contacting experts in the field.
Selection Criteria and Quality Assessment Specific inclusion and exclusion criteria, shown in Table 1, were established before conducting the search. We initially searched for articles pertaining to nerve injuries that occurred in the context of several cosmetic procedures. Articles specific to abdominoplasty were then selected from those results. Procedures that were nonsurgical, revisional (correctional procedures after a primary procedure), or reconstructive (procedures to correct a defect or pathology) were excluded, as were studies that did not mention nerve injury in the full text. To eliminate bias and provide the most accurate incidence of nerve injury possible, studies that noted a nerve injury incidence of 0 were included, and “zero” was recorded in the data input form. Our initial search yielded 4806 citations, 717 of which were eliminated as duplicates. Three independent reviewers (SA, JMF, and HMZ) evaluated titles and abstracts, applied the inclusion and exclusion criteria, and excluded all irrelevant studies. Full text was obtained for 458 citations, 42 of which related to abdominoplasty. Of the 42 citations, 26 were eliminated by the exclusion criteria during full-text review. Extensive hand-searching yielded 7 additional articles that met our criteria. Ultimately, a total of 23 citations were included and reviewed. Figure 1 details the process of identifying articles to include in this review. The quality of the studies was assessed using the American Society of Plastic Surgeons Evidence Rating Scale for Prognostic Studies, published in 2011.31
Data Extraction Two investigators (SA and HMZ) independently reviewed articles for data extraction. Characteristics recorded for each
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Total Risk of Nerve Injury
Figure 1. Citation attrition diagram.
article included year of publication, journal title, study type, and level of evidence (LOE). Population characteristics recorded included location, sex, average age, and average body mass index (BMI). Any mentions of nerve injury, including references to a lack of nerve injury, were documented. Whenever possible, investigators recorded the specific nerve injured, deficits associated with the nerve injury, and duration of injury.
Statistical Methods The specific data points from each article were recorded in a Microsoft Excel (Microsoft Corp, Redmond, Washington) data sheet. All data were pooled for analysis; specifically, we combined the patients, the number of nerve injuries, and the number of nerve deficits from the 23 selected articles. From our combined data, we calculated the risk by dividing the total number of nerve injuries by the total number of patients. A true metaanalysis was not feasible given the heterogeneity of the substrate studies.
Results Clinical Data A total of 23 studies discussed sensory changes or nerve injury after abdominoplasty: 4 case reports (LOE 5),32-35 3 case series (LOE 4),25,36,37 4 case-control studies (LOE 3),27-29,38 and 12 retrospective or prospective cohort studies (LOE 2).9,14,23,26,30,39-45 Two studies specifically mentioned a 0 rate of nerve injury.28,36 Table 2 details the characteristics of these studies.
The risk of any nerve injury calculated with data pooled from the 23 selected studies was 1.94% (n = 40/2061 patients undergoing abdominoplasty). Postabdominoplasty nerve injuries can be divided into those injured secondary to the abdominoplasty incision and those injured secondary to surgical positioning. The pooled risk calculated for incisional nerve injury was 1.46% (n = 30/2061). The pooled risk calculated for positional nerve injury was 0.49% (n = 10/2061 patients). Nerves injured from abdominoplasty incisions, with their respective risks, were the lateral femoral cutaneous (1.36%; n = 28/2061 patients) and the iliohypogastric (0.10%; n = 2). Nerves injured from surgical positioning during abdominoplasty, with their respective risks, were the brachial plexus (0.10%; n = 2/2061 patients), the musculocutaneous (0.10%; n = 2), the radial (0.05%; n = 1), the sciatic (0.19%; n = 4), and the common peroneal (0.05%; n = 1). Table 3 shows the risk of specific nerve injury after abdominoplasty as well as the rates of recovery for each.
Incisional Injuries Lateral Femoral Cutaneous Nerve The lateral femoral cutaneous nerve (LFCN) was injured after abdominoplasty in 6 studies9,14,26,38,39,44 and was the nerve most commonly injured after abdominoplasty. The percent of patients who sustained LFCN injury within each study varied greatly, ranging from 0.36%14 to 10%.39 The pooled risk calculated for injury to the LFCN was 1.36% (n = 28/2061 patients). Gmür et al’s prospective study of 73 patients sought to determine the safety of combining abdominoplasty with dermolipectomy procedures of the upper arms, inner thighs, breasts, and buttocks among patients who had undergone any weight loss.38 They noted that 1 patient had dysesthesia of the LFCN but do not elaborate further.38 A retrospective study by Floros and Davis26 examined the complications and results of 133 patients who had undergone abdominoplasty. They identified a total of 13 patients who experienced injury to the LFCN, with eventual recovery over an unspecified period of time in 4 patients and partial recovery in 1 patient. Eleven of the 13 patients with LFCN injuries were within a cohort of 34 patients who responded to a survey and attended followup clinics 4.5 years after their abdominoplasty, creating the oft-cited >30% rate of LFCN nerve injury (11 of 34).26 The higher number of patients with LFCN injury in the cohort of patients who attended postoperative clinics is likely due to closer follow-up over a longer period of time. This patient population is also less likely to have confounding postoperative surgical symptoms, simplifying the
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Journal of Plastic, Reconstructive, and Aesthetic Surgery
Annals of Plastic Surgery
Journal of the American College of Surgeons
British Journal of Plastic Surgery
Plastic and Reconstructive Surgery
Obesity Surgery
Obesity Surgery
Plastic and Reconstructive Surgery
Annals of Plastic Surgery
2006
2007
1997
1991
2004
2008
2005
2008
1994
2002
2010
Stewart et al14
Neaman and Hansen23
Nahabedian and Dellon25
Floros and Davis26
Farah et al27
Bussolaro et al28
Fels et al29
Dini et al30
Liszka et al32
Akinbingol et al33
Rawlani et al34
Plastic and Reconstructive Surgery
Aesthetic Plastic Surgery
Plastic and Reconstructive Surgery
2001
van Uchelen et al9
Journal
Year
Authors
Case report
Case report
Case report
Cohortretrospective
Cohortprospective
Case-control
Case-control
Cohortretrospective
Case report/series
Cohortretrospective
Cohortretrospective
Cohortretrospective
Study Type
5
5
5
2
3
3
3
2
4
2
2
2
Level of Evidence
1
1
1
41
25
24
20
133
13
206
278
86
No. of Patients
28
56
62
43.6
37
37.6
43.55
35
Unspecified
43
46
34.3 M/ 38.9 F
Average Age, y
Table 2. Studies and Data Gathered During Systematic Review With Pooled Calculations
0
0
0
18
25
0
11
4
0
1
0
60
Cutaneous
0
0
0
0
0
0
0
13
0
0
1
8
0
0
1
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
Lateral Femoral Cutaneous Iliohypogastric Musculocutaneous
No. of Injured Nerves
0
0
0
0
0
0
0
0
0
0
0
1
Radial
0
0
0
0
0
0
0
0
0
0
0
0
Common Peroneal
2
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
2
2
1
0
0
0
0
13
1
0
1
10
Sciatic Brachial Plexus No. of Total Injured
(continued)
Case report
Case report
Case report
0
0
0
0
9.77
7.69
0
0.36
11.63
% Injured
288
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British Journal of Plastic Surgery
Plastic and Reconstructive Surgery
Plastic and Reconstructive Surgery
Obesity Surgery
Aesthetic Surgery Journal
Aesthetic Surgery Journal
Journal of Plastic Surgery and Hand Surgery
2003
1997
1998
1999
2003
2012
2012
2012
Gmür et al38
Al-Qattan39
Zukowski et al40
Shestak41
Rhomberg et al42
Gray et al43
Pollock and Pollock44
Staalesen et al45
Hernia
2009
Palanivelu et al37
Annals of Plastic Surgery
Plastic and Reconstructive Surgery
Journal of Plastic, Reconstructive, and Aesthetic Surgery
2003
2010
Kiermeir et al35
Journal
Abramson36
Year
Authors
Table 2. (continued)
Cohortretrospective
Cohortretrospective
Cohortretrospective
Cohortretrospective
Cohortretrospective
Cohortretrospective
Cohortretrospective
Cohortprospective
Cohortprospective
Cohortretrospective
Case report
Study Type
161
2061
Sum Totals:
597
206
12
29
90
20
73
18
24
2
No. of Patients
2
2
2
2
2
2
2
3
4
4
5
Level of Evidence
40, nonbariatric; 41.5, postbariatric
46.5
40
37.3
Unspecified
33
41
41
41.8
Unspecified
31
Average Age, y
143
17
0
1
0
1
3
0
0
2
0
0
Cutaneous
28
0
3
0
0
0
0
2
1
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
2
0
0
0
1
0
0
0
0
0
0
0
Lateral Femoral Cutaneous Iliohypogastric Musculocutaneous
No. of Injured Nerves
1
0
0
0
0
0
0
0
0
0
0
0
Radial
1
0
0
0
0
0
0
0
1
0
0
0
Common Peroneal
4
0
0
0
0
0
0
0
0
0
0
2
2
0
0
0
0
0
0
0
0
0
0
0
0
3
0
1
0
0
2
2
0
0
2
Sciatic Brachial Plexus No. of Total Injured
0
0.50
0
8.33
0
0
10.0
2.74
0
0
Case report
% Injured
Ducic et al
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Table 3. Pooled Risk of Specific Nerve Injury After Abdominoplasty No. (%) of Patients Injureda
No. (%) Not Recovered
Lateral femoral cutaneous
28 (1.36)
21 (1.02)
Iliohypogastric
2 (0.10)
0
Brachial plexus
2 (0.10)
0
Musculocutaneous
2 (0.10)
0
Radial
1 (0.05)
0
Sciatic
4 (0.19)
2 (0.10)
Common peroneal
1 (0.05)
0
Nerve Incisional injuries Positional injuries
a
N = 2061.
