Perception of patients about professional performance and procedures performed in the pre, intra, and postoperative period of abdominoplasty

in the operating room during the intraoperative period. , 70.6% of the patients underwent postoperative procedures, 37.4% of whom were physiotherapists, the most common complication being edema representing 84.2%. Conclusion: The main indication for abdominoplasty was sagging skin, which is most often associated with liposuction. Most of the patients did not undergo preoperative procedures. They were performed after 1 to 3 days after the operation, with a physiotherapist, on the advice of an acquaintance, often three times a week, due to the complaint of edema. The most performed procedures were manual lymphatic drainage and therapeutic ultrasound. ■ ABSTRACT


INTRODUCTION
Since the 19th century, the female body pattern responds to skinny women, who continuously seek a beautiful and healthy body, accepting to undergo modifications to achieve what is understood as the current beauty standard 1 . Thus, the field of plastic surgery in Brazil grows every year. The International Society for Aesthetic Plastic Surgery (ISAPS) 2 points out that Brazil occupies the second place in the world ranking of aesthetic surgical procedures. Abdominoplasty is a procedure that has shown a significant evolution in the last century due to the development of new techniques, in addition to a better understanding of the anatomy, physiology, and aesthetics of the abdominal wall. In 2018, the Sociedade Brasileira de Cirurgia Plástica 3 reported that abdominoplasty is the third most performed cosmetic surgery in Brazil, representing around 15.9% of surgical procedures.

OBJECTIVE
The objective of this study was to analyze the perception of the patients about professional performance and the procedures performed in the pre, intra, and postoperative period of the abdominoplasty.

Study type
This one is a cross-sectional and observational study.

Ethical considerations
The study began after the approval of the Research Committee of the Universidade Paulista (UNIP), in São Paulo/SP (protocol number: 13022019.8.0000.5512). To carry out the research, all the volunteers signed and accepted the elements specified in the Free and Informed Consent Form.

Sample
The sample consisted of women aged between 18 and 60 years who underwent abdominoplasty only or associated with another surgical procedure in the last 12 months.

Digital Questionnaire
A self-administered digital questionnaire was developed by the researchers in this study using the "Google Forms." The questionnaire was divided into six stages, which were: -Free and Informed Consent Term: the objective of the research and the non-disclosure of the patient's personal data was explained. When answering "not accepted" in the Informed Consent Form, the questionnaire automatically ended, and when answering "accepted," the patient proceeded to the second stage of the questionnaire; -Gender: the alternatives were "female," "male," and "I prefer not to say." The patient only proceeded to the third stage if she marked "female" as an answer, otherwise the questionnaire was closed; -Personal data: information was collected such as name, age, race, email, cell phone number, marital status, region of Brazil in which she lives, body mass and height, educational level, if she had already become pregnant and how many pregnancies she had, the chief complaint for performing abdominoplasty, the age at which this procedure was performed and if there was another associated procedure; -Preoperative: it was asked if preoperative procedures were performed, professional category of the person responsible for the procedure, if she had manual lymphatic drainage done (and how many sessions), respiratory physiotherapy and exercises with the physical therapist before surgery, if she received postoperative guidance and which professional made such guidelines; -Intraoperative: it was asked if there was a physical therapist in the operating room during the surgery and if the procedures performed by the physical therapist during this period were important for the postoperative period; -Postoperative period: currently postoperative time; whether postoperative procedures were performed and the professional category of the person responsible for the procedure; who recommended the professional; how long after surgery did treatment begin; how many times a week was this treatment performed. Each patient answered about the pain and edema they felt in the postoperative period and quantified these complaints according to the Visual Numerical Scale (VNS), which varies from zero to ten (0-10), with zero without complaint and ten higher levels of complaint. Furthermore, if there was a change in sensitivity, if there were complications, if the compression mesh was used in the immediate postoperative period and for how long, if it was difficult to change the dressings and if this change was done alone or with help; what was the team and/or manual techniques used by the professional who performed the postoperative treatment, if she was satisfied with the postoperative treatment, scoring her level of satisfaction with the treatment using the VNS.
The email address of the digital questionnaire was made available on the Internet platform and was sent to patients through social networks and the WhatsApp® messaging application from June to December 2019.

