A few academic perspectives on social entrepreneurship.
\r\n\tThe aim of this volume is to offer an interdisciplinary perspective in which different aspects come together, for example; psychology, economics, sociology, medicine of the common subject of study: the health. All the researchers and experts of the various disciplines are invited to participate with their studies and their theoretical models to enrich the current international literature in the context of factors and aspects that can affect health.
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She subsequently held various\nteaching positions at the Department of Psychology and the Faculty of Medicine and Surgery of the\nUniversity of Parma.\nHer training continued with the attainment of the title of PhD in Neuroscience at the University of Turin,\nduring which she acquired and developed interdisciplinary skills and point of view through the application\nof bioimaging and psychophysiological methods to investigate the neurophysiological mechanisms involved\nduring communication and social interactions.",institutionString:"Universita della Svizzera Italiana",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"6",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"Universita della Svizzera Italiana",institutionURL:null,country:{name:"Switzerland"}}}],coeditorOne:{id:"233998",title:"Ph.D.",name:"Sara",middleName:null,surname:"Palermo",slug:"sara-palermo",fullName:"Sara Palermo",profilePictureURL:"https://mts.intechopen.com/storage/users/233998/images/system/233998.jpeg",biography:"Sara Palermo is a MSc in Clinical Psychology and a PhD in Experimental Neuroscience. Moreover, she obtained the National Scientific Enabling Certificate for Associate Professorship in April 2017 (ASN-2017). She is an expert in experimental neuroscience, clinical neuropsychology and advance neuropsychological testing. Moreover, she performs multidimensional geriatric evaluation and basic neurological symptomatology detection in patients with neurodegenerative disorders. She is also engaged in Activation Likelihood Estimation meta-analysis of neuroimaging studies.\r\nShe worked as a postdoc research fellow at the Department of Neuroscience 'Rita Levi Montalcini” in Turin until July 2017. Since then she works as research fellow at the Department of Psychology in Turin. To date, she owns three research Group memberships at the University of Turin (Italy). She is a member of the 'Center for the Study of Movement Disorders” (research area: Neurology) and the 'Placebo Responses Mapping Group” (research area: Physiology) at the Department of Neuroscience, and a member of the 'Neuropsychology of cognitive impairment and central nervous system degenerative diseases Group” at the Department of Psychology (Research Area: Psychobiology and physiological psychology).\r\nThe main topics of her research are the study of awareness of illness, metacognitive-executive deficits in neuropsychiatric and neurological disorders, physical and cognitive frailty in the elderly, and placebo/nocebo phenomena. Interestingly, all of them may represent appealing perspectives from which to study how neuropsychological abnormalities can be explained in terms of brain activities and with the use of neuropsychiatric and neuropsychological batteries considering a neurocognitive approach. 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It refers to the fact that modern business models are expected to address not only economic objectives but also social and environmental values [2]. Contemporary understanding of corporate models for sustainable development also assumes the understanding that the stakeholder toward whom the corporation is responsible needs to include a wide set of stakeholders including society at large. Porter and Kramer [4] refer this as the creation of “shared value”.
Assuming that corporations not only accept the notion of being held accountable for the past and current actions but also embrace forward looking understandings of corporate social responsibility (CSR), what is expected of the new business model? In order to include a vast number of stakeholders’ interests the model would have to be inclusive [3], in other words connected to the context in which it is developed. Developing a new business model is not merely a minor modification of existing theories, it refers to an entirely new epistemological chapter [5], new models where corporate the raison d’être is closely connected to societal needs [6]. The call for inclusive business models is associated with corporate challenges as well as opportunities. Communicating awareness of social and environmental values in strategic documents without enacting these values would quickly be labeled as greenwash. The corporation thus has to find ways to operationalize CSR on a strategic level as well as in daily operations. This is especially challenging for large corporations and multinational companies that, due to their complex and extensive character [7, 8].
The fastest growing markets of today are those in emerging economies [9, 10]. These markets have inspired Prahalad and Hart [7] to develop a conceptual model called base of the pyramid (BOP) that focuses on adapting business models to the local conditions. It is not a question of bringing western systems to developing economies. It is rather about innovation and fundamental changes of strategy to create business models that are economically sustainable and in line with the needs of local communities [7] in order to move beyond philanthropy and focus on common prosperity, referred to as “shared value” by Porter and Kramer [4].