diagnosis of LFCN injury. The remainder of the 99 patients were studied by chart review only, including 2 others who sustained LFCN injuries.26 A retrospective study by Al-Qattan39 presented the complications of 20 multiparous women with severe musculoaponeurotic laxity who had undergone abdominoplasty. Two patients in his cohort sustained injury to the LFCN that was described as “permanent,” without further elaboration. A retrospective study by van Uchelen et al9 sought to characterize postabdominoplasty complications in 86 patients. They noted that 7 women and 1 man sustained injury to the LFCN but do not elaborate further. A retrospective study by Stewart et al14 surveyed complications of 278 patients who had undergone abdominoplasty. They noted that 1 patient had altered thigh sensation. No further elaboration was provided. A retrospective study by Pollock and Pollock44 focused on the use of progressive tension sutures in 597 abdominoplasty patients. Their findings indicated that progressive tension sutures could minimize seroma and potentially decrease other complications. After undergoing abdominoplasty, 3 patients had pain radiating within the LFCN distribution. Their symptoms were treated by wound exploration with local anesthesia. It was discovered that the LFCN was entrapped by a 3-point suture that had been placed in the superficial fascia at the level of the incision. Release of the suture resulted in instant relief for these 3 patients.44 Deficits and consequences of LFCN injury were not extensively elaborated upon in these studies. One study reported “disastrous” consequences to 1 woman’s sex life as a result of an LFCN injury.26 Another study reported “dysesthesia,”38 and another reported pain after LFCN suture entrapment.44 Specific information regarding recovery from nerve injury was mentioned in 2 studies: Floros and Davis26 and Pollock and Pollock.44 Four patients in the Floros and Davis study recovered without any management over an
unspecified period of time. The 3 patients in the Pollock and Pollock study required exploration with local anesthesia to release sutures that had entrapped the LFCN. Assuming all other patients who sustained LFCN injury did not recover, only 25% (7 of 28 injured patients) recovered, so 1.02% (21 of 2061 patients) undergoing abdominoplasty sustained permanent injury to their LFCN.
Iliohypogastric Nerve The iliohypogastric nerve was the second most commonly injured nerve postabdominoplasty. The combined risk calculated for iliohypogastric nerve injury was 0.10% (n = 2/2061). Two cases were reported by Liszka et al32 and Nahabedian and Dellon.25 The case report by Liszka et al included information about a 62-year-old woman who had undergone abdominoplasty 4 years prior. Her symptoms of nerve injury began 6 weeks after the procedure.32 She initially complained of lower abdominal pain and “pulling,” which progressed to “poking and throbbing” that was accentuated by ambulation. These symptoms prevented her from resuming normal activities. Her examination showed nonfocal pain, except for tenderness along her scars. An extensive abdominal workup revealed no pathology. After referral to a pain clinic, the woman was diagnosed with sensory nerve entrapment, which was confirmed with lidocaine block of the iliohypogastric and ilioinguinal nerves. She underwent reexploration and neurolysis of her iliohypogastric nerves. Pathologic examination revealed a neuroma with foci of birefringent material consistent with suture. Her symptoms resolved with surgery.32 In the case series by Nahabedian and Dellon,25 1 patient sustained a postabdominoplasty injury to the iliohypogastric nerve, which was treated 43 months after her initial procedure. Symptoms of the injury included pain, burning, and/or numbness along the sensory distributions of the affected nerve. Tinel’s sign was positive at the site of nerve
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Table 4. Pooled Risk of Deficits After Abdominoplasty No. (%) of Patients With Deficita
No. (%) of Patients With Deficit at Abdominal Walla
Decreased sensation
158 (7.76)
128 (6.21)
Pain/neuroma/entrapment
22 (1.07)
21 (1.02)
Weakness
6 (0.29)
0
Paralysis
3 (0.15)
0
Deficit
a
N = 2061.
injury, and nerve block relieved the pain. The patient was treated with neuroma excision, and the transected nerve was allowed to retract into the retroperitoneum.25
compartments. Function recovered completely after a “few” months.
Nerve Deficits
Positional Injuries Six articles reported nerve injury after abdominoplasty due to patient positioning.9,33-35,38,42 The injured nerves, with calculation of pooled risks, were the brachial plexus33 (0.10%; n = 2/2061 patients), the musculocutaneous9,42 (0.10%; n = 2), the radial9 (0.05%; n = 1), the sciatic34,35 (0.19%; n = 4), and the common peroneal38 (0.05%; n = 1). The pooled risk calculated for nerve injury from patient positioning during abdominoplasty was 0.49% (n = 10/2061 patients). Akinbingol et al33 reported a bilateral brachial plexus injury after abdominoplasty, liposuction, and reduction mammaplasty. The patient recovered after 5 months. Van Uchelen et al9 reported 1 case of musculocutaneous and radial nerve neuropraxia after abdominoplasty. Rhomberg et al42 reported 1 case of musculocutaneous neuropraxia after abdominoplasty and mastopexy. The authors of both studies attributed the injuries to poor patient positioning, and Rhomberg et al42 specified arm hyperabduction for an extended period.46 Van Uchelen et al9 reported that the injury was “temporary,” while Rhomberg et al42 reported complete recovery after the second postoperative day. Rawlani et al34 reported bilateral sciatic neuropathy after combined abdominoplasty and mastopexy. Kiermeir et al35 reported 2 cases of sciatic nerve injury, the first after circumferential body lift and bilateral inner thigh lift and the second after bilateral mastopexy-breast augmentation, bilateral inner thigh lift, and abdominoplasty. The authors of both studies attributed the nerve injuries to traction created by hip flexion and knee extension.34,35,46 Rawlani et al34 did not elaborate on recovery. Kiermeir et al35 reported recovery after 6 months. In their prospective study, Gmür et al38 reported 1 case of compression syndrome of the anterior and lateral compartments of the lower leg during an abdominoplasty combined with dermolipectomies; this case required a fasciotomy and caused palsy of the anterior and lateral
The most common postabdominoplasty nerve deficit was decreased sensation (whether hypesthesia or anesthesia) in any sensory distribution, with 7.67% (n = 158/2061 patients) reporting these symptoms after abdominoplasty. The occurrence and maintenance of these postabdominoplasty deficits are not addressed within the literature. Articles that reported changes in sensation indicated follow-up times ranging from 4 to 60 months, but this was rarely specifically correlated with the presence of symptoms. The presence or absence of cutaneous sensation changes was specifically noted in 11 articles.9,23,26-30,36,41,43,45 Any surgical procedure is expected to affect cutaneous sensation, so sensory deficits near the surgical site were not included when calculating the incidence of specific nerve injuries (Table 3). The pooled risk of decreased sensation of the abdominal wall after abdominoplasty (Table 4) was calculated to be 6.21% (n = 128/2061 patients). Pain or neuroma was the second most common sensory deficit. Seven reports describe incidents of chronic pain after abdominoplasty.23,26,37,40,41,43,45 Zukowski et al40 described 3 patients with hypesthetic neuralgia occurring 3 to 4 months postoperatively. Of those, 1 patient’s symptoms resolved spontaneously, while the other 2 patients required 2 months of pain clinic with intercostal nerve blocks. Similarly, Gray et al43 treated chronic pain with xylocaine and steroid injections. Neaman and Hansen23 and Shestak41 treated patients’ symptoms with gabapentin, with Shestak reporting symptom resolution after 10 weeks of treatment. Floros and Davis26 and Staalesen et al45 each reported 2 patients with chronic pain, but neither discussed treatment. The case report by Liszka et al32 and the case series by Nahabedian and Dellon25 discussed iliohypogastric nerve entrapment, treated surgically, and both sets of authors reported pain as a common symptom. Akinbingol et al33 noted pain, numbness, and paralysis as
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Figure 2. Cutaneous sensory nerves of the abdominal wall and groin that may be injured during abdominoplasty. Innervated areas are highlighted in color.
common symptoms of positional brachial plexus injury. The combined calculated risk of pain or neuroma after abdominoplasty was 1.07% (n = 22/2061 patients), with most (n = 21) localizing this pain to the abdominal wall. Muscle weakness (0.29%; n = 6/2061 patients) and paralysis (0.15%; n = 3) were the least common deficits after abdominoplasty. These deficits were associated with
positional nerve injuries.9,33-35,38,42 Table 4 shows the pooled risks of deficits after abdominoplasty.
Discussion By collecting and pooling in a systematic review the results of studies that refer to postabdominoplasty nerve injuries
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Table 5. Relevant Nerve Anatomy Nerve
Course
Lateral femoral cutaneous
Origin at second and third lumbar roots Passes underneath psoas major and across iliac muscle Encompassed by iliac fascia as it approaches inguinal ligament Exits the abdomen to enter thigh near anterior superior iliac spine (ASIS) but at variable orientation Splints into anterior division, to provide sensation from the anterolateral thigh to the knee, and the posterior division to provide sensation to the lateral buttock
Iliohypogastric
Origin at T12 and L1 nerve roots Travels over quadratus lumborum and iliacus Travels through transversus to extend between the transversus and internal oblique Becomes cutaneous to the abdominal wall approximately 2 cm to superior inguinal ligament and 3 cm medial to the ASIS Divides near the midaxillary line at the iliac crest: medially to innervate lower abdomen above the inguinal ligament and anteromedial thigh, and laterally to innervate the posterolateral buttock Course parallel to ilioinguinal and subcostal Exists in reciprocal relationship with ilioinguinal, and they often communicate
or deficits, we sought to determine the risk of nerve injury after abdominoplasty and provide a comprehensive treatment algorithm for those injuries.