Data analysis
The data were tabulated in an Excel ® spreadsheet, and descriptive analyzes were performed with means and percentages of the responses obtained, which showed the most relevant values according to the questioned item.

RESULTS
A total of 376 patients showed interest in participating in the research. Of these, 354 patients answered the questionnaire thoroughly, and 22 patients were excluded for the following reasons: being male (n = 9) or preferred not to say gender (n = 4), and did not accept the Informed Free and Informed Consent Form (n = 9). Therefore, the final sample consisted of 354 patients who answered the digital questionnaire.

Demographic characteristics
The demographic characteristics of the patients are described in Table 1, whose analyzed variables are expressed in absolute and percentage values (%).

Intraoperative
Regarding the intraoperative, 59.9% (n = 212) reported not knowing if there was a physical therapist in the operating room, 32.8% (n = 116) answered "no" and 7.3% (n = 26) answered "yes " Regarding the importance of the physical therapist in the operating room, 18.3% (n = 35) answered that the procedures performed by the physical therapist were important for postoperative recovery.
The majority of patients (95.5%, n = 338) reported the use of the compression mesh in the immediate postoperative period, with the recommended use for 3 months for 33.1% (n = 117), for 2 months for 26.3% ( n = 93), for 4 months or more for 14.4% (n = 51) and only 12.7% of patients (n = 45) used it for 1 month.