The aim of this study is to identify critical factors for the implementation and management of an inclusive business model. These factors are contextualized at a regional and local level in an emerging economy setting as a part of an ongoing agro-food project in a multinational corporation.
In short, the empirical study that is presented on the following pages has its roots in a corporation, Stora Enso, that was willing to rethink their business model (the name happens to be “RETHINK”), two entrepreneurs that knew all about the context in which the model was developed and researchers that are fortunate to get the data about the ongoing project aimed at sustainable development [11]. After reviewing the literature, challenges for development of an inclusive business model seemed to outnumber the possible advantages and the empirical study started with doubts; how can this be done in practice? How can the existing corporate structure and values be adapted to the local and regional conditions? This case study offers a narrative of the development and implementation of a new business model. The context for the forestry-based business model is one of the poorest countries in Asia, Lao PDR. The case offers clarity to our questions, but before presenting the empirical case, a short presentation of approach, key concepts and an empirical background.
Based on the research objective and the realization that a holistic approach would offer a context bound understanding of the phenomenon (an inclusive business model), a single case study was selected. A flexible research design gave room for an abductive process in which literature reviews and empirical work were interwoven. In what Robson [12] refers to as real world research, studies of contemporary phenomena, it is challenging to decide on particular fixed frameworks and tools ex ante, so a flexible design, meaning constantly reconsidering both theoretical framework and empirical research conduct, has led to mind-breaking empirical findings and an awareness of alternative conceptual frameworks that could have been used. We had an epistemological starting point of the triple bottom line and understanding of the importance of stakeholder theory. These starting points were complemented with vast reviews of the entrepreneurship literature, in particular that related to social entrepreneurship.
The selected case study was a commission project that filled our needs in terms of the following criteria: a corporation that had or was in the process of developing an inclusive business model, willingness to share data about the process, and an additional criterion can be added that we were not aware of the importance of at the time of making research plans. It relates to the context in which this business model is developed and managed, the cultural, financial, social and environmental context offered by business operations in Lao PDR.
Primary data collection was carried out in ten semi-structured personal interviews with various stakeholders representing groups that were part of or influenced by Stora Enso’s Rethink project. Stakeholders were identified with support from employees of Stora Enso and the recent UNDP report [13] about the project. The interviews were summarized and made available for the interviewee when that was technically possible. A number of interviews were carried out with the assistance of a translator.
The process of qualitative data analysis is context bound and not fully predictable, and in particular, when working with narratives, new categories can occur that contribute to the initial contextual framework. Narrative analysis based on multiple information sources is applied in this project, and various techniques, such as matching and organizing data in tables and graphs was used to facilitate categorization [14]. Efforts made to ensure research quality includes the understanding of creating construct and internal validity through triangulation of data, external validity through caution in generalizing the results and reliability through the use of rigors research conduct including a case protocol.
Corporate social responsibility represents an evolving research field that offers a wide set of terms and theories, some of which are complex and indistinct [15, 16]. This section expands on CSR as a conceptual framework and underlines ideas and concepts that can extend the understanding of management in socially complex environments.
Ultimately, CSR is about the role of business in society and the fact that companies “have an obligation to work toward meeting the needs of a wider array of stakeholders” ([17], p. 244). Society at large, in particular media and NGO’s hold businesses accountable for issues that were not seen as business responsibilities twenty years ago [18]. External pressures, expectations, from wide set of stakeholders may thus serve as motives for rethinking a business model.
Corporate social responsibility is expressed in relationships between business and society, in strategies, conduct and communication. A strategic approach to CSR implies a focus on how to achieve competitive advantage through finding intersecting points of interest between business and society. A concept developed to describe this phenomenon is creating shared value (CSV) [4]. CSV is based on the idea that “a business needs a successful community, not only to create demand for its products but also to provide critical public assets and a supportive environment” ([4], p. 66). However the implementation and management of CSV is a complex process which depends on a firm’s culture context and strategy [19], and there is still a need for examples of how the strategy can be operationalized.
CSR may also be interpreted from a less instrumental perspective, leaving the strategic management behind, focusing on ethical or political aspects of corporate conduct. A political CSR view [20, 21] highlights the importance of adapting CSR to the context [17, 20, 22] for creating the shared value. Local institutions and culture inevitably have an effect on operations of the firm and sets the structure of the company’s responsibilities [20]. Societal needs such as health care, security, logistical networks and education are commonly seen as primary responsibilities of governments—but in the perspective of political CSR these needs are incorporated in an extended stakeholder definition and interpretation of corporate responsibilities. The extended interpretation of platforms for CSR is interpreted by McElhaney [23] as different levels where corporate conduct influences society (Figure 1).