Incidence of Nerve Injury After Abdominoplasty During review, we found 21 articles that mention nerve pathology after abdominoplasty, as well as 2 articles that specifically mention a lack of nerve injuries or sensory pathologies after abdominoplasty.28,36 After pooling the data from 23 relevant articles, we estimate that 1.94% (n = 40/2061 patients) who underwent abdominoplasty in those studies experienced some sort of nerve injury, with an approximate ratio of 3:1 related to direct trauma versus patient positioning. The mechanisms of nerve injury during any surgery may include direct mechanical injury (such as injury by scalpel, suture, or cautery), indirect neuropathy (injury caused by nerve entrapment in scar tissue created during surgery), or indirect compression neuropathy (injury resulting when surgical intervention creates tissue edema in and around a nerve located in a tight or unyielding anatomical space). Such injuries result in 1 of 3 resulting pathophysiologies: stump neuroma (in the case of transection), neuroma in continuity (in a mixed or incomplete direct nerve injury), or compression neuropathy (from scar or tissue edema at vulnerable anatomic tight points).47 The nerve most likely to be injured by direct trauma is the lateral femoral cutaneous nerve (LFCN), with 1.36% (n = 28) of patients in our pooled data experiencing injury to this nerve. We determined that of the patients who sustained an LFCN injury, only 25% were noted as recovering from their symptoms, including those who underwent surgical treatment. This indicates that 1.02% (n = 21) sustained permanent injury to the LFCN after abdominoplasty and suggests the need for earlier surgical intervention to address the compromised nerve.
The iliohypogastric nerve was the second most commonly injured nerve postabdominoplasty, with 0.10% (n = 2) of patients in our pooled data sustaining an injury to this nerve. Confirmed iliohypogastric nerve injuries in our review required surgery for the resolution of symptoms,25,32 although other articles that described pain symptoms consistent with iliohypogastric injury noted nonsurgical modalities such as gabapentin, steroid injections, or nerve blocks.23,40,41,43 Our results indicate that direct nerve injuries can best be avoided by ensuring thorough knowledge of the relevant anatomy and careful dissection within the nerves’ vulnerable regions, such as at the anterior superior iliac spine (ASIS) for the LFCN.32,48-50 Figure 2 and Table 5 detail the pertinent nerves. Specifically, the LFCN is best protected by recognizing the potential for anatomical variations in its relationship with the ASIS50 and by leaving a swath of undissected loose areolar tissue covering this region. Restricting dissection to the planes and area classically described for abdominoplasty is the best method of protecting the ilioinguinal, iliohypogastric, genitofemoral, and lateral intercostal nerve branches. Overly wide dissection, blind dissection between planes, and randomly placed “deep bites” of tissue (eg, during muscle plication or near the ASIS) all have the potential to create unintentional direct nerve injury. The medial cutaneous branches of the intercostal nerves that pierce the rectus abdominis muscle on their way to provide sensation to anterior abdominal skin must routinely be transected during the course of a standard abdominoplasty dissection; these transections are therefore considered a routine part of the procedure and are not considered “nerve injuries.” We calculated the risk of postabdominoplasty nerve injury due to patient positioning to be 0.49% (n = 10) in our patient pool. It is important to note that most of these injuries occurred during surgeries that combined procedures.33-35,38,42 Combining procedures increases operative time, which increases the time of malposition and likely precipitates injury.
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When presenting the symptoms of nerve pathology, many articles mentioned symptoms such as lower abdominal chronic pain without establishing the specific nerve responsible. For practicing physicians, the presentation of symptoms is more germane than the specific nerve injured, so we separated the symptoms of nerve pathology from the specific nerve injury. The most common postabdominoplasty nerve deficit was paresthesia related to decreased sensation, with 7.67% (n = 158) experiencing this symptom and most (n=128) experiencing it on the abdominal wall. Chronic pain or neuroma was the second most common postabdominoplasty deficit, at 1.07% (n = 22). Positional nerve injuries are best prevented by ensuring thoughtful preoperative planning and recognizing that combined or lengthy procedures increase the risk for such injuries. However, our review suggests that some nerve injuries may be impossible to avoid; examples include direct nerve injuries caused by unusual anatomical variations and indirect nerve injuries caused by nerve entrapment during the normal process of scar tissue formation. In such cases, and certainly in the case of a recognized direct nerve injury, the best outcomes will be achieved by following an evidence-based approach to diagnosis and a management algorithm that emphasizes efficient diagnosis of the injury and early involvement of a peripheral nerve surgeon for treatment of refractory pain.51-54
Comprehensive Treatment Algorithm On the basis of our findings, we present a comprehensive treatment algorithm for postabdominoplasty nerve injuries. Management principles in peripheral nerve surgery begin with a rigorous diagnostic workup. Unless there is a high index of suspicion, these nerve injuries often go misdiagnosed or improperly managed for extended periods of time,55 leading to a diminished quality of life for patients. For example, the patients described by Liszka et al32 and Nahabedian and Dellon25 were not definitively treated until more than 40 months after their initial abdominoplasty procedures. Patients with postabdominoplasty nerve injuries or deficits are often chronically and unnecessarily prescribed opioids and other pain medications to mask symptoms. It is not uncommon for them to be referred for psychiatric evaluation and subsequently started on antidepressants. Prolonged medical management risks the development of medication abuse or dependence, as well as further exposing the patient to the medications’ morbidities. Additionally, untreated neuralgic pain can become amplified by the nervous system through the processes of peripheral and central sensitization47,56,57; if treatment is delayed for an extended period, the pain may become centrally generated and no longer be responsive to deactivation of peripheral pain generators, effectively becoming permanent.
Expected postoperative pain as well as the broad, confounding differential diagnosis of lower abdominal pain may cloud the picture of nerve injury. Therefore, the diagnostic workup of patients with chronic postoperative abdominal wall pain must begin with an exclusion of other potential causes. In addition to a comprehensive history and physical examination, targeted abdominal examination should exclude surgical complications such as infection or fluid collection. Seroma and hematoma are well-known complications of abdominoplasty. Patients not in the immediate postoperative period should also receive a workup for familiar causes of abdominal pain such as hernia, endometriosis, or abdominal visceral disease. If all of the above are excluded, it is prudent to consider a neuropathic cause of pain. Our review showed that nerve injury may present as sharp or burning pain, numbness, paresthesias, hyperesthesias, or allodynia. Pain due to nerve injury may begin shortly after the procedure or may present in a delayed fashion, but it inevitably persists beyond the expected recovery period. It is frequently located near an incision or within the expected sensory distribution of a peripheral nerve. Neuropathic pain of the abdominal wall is often of variable intensity and duration and may be accentuated by walking, stooping, and intercourse, or relieved by thigh flexion and the recumbent position.58 Symptoms can be elicited with light pinching or pressure over the affected area, which is often localized, discrete, and accompanied by a positive Tinel’s sign. A diagnosis of nerve injury can be confirmed using local anesthetic nerve blocks proximal to the point of maximal pain and along the course of the suspected nerve. Traditionally, a surgically correctable nerve injury has been indicated by a pain reduction of 5 or more points on a 10-point scale when using nerve blocks.59 This method, however, does not accurately predict surgical outcome due to the highly variable anatomic course of nerves in the abdominal wall and high incidence of false-negative results.51 For positional compression or traction injuries of nerves in the extremities, electrodiagnostic testing may be used in the acute setting to establish the existence of nerve injury or in a delayed fashion (3-4 weeks postinjury) to document denervation or recovery.46 When nerve injury is determined to be the cause of postabdominoplasty pain, the literature reports that appropriate therapy begins with conservative modalities. Either the patient or a physical therapist may be recruited to perform scar massage, desensitization, and sensory reeducation with simple maneuvers such as purposefully touching the area or allowing running water to pass over the area in the shower. Conservative management is initially appropriate because the pain associated with many nerve injuries will self-resolve with time. Sharing this information with the patient, in addition to validating the cause of his or her
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pain, may ease the emotional stress and uncertainty that often accompany chronic pain. In the short term, pharmacologic treatment with pain medications (opioid and nonopioid), anticonvulsants, tricyclic antidepressants, nerve blocks, or steroid injections may also be useful. If pain does not improve in about 3 months (to a maximum of 6 months), a change of course is indicated, and it is appropriate to involve a peripheral nerve surgeon to evaluate the patient for surgical management of the pain. Appropriate referral and change of strategy are crucial at this juncture to avoid the scenarios, described above, wherein patients become increasingly dependent on medications and have diminishing quality of life or wherein the chronic pain becomes progressively centralized and difficult to treat definitively.47,56,57 These outcomes can be avoided by employing peripheral nerve surgery at the appropriate time to address the cause, not just the symptoms, of a nerve injury. The exact timing of surgical intervention will vary depending on the patient. Patients with debilitating pain and a well-localized lesion that responds to local anesthetic blocks are more likely to benefit from early surgery. It is not always necessary to wait 3 months after the onset of pain to perform surgical treatment. In some cases, patients may benefit from returning to the operating room shortly after the initial abdominoplasty (such as for an LFCN entrapped in a suture). It is appropriate to observe patients with less distressing symptoms, more poorly localized pain, or signs of improvement between office visits for 6 months to allow maximal time for spontaneous recovery. Surgical treatment of postabdominoplasty nerve injuries involves exploring the suspected injured nerves with neurolysis of entrapped nerves or neuroma excision and implantation of injured nerves into muscle or retroperitoneum.48,55,60 Due to the highly variable anatomic course of these nerves and the risk of further nerve injury, only a surgeon experienced in these procedures should proceed. In practice, we apply a similar algorithm to patients who present with pain after abdominal wall reconstruction procedures, as these patients can have nerve injuries and presentations similar to those of abdominoplasty patients.