DISCUSSION
The 2018 Census of the Sociedade Brasileira de Cirurgia Plástica 3 points that the southeast region is the one with the highest number of plastic surgeries performed in Brazil (51.1%). This fact justifies the main number of responses obtained from the states of São Paulo, Rio de Janeiro, and Minas Gerais (75.4%). The age range of patients who undergo plastic surgery was  In relation to the change in sensitivity, 37% (n = 131) of the patients reported decreased sensitivity, 30.8% (n = 109), absent sensitivity, 17.5% (n = 62), normal sensitivity, and 14.7% (n = 52). ) increased sensitivity.
Regarding postoperative complications, 84.2% (n = 298) reported that edema was a complication, 21.8% (n = 77) hematoma, 19.8% (n = 70) seroma, 15.8% (n = 56) scar dehiscence and 11.9% (n = 42) fibrosis ( Figure 3). 71% between 19 and 50 years old, and in the present study, 88% between 18 and 45 years old. The primary motivation for performing plastic surgery is aesthetics (60.3%), which corroborates the responses of patients on the motivation to perform abdominoplasty, being skin flaccidity, abdominal diastasis, and localized adiposity. Abdominoplasty is the most commonly performed procedure for the correction of deformities of the abdominal wall, due to the significant loss of weight after treatment for obesity, bloating, sagging skin, localized fat, hernia, tumor resection, pregnancy, multiple, previous surgeries and abdominal diastasis. The complaint of localized adiposity for abdominoplasty may justify the fact that liposuction was the frequently associated procedure 7 .
Most patients did not perform preoperative procedures, and those who did reported having done it with the doctor. The importance of performing non-preoperative respiratory physiotherapy is suggested, due to lipoabdominoplasty with negative repercussions on chest mobilization and recent nonpostoperative lung function 9 . When carrying out a program of respiratory exercises, it could be reduced to intra-abdominal, non-intraoperative pressure 10,12 . The intraoperative physical therapy performance is still recent, since 92.7% of the patients did not know or said they did not have a physical therapist during the surgery. Physiotherapy performed from the preoperative period reduces edema, ecchymosis, and fibrosis in the postoperative period, in addition to decreasing the number of physical therapy sessions and accelerating the patient's recovery in the postoperative period of abdominal surgeries, using manual lymphatic drainage, resources of electrothermal phototherapy and/or application of taping in the operated area 4 .
Virtually all patients reported receiving postoperative guidance given by the physician, reducing the risk of complications. The most-reported postoperative complication was edema (84.2%), which differs from the findings in the literature 12,16,21 , presumably because it is an expected event due to the tissue injury caused, surveys do not include it as a complication 4, 5 7,8,14 . The most observed complication is seroma, around 15% 12,13,21 , statistically more frequent in surgeries combined with other procedures 12,16,21 . The sum of the responses of the patients in the present study obtained an index of 19.8%, close to the mentioned values. Infection occurs in approximately 1 to 3.8% 12,21 of patients, while the questionnaire showed 6.2%. With an incidence close to 2%, the hematoma is the third most common complication in abdominoplasty 12,21 . However, the prevalence shown here was 21.8%; possibly, such discrepancy may be justified because patients did not know how to report the difference between hematoma and ecchymosis.
Most of the patients reported having undergone postoperative procedures (70.6%), with a physical therapist (37.4%) and an esthetician (37.1%). The Brazilian Society of Plastic Surgery3 recommends that physiotherapists perform the postoperative period of cosmetic and restorative plastic surgery. The professional who worked in the postoperative period was indicated by an acquaintance (31.8%), the doctor (30.7%), or found him alone (22.2%). The surgeon must recommend the professional who will work with the patient in the postoperative period. Tacani 24 , that acts in the prevention, promotion, and recovery of the integumentary system, this includes professional performance in the pre and postoperative period. of plastic and cosmetic surgeries There is no consensus on the ideal start for postoperative procedures. Patients started postoperative treatment between 1 and 7 days, considering an early onset. It is considered positive, since the later the treatment for tissue fibrosis begins, the worse its prognosis, with collagen disorganization, which makes reorganization even more difficult 4,7,25 . The treatment was carried out with a frequency of 3 times per week (35.7%), corroborating the literature 4,14 .
Regarding the procedures used by the professional, the indication for manual lymphatic drainage (87%) and therapeutic ultrasound (51.7%) were used. Both are believed to be recommended for tissue recovery, the prevention and reduction of edema, fibrosis and adhesions, the prevention of scar retraction, and the elimination of postoperative pain 4,5,14 . Manual lymphatic drainage is the technique most indicated by plastic surgeons 8,22 .
It is important to note that the questions in the questionnaire were prepared after a bibliographic survey, considering the most common situations related to abdominoplasty. The sample was made up of patients from all regions of Brazil, but there was no evaluation of these by a professional in person, it is worth considering that the patient may not know precisely some data, such as the category of professional who attended the postoperative. Despite this, it is a pioneering study to characterize the management of patients undergoing abdominoplasty. It is suggested that more studies be developed to assess patients' perception of what professionals have been doing for the pre, intra and postoperative treatment of abdominoplasty. Based on these findings, a reflection of the professionals involved in the care management of this patient is suggested, as well as it is recommended to carry out controlled and randomized clinical trials to verify the effectiveness of each of the items discussed here.

CONCLUSION
The primary indication for abdominoplasty was sagging skin, which is most often associated with liposuction. Most patients did not undergo preoperative procedures and performed postoperatively started after 1 to 3 days, with a physiotherapist, as indicated by an acquaintance, often three times a week, due to the complaint of edema. The most performed procedures were manual lymphatic drainage and therapeutic ultrasound.

COLLABORATIONS NLS
Analysis and/or data interpretation, conception and design study, data curation, final manuscript approval, methodology, project administration, realization of operations and/or trials, writing -original draft preparation.

IGEO
Analysis and/or data interpretation, data curation, final manuscript approval.

RET
Analysis and/or data interpretation, data curation, final manuscript approval, methodology.

CSB
Conception and design study, final manuscript approval, writing -original draft preparation.

IFBM
Analysis and/or data interpretation, final manuscript approval, project administration, writing -original draft preparation.

TSF
Analysis and/or data interpretation, data curation, final manuscript approval, writing -original draft preparation.

AFPM
Analysis and/or data interpretation, conception and design study, data curation, final manuscript approval, methodology, project administration, writing -original draft preparation.