Corporate Social Responsibility as platforms for creating values ([23], p. 22).
Figure 1 illustrates that CSR can be expressed in various ways, ranging from local engagement at a facility, influencing the immediate community, to political CSR expressed in powerful positions influencing industrial development in a long-term perspective. Accordingly, continued globalization and increasing international trade may lead to corporate opportunities to contribute to sustainable development in local as well as global development [17] but it would assume an inclusive corporate model. The change agents that may develop an inclusive business model can be referred to as social entrepreneurs.
Michelini and Fiorentino [9] present corporate social entrepreneurship (CSE) and inclusive business models as potential strategies for creating shared value and finding new business opportunities. The concept of a new business model, in this particular context, implies that “the triple bottom line” and “shared values” are operationalized and implemented, not only in long-term strategies, but also in the actual daily operations and management of day to day business.
CSE is the process in which a basis for shared values is identified. An inclusive business model is formed when the local community is involved as a business partner in operations to generate long-term value for the company and the community [9]. Both of these concepts highlight the discussion of management and the various ways of approaching a new business environment.
The strategy of social entrepreneurship (Table 1) suggests that there are central elements of responsiveness and innovation in the process of finding business opportunities in a socially challenging context.
Perspective | The contribution points to… | Sources |
---|---|---|
The transition to the sustainable enterprise | The importance of looking at social entrepreneurship in corporate governance | Keijzers [24] |
Social entrepreneurship as an “untidy concept” | The use of the concept social entrepreneurship with different meanings, which points to needs for defining the concept when using it. The authors also point to difficulties to generalize due to the context bound nature of the concept | Peredo and McLean [25] |
Exploratory comparative analysis of business entrepreneurship and social entrepreneur ship | Commonalities and differences between social and commercial entrepreneurship. Revised social entrepreneurship framework with Social Value Proposition (SVP) in the center | Austin et al.[26] |
The important role of entrepreneurship in sustainable development | Outline of research done and suggestions for future directions in the research area concerned with sustainable development and entrepreneurship | Hall et al. [27] |
Impact of context on entrepreneurship, social embeddedness | Needs for contextualizing the field of research for entrepreneurship | Welter [28] |
Motives and outcomes from a social and commercial perspective | Differences and similarities between social and commercial objectives | Austin et al. [29] |
Corporate social entrepreneurship as the base for new business models | Various approaches to value creation in low-income communities: social business models and inclusive business models | Michelini and Fiorentino [9] |
A few academic perspectives on social entrepreneurship.
Our interpretation of social entrepreneurship relates to context bound [28] entrepreneurial activities with embedded social purposes [29] that may be carried out by an individual or a group of individuals [25]. These entrepreneurial activities are carried out in specific organizational and institutional context, which points to difficulties to generalize. As expressed by Austin et al. ([26], p. 16) “What might be deemed an unfavorable contextual factor for market-based commercial entrepreneurship could be seen as an opportunity for a social entrepreneur aiming to address social need arising from market failure”.
A stable institutional environment is crucial in market development [30]. An institutional environment may refer to financial and legal institutions, political governance, educational systems and many other resources that in the case of many emerging economies are underdeveloped. Shortcomings of these systems imply increased corporate costs but also opportunities for corporate management to develop and get access to resources, so-called inclusive networks [31]. An inclusive network implicates interactions between individuals, communities, organizations and companies and can serve as a structure for creating predictability in an unstable environment thus creating opportunities for economic activity. One way of gaining access to an inclusive network is to implement an issue focused view of stakeholders [31], which implies that the firm identifies and addresses issues that are of interest to various stakeholders, and thereby develop and participate in issue driven networks. Social entrepreneurship may thus be based on a common interest and it is not only adapting to the context, it also influences the context [28] for example a local market or community.
The forest-based industry has some specific characteristics that make it particularly interesting from the perspective of CSR [32]. Forest areas cover about 30 % of the land of world ([33], p. 11); and as stated by Mikkilä ([33], p. 11) “millions of people interact frequently with the forests and are directly or indirectly dependent on them”. Accordingly, the resource based character of the forestry industry implies that forest companies inevitably have an impact on the socio-economic conditions in the area in which they operate [33]. Hence, there is a clear connection between the forest industry and poverty alleviation as a large number of individuals’ livelihoods depends on land and forest-based resources.