Limitations This review is limited by the quality of the available studies as well as their level of emphasis on postabdominoplasty nerve injuries. While general complications of abdominoplasty are the focus of many studies, most articles do not mention nerves. It is not known whether this lack of discussion is due to lack of injury or lack of consideration of nerve injury as a potential complication of abdominoplasty. To resolve this issue, we refined our exclusion criteria to remove articles that did not specifically mention either the presence or absence of nerve
injuries as complications. We calculated the incidence of postabdominoplasty injury by assuming that an article that mentions a nerve deficit will have authors who exclude other deficits. For example, if an article noted that only one patient had decreased sensation without commenting on pain and weakness, we assumed that the incidence of pain and weakness was zero. Our exclusion criteria failed to identify those articles whose authors believe that not mentioning a complication after abdominoplasty (such as decreased sensation, weakness, and pain) automatically implies that the incidence is zero. In other words, the article had to explicitly state the absence or presence of neurological deficits in order to be included, and in doing so we also excluded studies that did not consider nerve injury as a possible complication after abdominoplasty. Whether this method overestimates, underestimates, or accurately estimates the incidence of nerve injury is a matter of contention. For example, we calculated that 7.67% of patients had decreased sensation after abdominoplasty. Due to underreporting of this common abdominoplasty-related morbidity, this is most likely an underestimation of the true incidence of sensation changes. The format of this study was also restricted by the quality and heterogeneity of available information. At best, a systematic review of articles is accompanied by a statistical meta-analysis. In this case, the heterogeneity in format and reporting of the substrate studies made a meta-analysis unfeasible. Instead, in order to best represent what is published in the known literature, we performed a comprehensive systematic review to identify and analyze all appropriate articles. To estimate rates of individual injury types for the same procedure among very different study types, we performed a pooled analysis in place of a true meta-analysis. The pooled analysis is drawn from the information garnered in the systematic review and is intended to provide a best estimate for the incidence of nerve injuries or deficits after abdominoplasty. This information can potentially be used by surgeons to determine whether the number of nerve injuries they encounter is in line with published series, by patients to better understand the risks of abdominoplasty, and by researchers to explore this topic in the future. Articles variably reported nerve injuries either as injuries to specific nerves (eg, iliohypogastric nerve injury) or as symptoms that denote a nerve injury (eg, chronic pain, numbness, allodynia). In many cases, those articles that reported symptoms did not seek out the specific nerves responsible, clarify their diagnosis algorithm, or establish treatment protocols. Chronic lower-abdominal pain, for example, is suspect for nerve entrapment, but we were unable to verify true nerve injury based solely on this information, which leads to underestimation of the true incidence of nerve injury after abdominoplasty. Because of
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the inconsistency in reporting methods, our records followed a more complex system of tallying both “nerve injuries” and “symptoms/deficits.” In an effort to be as inclusive as possible and arrive at the most accurate estimate of actual nerve injury rates, symptoms and deficits associated with nerve injuries were treated as surrogates for nerve injuries and were tallied separately when authors chose to report only these results. We included LOE 4 and LOE 5 studies in our review and our calculations of the incidence of postabdominoplasty nerve injury. The three LOE 4 case series presented patients who experienced iliohypogastric nerve injury, chronic pain, or no injury after abdominoplasty. The four LOE 5 case reports presented patients with iliohypogastric nerve, brachial plexus, and sciatic nerve injuries. The exclusion of LOE 4 and LOE 5 articles would completely remove iliohypogastric nerve, sciatic nerve, and brachial plexus injuries after abdominoplasty from our results, preventing awareness and minimizing the importance of these nerves. Additional data, including the study type, practice type, length of follow-up, male to female ratio, average BMI of patients, and abdominoplasty technique were also recorded. However, due to small sample size as well as differences in study design and reporting, we were unable to draw firm conclusions about specific factors that increase the risk of nerve injuries after abdominoplasties.
Conclusions Despite the high number of nerves along the course of abdominoplasty incisions and documented cases of injury, postabdominoplasty nerve injury is an underexplored risk of the procedure. Being aware of the rate of abdominoplastyrelated nerve injuries is important for both patients, whose quality of life stands to be affected, and physicians, who must recognize and manage these complications. A thorough knowledge of anatomy and anatomical variations helps prevent injuries, but a high index of suspicion should be maintained to accurately diagnose nerve injuries in patients presenting with chronic postoperative pain or apparent nerve dysfunction. A comprehensive treatment algorithm for these injuries based on available evidence in the literature is presented in this review. Appropriate and timely treatment by a multidisciplinary team, including a peripheral nerve surgeon, is critical to optimize patient outcomes after such injuries. Although this review estimates a low incidence of abdominoplasty-related nerve injuries, a more accurate incidence can only be obtained through better reporting of nerve injuries in future studies of abdominoplasty.
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, or publication of this article.
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34. Rawlani R, Lee MJ, Dumanian GA. Bilateral sciatic neurapraxia following combined abdominoplasty and mastopexy. Plast Reconstr Surg. 2010;125(1):31e-32e. 35. Kiermeir D, Banic A, Rösler K, Erni D. Sciatic neuropathy after body contouring surgery in massive weight loss patients. J Plast Reconstr Aesthetic Surg. 2010;63(5):e454 -e457. 36. Abramson DL. Ultrasound-assisted abdominoplasty: combining modalities in a safe and effective technique. Plast Reconstr Surg. 2003;112(3):898-902. 37. Palanivelu C, Rangarajan M, Jategaonkar PA, Amar V, Gokul KS, Srikanth B. Laparoscopic repair of diastasis recti using the ‘Venetian blinds’ technique of plication with prosthetic reinforcement: a retrospective study. Hernia. 2009;13(3):287-292. 38. Gmür RU, Banic A, Erni D. Is it safe to combine abdominoplasty with other dermolipectomy procedures to correct skin excess after weight loss? Ann Plast Surg. 2003;51(4):353-357. 39. Al-Qattan MM. Abdominoplasty in multiparous women with severe musculoaponeurotic laxity. Br J Plast Surg. 1997;50(6):450-455. 40. Zukowski ML, Ash K, Spencer D, Malanoski M, Moore G. Endoscopic intracorporal abdominoplasty: a review of 85 cases. Plast Reconstr Surg. 1998;102(2):516-527. 41. Shestak KC. Marriage abdominoplasty expands the mini-abdominoplasty concept. Plast Reconstr Surg. 1999;103(3):1020-1031. 42. Rhomberg M, Pülzl P, Piza-Katzer H. Single-stage abdominoplasty and mastopexy after weight loss following gastric banding. Obes Surg. 2003;13(3):418-423. 43. Gray S, Gittleman E, Moliver CL. Safety in office-based full abdominoplasty. Aesthetic Surg J. 2012;32(2):200206. 44. Pollock TA, Pollock H. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthetic Surg J. 2012;32(6):729-742. 45. Staalesen T, Olsen MF, Elander A. Complications of abdominoplasty after weight loss as a result of bariatric surgery or dieting/postpregnancy. J Plast Surg Hand Surg. 2012;46(6):416-420. 46. Winfree CJ, Kline DG. Intraoperative positioning nerve injuries. Surg Neurol. 2005;63(1):5-18. 47. Woolf CJ. What is this thing called pain? J Clin Invest. 2010;120(11):3742-3744. 48. Rab M, Ebmer, Dellon AL. Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain. Plast Reconstr Surg. 2001;108(6):1618-1623. 49. Choi PD, Nath R, Mackinnon SE. Iatrogenic injury to the ilioinguinal and iliohypogastric nerves in the groin: a case report, diagnosis, and management. Ann Plast Surg. 1996;37(1):60-65. 50. Aszmann OC, Dellon ES, Dellon AL. Anatomical course of the lateral femoral cutaneous nerve and its susceptibility to compression and injury. Plast Reconstr Surg. 1997;100(3):600-604.
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Abdominoplasty-Related Nerve Injuries: Systematic Review and Treatment Options Ivica Ducic, Hesham M. Zakaria, John M. Felder III and Sarah Arnspiger Aesthetic Surgery Journal 2014 34: 284 originally published online 16 January 2014 DOI: 10.1177/1090820X13516341 The online version of this article can be found at: http://aes.sagepub.com/content/34/2/284
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research-article2014
AESXXX10.1177/1090820X13516341Aesthetic Surgery JournalDucic et al
Body Contouring
Abdominoplasty-Related Nerve Injuries: Systematic Review and Treatment Options
Aesthetic Surgery Journal 2014, Vol. 34(2) 284– 297 © 2014 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www. sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X13516341 www.aestheticsurgeryjournal.com
Ivica Ducic, MD, PhD; Hesham M. Zakaria, MD; John M. Felder III, MD; and Sarah Arnspiger, BA
Abstract Background: Abdominoplasty is a common cosmetic procedure; nerve injury is an underexplored risk of the procedure. Objective: The authors review existing literature to examine the incidence and treatment of nerve injuries after abdominoplasty procedures and provide a treatment algorithm based on their results. Methods: A search of the literature on MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews was undertaken. After full-text review, 23 articles met our criteria. Any mentions of nerve injury, including references to a lack of nerve injury, were documented. All data were pooled for analysis. From our combined data, we calculated the risks of postabdominoplasty nerve injury by dividing the total number of nerve injuries by the total number of patients. Results: Pooled data showed that 1.94% of patients sustained specific nerve injury, and 1.02% of patients sustained permanent injury after abdominoplasty. In addition, 7.67% experienced decreased sensation, 1.07% reported chronic pain, and 0.44% reported temporary weakness or paralysis. Nerves directly injured were the lateral femoral cutaneous (1.36% of patients) and iliohypogastric (0.10%) nerves. Nerves injured from surgical positioning were the brachial plexus (0.10%), musculocutaneous (0.10%), radial (0.05%), sciatic (0.19%), and common peroneal (0.05%) nerves. Conclusions: Although our results showed a low incidence of postabdominoplasty nerve injury, the lasting impact on affected patients’ quality of life can be significant. Appropriate and timely treatment by a multidisciplinary team is critical to optimize patient outcomes. Better reporting of nerve injuries in future studies of abdominoplasty will provide more accurate information about the incidence and consequences of these injuries. Level of Evidence: 4 Keywords abdominoplasty, body contouring, aesthetic surgery, cosmetic surgery, chronic pain, nerve injury, surgical complications Accepted for publication July 9, 2013.
