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Knapp et al. Plast Aesthet Res 2020;7:7 I http://dx.doi.org/10.20517/2347-9264.2019.69 Page 9 of 14

prevent contamination are popular with some surgeons, but current data show no real impact on the rate
[135]
of SSIs in general surgery . The impact of surgical drains in the presence of synthetic mesh during AWR
has been largely debated; however, a retrospective study provided evidence that their use does not increase
[136]
SSI and may be protective against surgical site occurrences such as seroma . Supplemental oxygenation
in the perioperative period has been studied in colorectal surgery with two landmark studies showing
a benefit by reducing SSIs [137,138] . A meta-analysis favored supplemental oxygen protocols in higher-risk
[139]
populations ; however, there are no studies specific to AWR.
Another difficult topic in open abdominal surgery is pain control. Multimodal pain control with both
pharmacological and non-pharmacological techniques are continuously being revisited to find the optimal
regimen. Pain, and therefore pain control, is very subjective and has to be approached on an individual
basis. Common pharmacological modalities include systemic opioids, local or regional blocks, central
neuraxial infusions, acetaminophen, non-steroidal anti-inflammatory drugs, gamma-aminobutyric acid
[140]
analogs, and beta-blockers to name a few . Several non-pharmacological techniques such as acupuncture,
music therapy, and hypnosis have mixed evidence regarding efficacy. The role of preoperative anxiety on
postoperative experience is often overlooked and may be an avenue for improvement. A meta-analysis
of 54 studies showed an association between preoperative anxiety and postoperative pain and analgesia
[141]
requirements . In addition to psychological preparation, proper education, and open communication of
risks, benefits, and expectations prior to surgery, music therapy may be an additional strategy to help ease
[142]
anxiety . Music likely shifts the patient attention and aids in cognitive coping. One study showed that
[143]
patients report lower pain scores when exposed to music in the post-anesthesia care unit and a meta-
analysis showed music leads to reduced anxiety in mechanically ventilated patients, as evidenced by lower
[144]
respiratory rates and systolic blood pressures, and may even reduce sedative and analgesia requirements .
CONCLUSION
As the incidence and complexity of VHR and AWR continues to rise, so does the importance of addressing
all adjustable elements to achieve optimal outcomes. Identifying and intervening on these modifiable
risk factors in the pre-, intra-, and immediately postoperative period is key to consistent success. It could
certainly be argued that outcomes for these increasingly complex cases are less dependent on operative
technique and more dependent on prehabilitation, addressing patient comorbidities preoperatively,
adequate glucose control, focus on proper nutrition, and awareness of the microbiome.

DECLARATIONS
Authors’ contributions
Participated in accumulation of data, literature review, writing and editing the manuscript: Knapp N,
Jedrzejewski B, Martindale R
The authors have had equal contributions to this article.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Dr’s Knapp and Jedrzejewski have no conflicts of interest. Dr. Martindale has no direct conflicts of interest
in this manuscript or subject matter but remains a consultant for Bard and Allergan.