Abdominoplasty is one of the most common cosmetic procedures, with 144 929 completed in the United States in 2010. This number represents an increase of over 300% since 1997.1 The procedure’s popularity is expected to continue to rise due to a growing demand for post–massive weight loss contouring procedures, an increase in the overall number of aesthetic surgery procedures, and an aging “baby boomer” population. Given the growing number of abdominoplasties being performed, it is increasingly important for surgeons and patients to understand the risks and morbidity of this procedure.2-4
The most common complications of abdominoplasties can be divided into 3 categories: immediate, early, and late complications. Immediate complications, which are also From the Departments of Neurosurgery and Plastic Surgery, Georgetown University Hospital, Washington, DC.
Corresponding Author: Dr Ivica Ducic, Departments of Plastic Surgery and Neurosurgery, Peripheral Nerve Surgery Institute, Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007, USA. E-mail: [email protected]
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Table 1. Inclusion and Exclusion Criteria for Systematic Review Inclusion Criteria
Exclusion Criteria
• English language • Patient age 13 years or older • Study type: randomized controlled trials; cohorts; case series; case reports; cross-sectional studies; meta-analyses; systematic reviews • Procedure was abdominoplasty • Procedure was surgical • Procedure was cosmetic (not reconstructive or revisional)
the most life-threatening and least common, are deep vein thrombosis,5-7 pulmonary emboli,8-10 and fat emboli. Early complications are seroma, hematoma, infection, and skin necrosis/dehiscence.11-15 Late complications include asymmetry of abdominal contour, recurrent diastasis, and scar hypertrophy.3 The risk of these complications is increased in patients who are obese,16-19 patients who smoke,20-22 and patients who have diabetes mellitus.13,23 A lesser-discussed, underexplored risk of abdominoplasty procedures is nerve injury. The standard abdominoplasty technique requires an incision along the lower aspect of the abdomen, where nerves such as the femoral, lateral femoral cutaneous, iliohypogastric, and ilioinguinal are potentially within the surgical field. Damage to these nerves is associated with chronic pain, numbness, and paralysis and can drastically affect a patient’s quality of life.24-26 Articles exist that specifically characterize skin sensitivity changes after abdominoplasty,27-30 but most studies only briefly mention nerve injury as a potential complication. We sought to determine the incidence of nerve injury after abdominoplasty by performing a systematic review of the literature with pooled analysis of results from the existing literature. Secondarily, we present a comprehensive treatment algorithm for patients who do experience nerve injury. This information can further patients’ understanding of abdominoplasty’s risks and raise plastic surgeons’ awareness of the incidence and treatment of postabdominoplasty nerve injury.
Methods Search Strategy We conducted a search of the literature on MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews. The strategy was to use the “and” function to combine terms identifying procedures with terms identifying nerve injury. Key search terms for abdominoplasty included abdominoplast*, body contour*, and liposuction. Key search terms for nerve injury included hypesthesia, nerve damage, nerve injur*, neuralg*, neuroma, neuropath*, numb*, pain, paraly*, paresis, paresthesia, sens*, and weak*. Subject headings were incorporated wherever possible. The search was deliberately broad in order to capture the
• • • • • • •
Non-English language Patient age younger than 13 years Study type: narrative review; editorial; letter; commentary; erratum No mention of rate of nerve injury Procedure was not abdominoplasty Procedure was not surgical Procedure was reconstructive or revisional (not cosmetic)
greatest number of articles. It was not limited by date of publication but was limited to the English language. With the exception of narrative reviews, editorials, letters, commentaries, and erratum, all study types were included. Additional studies were identified by reviewing the reference lists of relevant articles from our search results and by contacting experts in the field.
Selection Criteria and Quality Assessment Specific inclusion and exclusion criteria, shown in Table 1, were established before conducting the search. We initially searched for articles pertaining to nerve injuries that occurred in the context of several cosmetic procedures. Articles specific to abdominoplasty were then selected from those results. Procedures that were nonsurgical, revisional (correctional procedures after a primary procedure), or reconstructive (procedures to correct a defect or pathology) were excluded, as were studies that did not mention nerve injury in the full text. To eliminate bias and provide the most accurate incidence of nerve injury possible, studies that noted a nerve injury incidence of 0 were included, and “zero” was recorded in the data input form. Our initial search yielded 4806 citations, 717 of which were eliminated as duplicates. Three independent reviewers (SA, JMF, and HMZ) evaluated titles and abstracts, applied the inclusion and exclusion criteria, and excluded all irrelevant studies. Full text was obtained for 458 citations, 42 of which related to abdominoplasty. Of the 42 citations, 26 were eliminated by the exclusion criteria during full-text review. Extensive hand-searching yielded 7 additional articles that met our criteria. Ultimately, a total of 23 citations were included and reviewed. Figure 1 details the process of identifying articles to include in this review. The quality of the studies was assessed using the American Society of Plastic Surgeons Evidence Rating Scale for Prognostic Studies, published in 2011.31
Data Extraction Two investigators (SA and HMZ) independently reviewed articles for data extraction. Characteristics recorded for each
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Total Risk of Nerve Injury
Figure 1. Citation attrition diagram.
article included year of publication, journal title, study type, and level of evidence (LOE). Population characteristics recorded included location, sex, average age, and average body mass index (BMI). Any mentions of nerve injury, including references to a lack of nerve injury, were documented. Whenever possible, investigators recorded the specific nerve injured, deficits associated with the nerve injury, and duration of injury.
Statistical Methods The specific data points from each article were recorded in a Microsoft Excel (Microsoft Corp, Redmond, Washington) data sheet. All data were pooled for analysis; specifically, we combined the patients, the number of nerve injuries, and the number of nerve deficits from the 23 selected articles. From our combined data, we calculated the risk by dividing the total number of nerve injuries by the total number of patients. A true metaanalysis was not feasible given the heterogeneity of the substrate studies.
Results Clinical Data A total of 23 studies discussed sensory changes or nerve injury after abdominoplasty: 4 case reports (LOE 5),32-35 3 case series (LOE 4),25,36,37 4 case-control studies (LOE 3),27-29,38 and 12 retrospective or prospective cohort studies (LOE 2).9,14,23,26,30,39-45 Two studies specifically mentioned a 0 rate of nerve injury.28,36 Table 2 details the characteristics of these studies.
The risk of any nerve injury calculated with data pooled from the 23 selected studies was 1.94% (n = 40/2061 patients undergoing abdominoplasty). Postabdominoplasty nerve injuries can be divided into those injured secondary to the abdominoplasty incision and those injured secondary to surgical positioning. The pooled risk calculated for incisional nerve injury was 1.46% (n = 30/2061). The pooled risk calculated for positional nerve injury was 0.49% (n = 10/2061 patients). Nerves injured from abdominoplasty incisions, with their respective risks, were the lateral femoral cutaneous (1.36%; n = 28/2061 patients) and the iliohypogastric (0.10%; n = 2). Nerves injured from surgical positioning during abdominoplasty, with their respective risks, were the brachial plexus (0.10%; n = 2/2061 patients), the musculocutaneous (0.10%; n = 2), the radial (0.05%; n = 1), the sciatic (0.19%; n = 4), and the common peroneal (0.05%; n = 1). Table 3 shows the risk of specific nerve injury after abdominoplasty as well as the rates of recovery for each.
Incisional Injuries Lateral Femoral Cutaneous Nerve The lateral femoral cutaneous nerve (LFCN) was injured after abdominoplasty in 6 studies9,14,26,38,39,44 and was the nerve most commonly injured after abdominoplasty. The percent of patients who sustained LFCN injury within each study varied greatly, ranging from 0.36%14 to 10%.39 The pooled risk calculated for injury to the LFCN was 1.36% (n = 28/2061 patients). Gmür et al’s prospective study of 73 patients sought to determine the safety of combining abdominoplasty with dermolipectomy procedures of the upper arms, inner thighs, breasts, and buttocks among patients who had undergone any weight loss.38 They noted that 1 patient had dysesthesia of the LFCN but do not elaborate further.38 A retrospective study by Floros and Davis26 examined the complications and results of 133 patients who had undergone abdominoplasty. They identified a total of 13 patients who experienced injury to the LFCN, with eventual recovery over an unspecified period of time in 4 patients and partial recovery in 1 patient. Eleven of the 13 patients with LFCN injuries were within a cohort of 34 patients who responded to a survey and attended followup clinics 4.5 years after their abdominoplasty, creating the oft-cited >30% rate of LFCN nerve injury (11 of 34).26 The higher number of patients with LFCN injury in the cohort of patients who attended postoperative clinics is likely due to closer follow-up over a longer period of time. This patient population is also less likely to have confounding postoperative surgical symptoms, simplifying the
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Journal of Plastic, Reconstructive, and Aesthetic Surgery
Annals of Plastic Surgery
Journal of the American College of Surgeons
British Journal of Plastic Surgery
Plastic and Reconstructive Surgery
Obesity Surgery
Obesity Surgery
Plastic and Reconstructive Surgery
Annals of Plastic Surgery
2006
2007
1997
1991
2004
2008
2005
2008
1994
2002
2010
Stewart et al14
Neaman and Hansen23
Nahabedian and Dellon25
Floros and Davis26
Farah et al27
Bussolaro et al28
Fels et al29
Dini et al30
Liszka et al32
Akinbingol et al33
Rawlani et al34
Plastic and Reconstructive Surgery
Aesthetic Plastic Surgery
Plastic and Reconstructive Surgery
2001
van Uchelen et al9
Journal
Year
Authors
Case report
Case report
Case report
Cohortretrospective
Cohortprospective
Case-control
Case-control
Cohortretrospective
Case report/series
Cohortretrospective
Cohortretrospective
Cohortretrospective
Study Type
5
5
5
2
3
3
3
2
4
2
2
2
Level of Evidence
1
1
1
41
25
24
20
133
13
206
278
86
No. of Patients
28
56
62
43.6
37
37.6
43.55
35
Unspecified
43
46
34.3 M/ 38.9 F
Average Age, y
Table 2. Studies and Data Gathered During Systematic Review With Pooled Calculations
0
0
0
18
25
0
11
4
0
1
0
60
Cutaneous
0
0
0
0
0
0
0
13
0
0
1
8
0
0
1
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
Lateral Femoral Cutaneous Iliohypogastric Musculocutaneous
No. of Injured Nerves
0
0
0
0
0
0
0
0
0
0
0
1
Radial
0
0
0
0
0
0
0
0
0
0
0
0
Common Peroneal
2
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
2
2
1
0
0
0
0
13
1
0
1
10
Sciatic Brachial Plexus No. of Total Injured
(continued)
Case report
Case report
Case report
0
0
0
0
9.77
7.69
0
0.36
11.63
% Injured
288
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British Journal of Plastic Surgery
Plastic and Reconstructive Surgery
Plastic and Reconstructive Surgery
Obesity Surgery
Aesthetic Surgery Journal
Aesthetic Surgery Journal
Journal of Plastic Surgery and Hand Surgery
2003
1997
1998
1999
2003
2012
2012
2012
Gmür et al38
Al-Qattan39
Zukowski et al40
Shestak41
Rhomberg et al42
Gray et al43
Pollock and Pollock44
Staalesen et al45
Hernia
2009
Palanivelu et al37
Annals of Plastic Surgery
Plastic and Reconstructive Surgery
Journal of Plastic, Reconstructive, and Aesthetic Surgery
2003
2010
Kiermeir et al35
Journal
Abramson36
Year
Authors
Table 2. (continued)
Cohortretrospective
Cohortretrospective
Cohortretrospective
Cohortretrospective
Cohortretrospective
Cohortretrospective
Cohortretrospective
Cohortprospective
Cohortprospective
Cohortretrospective
Case report
Study Type
161
2061
Sum Totals:
597
206
12
29
90
20
73
18
24
2
No. of Patients
2
2
2
2
2
2
2
3
4
4
5
Level of Evidence
40, nonbariatric; 41.5, postbariatric
46.5
40
37.3
Unspecified
33
41
41
41.8
Unspecified
31
Average Age, y
143
17
0
1
0
1
3
0
0
2
0
0
Cutaneous
28
0
3
0
0
0
0
2
1
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
2
0
0
0
1
0
0
0
0
0
0
0
Lateral Femoral Cutaneous Iliohypogastric Musculocutaneous
No. of Injured Nerves
1
0
0
0
0
0
0
0
0
0
0
0
Radial
1
0
0
0
0
0
0
0
1
0
0
0
Common Peroneal
4
0
0
0
0
0
0
0
0
0
0
2
2
0
0
0
0
0
0
0
0
0
0
0
0
3
0
1
0
0
2
2
0
0
2
Sciatic Brachial Plexus No. of Total Injured
0
0.50
0
8.33
0
0
10.0
2.74
0
0
Case report
% Injured
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Table 3. Pooled Risk of Specific Nerve Injury After Abdominoplasty No. (%) of Patients Injureda
No. (%) Not Recovered
Lateral femoral cutaneous
28 (1.36)
21 (1.02)
Iliohypogastric
2 (0.10)
0
Brachial plexus
2 (0.10)
0
Musculocutaneous
2 (0.10)
0
Radial
1 (0.05)
0
Sciatic
4 (0.19)
2 (0.10)
Common peroneal
1 (0.05)
0
Nerve Incisional injuries Positional injuries
a
N = 2061.
diagnosis of LFCN injury. The remainder of the 99 patients were studied by chart review only, including 2 others who sustained LFCN injuries.26 A retrospective study by Al-Qattan39 presented the complications of 20 multiparous women with severe musculoaponeurotic laxity who had undergone abdominoplasty. Two patients in his cohort sustained injury to the LFCN that was described as “permanent,” without further elaboration. A retrospective study by van Uchelen et al9 sought to characterize postabdominoplasty complications in 86 patients. They noted that 7 women and 1 man sustained injury to the LFCN but do not elaborate further. A retrospective study by Stewart et al14 surveyed complications of 278 patients who had undergone abdominoplasty. They noted that 1 patient had altered thigh sensation. No further elaboration was provided. A retrospective study by Pollock and Pollock44 focused on the use of progressive tension sutures in 597 abdominoplasty patients. Their findings indicated that progressive tension sutures could minimize seroma and potentially decrease other complications. After undergoing abdominoplasty, 3 patients had pain radiating within the LFCN distribution. Their symptoms were treated by wound exploration with local anesthesia. It was discovered that the LFCN was entrapped by a 3-point suture that had been placed in the superficial fascia at the level of the incision. Release of the suture resulted in instant relief for these 3 patients.44 Deficits and consequences of LFCN injury were not extensively elaborated upon in these studies. One study reported “disastrous” consequences to 1 woman’s sex life as a result of an LFCN injury.26 Another study reported “dysesthesia,”38 and another reported pain after LFCN suture entrapment.44 Specific information regarding recovery from nerve injury was mentioned in 2 studies: Floros and Davis26 and Pollock and Pollock.44 Four patients in the Floros and Davis study recovered without any management over an
unspecified period of time. The 3 patients in the Pollock and Pollock study required exploration with local anesthesia to release sutures that had entrapped the LFCN. Assuming all other patients who sustained LFCN injury did not recover, only 25% (7 of 28 injured patients) recovered, so 1.02% (21 of 2061 patients) undergoing abdominoplasty sustained permanent injury to their LFCN.
Iliohypogastric Nerve The iliohypogastric nerve was the second most commonly injured nerve postabdominoplasty. The combined risk calculated for iliohypogastric nerve injury was 0.10% (n = 2/2061). Two cases were reported by Liszka et al32 and Nahabedian and Dellon.25 The case report by Liszka et al included information about a 62-year-old woman who had undergone abdominoplasty 4 years prior. Her symptoms of nerve injury began 6 weeks after the procedure.32 She initially complained of lower abdominal pain and “pulling,” which progressed to “poking and throbbing” that was accentuated by ambulation. These symptoms prevented her from resuming normal activities. Her examination showed nonfocal pain, except for tenderness along her scars. An extensive abdominal workup revealed no pathology. After referral to a pain clinic, the woman was diagnosed with sensory nerve entrapment, which was confirmed with lidocaine block of the iliohypogastric and ilioinguinal nerves. She underwent reexploration and neurolysis of her iliohypogastric nerves. Pathologic examination revealed a neuroma with foci of birefringent material consistent with suture. Her symptoms resolved with surgery.32 In the case series by Nahabedian and Dellon,25 1 patient sustained a postabdominoplasty injury to the iliohypogastric nerve, which was treated 43 months after her initial procedure. Symptoms of the injury included pain, burning, and/or numbness along the sensory distributions of the affected nerve. Tinel’s sign was positive at the site of nerve
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Table 4. Pooled Risk of Deficits After Abdominoplasty No. (%) of Patients With Deficita
No. (%) of Patients With Deficit at Abdominal Walla
Decreased sensation
158 (7.76)
128 (6.21)
Pain/neuroma/entrapment
22 (1.07)
21 (1.02)
Weakness
6 (0.29)
0
Paralysis
3 (0.15)
0
Deficit
a
N = 2061.
injury, and nerve block relieved the pain. The patient was treated with neuroma excision, and the transected nerve was allowed to retract into the retroperitoneum.25
compartments. Function recovered completely after a “few” months.
Nerve Deficits
Positional Injuries Six articles reported nerve injury after abdominoplasty due to patient positioning.9,33-35,38,42 The injured nerves, with calculation of pooled risks, were the brachial plexus33 (0.10%; n = 2/2061 patients), the musculocutaneous9,42 (0.10%; n = 2), the radial9 (0.05%; n = 1), the sciatic34,35 (0.19%; n = 4), and the common peroneal38 (0.05%; n = 1). The pooled risk calculated for nerve injury from patient positioning during abdominoplasty was 0.49% (n = 10/2061 patients). Akinbingol et al33 reported a bilateral brachial plexus injury after abdominoplasty, liposuction, and reduction mammaplasty. The patient recovered after 5 months. Van Uchelen et al9 reported 1 case of musculocutaneous and radial nerve neuropraxia after abdominoplasty. Rhomberg et al42 reported 1 case of musculocutaneous neuropraxia after abdominoplasty and mastopexy. The authors of both studies attributed the injuries to poor patient positioning, and Rhomberg et al42 specified arm hyperabduction for an extended period.46 Van Uchelen et al9 reported that the injury was “temporary,” while Rhomberg et al42 reported complete recovery after the second postoperative day. Rawlani et al34 reported bilateral sciatic neuropathy after combined abdominoplasty and mastopexy. Kiermeir et al35 reported 2 cases of sciatic nerve injury, the first after circumferential body lift and bilateral inner thigh lift and the second after bilateral mastopexy-breast augmentation, bilateral inner thigh lift, and abdominoplasty. The authors of both studies attributed the nerve injuries to traction created by hip flexion and knee extension.34,35,46 Rawlani et al34 did not elaborate on recovery. Kiermeir et al35 reported recovery after 6 months. In their prospective study, Gmür et al38 reported 1 case of compression syndrome of the anterior and lateral compartments of the lower leg during an abdominoplasty combined with dermolipectomies; this case required a fasciotomy and caused palsy of the anterior and lateral
The most common postabdominoplasty nerve deficit was decreased sensation (whether hypesthesia or anesthesia) in any sensory distribution, with 7.67% (n = 158/2061 patients) reporting these symptoms after abdominoplasty. The occurrence and maintenance of these postabdominoplasty deficits are not addressed within the literature. Articles that reported changes in sensation indicated follow-up times ranging from 4 to 60 months, but this was rarely specifically correlated with the presence of symptoms. The presence or absence of cutaneous sensation changes was specifically noted in 11 articles.9,23,26-30,36,41,43,45 Any surgical procedure is expected to affect cutaneous sensation, so sensory deficits near the surgical site were not included when calculating the incidence of specific nerve injuries (Table 3). The pooled risk of decreased sensation of the abdominal wall after abdominoplasty (Table 4) was calculated to be 6.21% (n = 128/2061 patients). Pain or neuroma was the second most common sensory deficit. Seven reports describe incidents of chronic pain after abdominoplasty.23,26,37,40,41,43,45 Zukowski et al40 described 3 patients with hypesthetic neuralgia occurring 3 to 4 months postoperatively. Of those, 1 patient’s symptoms resolved spontaneously, while the other 2 patients required 2 months of pain clinic with intercostal nerve blocks. Similarly, Gray et al43 treated chronic pain with xylocaine and steroid injections. Neaman and Hansen23 and Shestak41 treated patients’ symptoms with gabapentin, with Shestak reporting symptom resolution after 10 weeks of treatment. Floros and Davis26 and Staalesen et al45 each reported 2 patients with chronic pain, but neither discussed treatment. The case report by Liszka et al32 and the case series by Nahabedian and Dellon25 discussed iliohypogastric nerve entrapment, treated surgically, and both sets of authors reported pain as a common symptom. Akinbingol et al33 noted pain, numbness, and paralysis as
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Figure 2. Cutaneous sensory nerves of the abdominal wall and groin that may be injured during abdominoplasty. Innervated areas are highlighted in color.
common symptoms of positional brachial plexus injury. The combined calculated risk of pain or neuroma after abdominoplasty was 1.07% (n = 22/2061 patients), with most (n = 21) localizing this pain to the abdominal wall. Muscle weakness (0.29%; n = 6/2061 patients) and paralysis (0.15%; n = 3) were the least common deficits after abdominoplasty. These deficits were associated with
positional nerve injuries.9,33-35,38,42 Table 4 shows the pooled risks of deficits after abdominoplasty.
Discussion By collecting and pooling in a systematic review the results of studies that refer to postabdominoplasty nerve injuries
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Table 5. Relevant Nerve Anatomy Nerve
Course
Lateral femoral cutaneous
Origin at second and third lumbar roots Passes underneath psoas major and across iliac muscle Encompassed by iliac fascia as it approaches inguinal ligament Exits the abdomen to enter thigh near anterior superior iliac spine (ASIS) but at variable orientation Splints into anterior division, to provide sensation from the anterolateral thigh to the knee, and the posterior division to provide sensation to the lateral buttock
Iliohypogastric
Origin at T12 and L1 nerve roots Travels over quadratus lumborum and iliacus Travels through transversus to extend between the transversus and internal oblique Becomes cutaneous to the abdominal wall approximately 2 cm to superior inguinal ligament and 3 cm medial to the ASIS Divides near the midaxillary line at the iliac crest: medially to innervate lower abdomen above the inguinal ligament and anteromedial thigh, and laterally to innervate the posterolateral buttock Course parallel to ilioinguinal and subcostal Exists in reciprocal relationship with ilioinguinal, and they often communicate
or deficits, we sought to determine the risk of nerve injury after abdominoplasty and provide a comprehensive treatment algorithm for those injuries.
Incidence of Nerve Injury After Abdominoplasty During review, we found 21 articles that mention nerve pathology after abdominoplasty, as well as 2 articles that specifically mention a lack of nerve injuries or sensory pathologies after abdominoplasty.28,36 After pooling the data from 23 relevant articles, we estimate that 1.94% (n = 40/2061 patients) who underwent abdominoplasty in those studies experienced some sort of nerve injury, with an approximate ratio of 3:1 related to direct trauma versus patient positioning. The mechanisms of nerve injury during any surgery may include direct mechanical injury (such as injury by scalpel, suture, or cautery), indirect neuropathy (injury caused by nerve entrapment in scar tissue created during surgery), or indirect compression neuropathy (injury resulting when surgical intervention creates tissue edema in and around a nerve located in a tight or unyielding anatomical space). Such injuries result in 1 of 3 resulting pathophysiologies: stump neuroma (in the case of transection), neuroma in continuity (in a mixed or incomplete direct nerve injury), or compression neuropathy (from scar or tissue edema at vulnerable anatomic tight points).47 The nerve most likely to be injured by direct trauma is the lateral femoral cutaneous nerve (LFCN), with 1.36% (n = 28) of patients in our pooled data experiencing injury to this nerve. We determined that of the patients who sustained an LFCN injury, only 25% were noted as recovering from their symptoms, including those who underwent surgical treatment. This indicates that 1.02% (n = 21) sustained permanent injury to the LFCN after abdominoplasty and suggests the need for earlier surgical intervention to address the compromised nerve.
The iliohypogastric nerve was the second most commonly injured nerve postabdominoplasty, with 0.10% (n = 2) of patients in our pooled data sustaining an injury to this nerve. Confirmed iliohypogastric nerve injuries in our review required surgery for the resolution of symptoms,25,32 although other articles that described pain symptoms consistent with iliohypogastric injury noted nonsurgical modalities such as gabapentin, steroid injections, or nerve blocks.23,40,41,43 Our results indicate that direct nerve injuries can best be avoided by ensuring thorough knowledge of the relevant anatomy and careful dissection within the nerves’ vulnerable regions, such as at the anterior superior iliac spine (ASIS) for the LFCN.32,48-50 Figure 2 and Table 5 detail the pertinent nerves. Specifically, the LFCN is best protected by recognizing the potential for anatomical variations in its relationship with the ASIS50 and by leaving a swath of undissected loose areolar tissue covering this region. Restricting dissection to the planes and area classically described for abdominoplasty is the best method of protecting the ilioinguinal, iliohypogastric, genitofemoral, and lateral intercostal nerve branches. Overly wide dissection, blind dissection between planes, and randomly placed “deep bites” of tissue (eg, during muscle plication or near the ASIS) all have the potential to create unintentional direct nerve injury. The medial cutaneous branches of the intercostal nerves that pierce the rectus abdominis muscle on their way to provide sensation to anterior abdominal skin must routinely be transected during the course of a standard abdominoplasty dissection; these transections are therefore considered a routine part of the procedure and are not considered “nerve injuries.” We calculated the risk of postabdominoplasty nerve injury due to patient positioning to be 0.49% (n = 10) in our patient pool. It is important to note that most of these injuries occurred during surgeries that combined procedures.33-35,38,42 Combining procedures increases operative time, which increases the time of malposition and likely precipitates injury.
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When presenting the symptoms of nerve pathology, many articles mentioned symptoms such as lower abdominal chronic pain without establishing the specific nerve responsible. For practicing physicians, the presentation of symptoms is more germane than the specific nerve injured, so we separated the symptoms of nerve pathology from the specific nerve injury. The most common postabdominoplasty nerve deficit was paresthesia related to decreased sensation, with 7.67% (n = 158) experiencing this symptom and most (n=128) experiencing it on the abdominal wall. Chronic pain or neuroma was the second most common postabdominoplasty deficit, at 1.07% (n = 22). Positional nerve injuries are best prevented by ensuring thoughtful preoperative planning and recognizing that combined or lengthy procedures increase the risk for such injuries. However, our review suggests that some nerve injuries may be impossible to avoid; examples include direct nerve injuries caused by unusual anatomical variations and indirect nerve injuries caused by nerve entrapment during the normal process of scar tissue formation. In such cases, and certainly in the case of a recognized direct nerve injury, the best outcomes will be achieved by following an evidence-based approach to diagnosis and a management algorithm that emphasizes efficient diagnosis of the injury and early involvement of a peripheral nerve surgeon for treatment of refractory pain.51-54
Comprehensive Treatment Algorithm On the basis of our findings, we present a comprehensive treatment algorithm for postabdominoplasty nerve injuries. Management principles in peripheral nerve surgery begin with a rigorous diagnostic workup. Unless there is a high index of suspicion, these nerve injuries often go misdiagnosed or improperly managed for extended periods of time,55 leading to a diminished quality of life for patients. For example, the patients described by Liszka et al32 and Nahabedian and Dellon25 were not definitively treated until more than 40 months after their initial abdominoplasty procedures. Patients with postabdominoplasty nerve injuries or deficits are often chronically and unnecessarily prescribed opioids and other pain medications to mask symptoms. It is not uncommon for them to be referred for psychiatric evaluation and subsequently started on antidepressants. Prolonged medical management risks the development of medication abuse or dependence, as well as further exposing the patient to the medications’ morbidities. Additionally, untreated neuralgic pain can become amplified by the nervous system through the processes of peripheral and central sensitization47,56,57; if treatment is delayed for an extended period, the pain may become centrally generated and no longer be responsive to deactivation of peripheral pain generators, effectively becoming permanent.
Expected postoperative pain as well as the broad, confounding differential diagnosis of lower abdominal pain may cloud the picture of nerve injury. Therefore, the diagnostic workup of patients with chronic postoperative abdominal wall pain must begin with an exclusion of other potential causes. In addition to a comprehensive history and physical examination, targeted abdominal examination should exclude surgical complications such as infection or fluid collection. Seroma and hematoma are well-known complications of abdominoplasty. Patients not in the immediate postoperative period should also receive a workup for familiar causes of abdominal pain such as hernia, endometriosis, or abdominal visceral disease. If all of the above are excluded, it is prudent to consider a neuropathic cause of pain. Our review showed that nerve injury may present as sharp or burning pain, numbness, paresthesias, hyperesthesias, or allodynia. Pain due to nerve injury may begin shortly after the procedure or may present in a delayed fashion, but it inevitably persists beyond the expected recovery period. It is frequently located near an incision or within the expected sensory distribution of a peripheral nerve. Neuropathic pain of the abdominal wall is often of variable intensity and duration and may be accentuated by walking, stooping, and intercourse, or relieved by thigh flexion and the recumbent position.58 Symptoms can be elicited with light pinching or pressure over the affected area, which is often localized, discrete, and accompanied by a positive Tinel’s sign. A diagnosis of nerve injury can be confirmed using local anesthetic nerve blocks proximal to the point of maximal pain and along the course of the suspected nerve. Traditionally, a surgically correctable nerve injury has been indicated by a pain reduction of 5 or more points on a 10-point scale when using nerve blocks.59 This method, however, does not accurately predict surgical outcome due to the highly variable anatomic course of nerves in the abdominal wall and high incidence of false-negative results.51 For positional compression or traction injuries of nerves in the extremities, electrodiagnostic testing may be used in the acute setting to establish the existence of nerve injury or in a delayed fashion (3-4 weeks postinjury) to document denervation or recovery.46 When nerve injury is determined to be the cause of postabdominoplasty pain, the literature reports that appropriate therapy begins with conservative modalities. Either the patient or a physical therapist may be recruited to perform scar massage, desensitization, and sensory reeducation with simple maneuvers such as purposefully touching the area or allowing running water to pass over the area in the shower. Conservative management is initially appropriate because the pain associated with many nerve injuries will self-resolve with time. Sharing this information with the patient, in addition to validating the cause of his or her
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pain, may ease the emotional stress and uncertainty that often accompany chronic pain. In the short term, pharmacologic treatment with pain medications (opioid and nonopioid), anticonvulsants, tricyclic antidepressants, nerve blocks, or steroid injections may also be useful. If pain does not improve in about 3 months (to a maximum of 6 months), a change of course is indicated, and it is appropriate to involve a peripheral nerve surgeon to evaluate the patient for surgical management of the pain. Appropriate referral and change of strategy are crucial at this juncture to avoid the scenarios, described above, wherein patients become increasingly dependent on medications and have diminishing quality of life or wherein the chronic pain becomes progressively centralized and difficult to treat definitively.47,56,57 These outcomes can be avoided by employing peripheral nerve surgery at the appropriate time to address the cause, not just the symptoms, of a nerve injury. The exact timing of surgical intervention will vary depending on the patient. Patients with debilitating pain and a well-localized lesion that responds to local anesthetic blocks are more likely to benefit from early surgery. It is not always necessary to wait 3 months after the onset of pain to perform surgical treatment. In some cases, patients may benefit from returning to the operating room shortly after the initial abdominoplasty (such as for an LFCN entrapped in a suture). It is appropriate to observe patients with less distressing symptoms, more poorly localized pain, or signs of improvement between office visits for 6 months to allow maximal time for spontaneous recovery. Surgical treatment of postabdominoplasty nerve injuries involves exploring the suspected injured nerves with neurolysis of entrapped nerves or neuroma excision and implantation of injured nerves into muscle or retroperitoneum.48,55,60 Due to the highly variable anatomic course of these nerves and the risk of further nerve injury, only a surgeon experienced in these procedures should proceed. In practice, we apply a similar algorithm to patients who present with pain after abdominal wall reconstruction procedures, as these patients can have nerve injuries and presentations similar to those of abdominoplasty patients.
Limitations This review is limited by the quality of the available studies as well as their level of emphasis on postabdominoplasty nerve injuries. While general complications of abdominoplasty are the focus of many studies, most articles do not mention nerves. It is not known whether this lack of discussion is due to lack of injury or lack of consideration of nerve injury as a potential complication of abdominoplasty. To resolve this issue, we refined our exclusion criteria to remove articles that did not specifically mention either the presence or absence of nerve
injuries as complications. We calculated the incidence of postabdominoplasty injury by assuming that an article that mentions a nerve deficit will have authors who exclude other deficits. For example, if an article noted that only one patient had decreased sensation without commenting on pain and weakness, we assumed that the incidence of pain and weakness was zero. Our exclusion criteria failed to identify those articles whose authors believe that not mentioning a complication after abdominoplasty (such as decreased sensation, weakness, and pain) automatically implies that the incidence is zero. In other words, the article had to explicitly state the absence or presence of neurological deficits in order to be included, and in doing so we also excluded studies that did not consider nerve injury as a possible complication after abdominoplasty. Whether this method overestimates, underestimates, or accurately estimates the incidence of nerve injury is a matter of contention. For example, we calculated that 7.67% of patients had decreased sensation after abdominoplasty. Due to underreporting of this common abdominoplasty-related morbidity, this is most likely an underestimation of the true incidence of sensation changes. The format of this study was also restricted by the quality and heterogeneity of available information. At best, a systematic review of articles is accompanied by a statistical meta-analysis. In this case, the heterogeneity in format and reporting of the substrate studies made a meta-analysis unfeasible. Instead, in order to best represent what is published in the known literature, we performed a comprehensive systematic review to identify and analyze all appropriate articles. To estimate rates of individual injury types for the same procedure among very different study types, we performed a pooled analysis in place of a true meta-analysis. The pooled analysis is drawn from the information garnered in the systematic review and is intended to provide a best estimate for the incidence of nerve injuries or deficits after abdominoplasty. This information can potentially be used by surgeons to determine whether the number of nerve injuries they encounter is in line with published series, by patients to better understand the risks of abdominoplasty, and by researchers to explore this topic in the future. Articles variably reported nerve injuries either as injuries to specific nerves (eg, iliohypogastric nerve injury) or as symptoms that denote a nerve injury (eg, chronic pain, numbness, allodynia). In many cases, those articles that reported symptoms did not seek out the specific nerves responsible, clarify their diagnosis algorithm, or establish treatment protocols. Chronic lower-abdominal pain, for example, is suspect for nerve entrapment, but we were unable to verify true nerve injury based solely on this information, which leads to underestimation of the true incidence of nerve injury after abdominoplasty. Because of
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the inconsistency in reporting methods, our records followed a more complex system of tallying both “nerve injuries” and “symptoms/deficits.” In an effort to be as inclusive as possible and arrive at the most accurate estimate of actual nerve injury rates, symptoms and deficits associated with nerve injuries were treated as surrogates for nerve injuries and were tallied separately when authors chose to report only these results. We included LOE 4 and LOE 5 studies in our review and our calculations of the incidence of postabdominoplasty nerve injury. The three LOE 4 case series presented patients who experienced iliohypogastric nerve injury, chronic pain, or no injury after abdominoplasty. The four LOE 5 case reports presented patients with iliohypogastric nerve, brachial plexus, and sciatic nerve injuries. The exclusion of LOE 4 and LOE 5 articles would completely remove iliohypogastric nerve, sciatic nerve, and brachial plexus injuries after abdominoplasty from our results, preventing awareness and minimizing the importance of these nerves. Additional data, including the study type, practice type, length of follow-up, male to female ratio, average BMI of patients, and abdominoplasty technique were also recorded. However, due to small sample size as well as differences in study design and reporting, we were unable to draw firm conclusions about specific factors that increase the risk of nerve injuries after abdominoplasties.
Conclusions Despite the high number of nerves along the course of abdominoplasty incisions and documented cases of injury, postabdominoplasty nerve injury is an underexplored risk of the procedure. Being aware of the rate of abdominoplastyrelated nerve injuries is important for both patients, whose quality of life stands to be affected, and physicians, who must recognize and manage these complications. A thorough knowledge of anatomy and anatomical variations helps prevent injuries, but a high index of suspicion should be maintained to accurately diagnose nerve injuries in patients presenting with chronic postoperative pain or apparent nerve dysfunction. A comprehensive treatment algorithm for these injuries based on available evidence in the literature is presented in this review. Appropriate and timely treatment by a multidisciplinary team, including a peripheral nerve surgeon, is critical to optimize patient outcomes after such injuries. Although this review estimates a low incidence of abdominoplasty-related nerve injuries, a more accurate incidence can only be obtained through better reporting of nerve injuries in future studies of abdominoplasty.
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, or publication of this article.
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