One of the world’s largest industry groups in the pulp and paper sector today is the Nordic forestry company Stora Enso. The group has about 30,000 employees in 35 countries and is active within four major business areas: printing and reading, renewable packaging, biomaterials and building and living [34]. Stora Enso sources most of its wood from Sweden, Finland, the Baltic countries and Russia but is increasingly focusing on markets and plantation sources in Latin America, China and Southeast Asia [34]. The objective of the expansions is to meet an increased demand for pulp and paper products in these areas. In 1999 the Stora Enso group published their first environmental and social policy, and in 2011 the group introduced a whole new corporate model called “Rethink” [11]. However, the company has received extensive critique from various stakeholders for not taking enough responsibility for the socio-economic effects of their operations. The expansion of Eucalyptus plantations in China has been particularly noted and criticized by NGOs and media. In China, the substantial amount of land utilized has led to land conflicts with local populations caused by great dissatisfaction associated with the pricing of land and the handling of land rights by governmental local authorities [35].
With lessons learned from China, Stora Enso decided to expand their operations into the country of Lao PDR in 2006. Lao PDR offers a close to perfect biological setting for running successful Eucalyptus plantations, but it also possess a rather unique set of challenges, related to the institutional environment. Despite a growing economy in the urban areas, the rural parts of Lao PDR are still suffering from poverty. An extensive bureaucracy and corruption have prevented economic development from reaching the rural parts of the country, where lack of knowledge leads to continued extensive use of shifting cultivation that causes food insecurity and extensive deforestation. In addition, there are great challenges related to the remains of the Vietnam War. These remains are unexploded ordinance (UXO), cluster bombs that have a high failure rate (30%) and therefore pose a risk of explosion when removed [36]. These UXOs limit the land use for cultivation and other uses.
As Stora Enso started to plan for possible activity in Lao PDR (hereby referred to as Laos), the first step was to investigate the availability of land. Stora Enso hired Mr. Fogde as a consultant due to extensive local knowledge and thirty years of experience from the forest industry in Laos.
The investigation showed that there were plenty of suitable land, but Mr. Fogde indicated that the business model could not be structured in the traditional way as the ground had to be cleared from UXO to ensure safety and a long-term perspective in using the land. The next step in the process was to conduct a socio-economic study in the area. The study consisted of visits to the villages, surveys and interviews with the members of the villages were conducted. Ms. Axelsson, who had her educational background in South East Asia science, was one of the persons who conducted the study, and at a later stage she was hired by Stora Enso as the CSR and HR-manager in Laos.
The beneficial conditions for forestry in the country in combination with the socio-economic survey formed the basis of the business model. Through positive experiences at Stora Enso’s testing-operations in Thailand the idea of implementing agroforestry became relevant. By combining Eucalyptus with rice in the plantations and hiring locals as daily workers, the villages could get access to yields of rice that are significantly higher than yields from shifting cultivation, also known as “slash and burn”, which is the traditional method. Moreover, including the villagers in the fundamental part of the business model decreases the risk of conflicts as the villages have a traditional right to the land surrounding the village. As the majority of land in Lao PDR has not undergone any classification or division of property, the process of determining which land that belongs to the villagers has to be conducted by Stora Enso in collaboration with villagers. This, however, serves as a benefit when applying for land concessions from the government as the inclusive approach increases trustworthiness and makes it possible to avoid the prevailing procedures characterized by corruption. After the completion of an in-depth socio-economic study in the region, the structure of the business model developed. As the rotation period of a Eucalyptus tree is seven years, the model came to include seven steps (Figure 2).
A seven-year rotational model of the agroforestry model with Eucalyptus and rice/cash crop/grazing ([11], p. 31).
After land concession is granted and UXO are cleared, the Eucalyptus trees are planted with the intercrop, in this case, rice. Planting is managed by staff recruited from agriculture and forestry-based educational programs in the country, together with local villagers who are educated by managers in the planting of rice and Eucalyptus. Growing rice is possible for the first two years but then has to be replaced by cash crops and suitable grazing crops for livestock.
Mr. Fogde’s 30 years of experience in Laos, serving as the COO of Stora Enso Laos, has resulted in a wide network of contacts and an understanding of the social and institutional mechanisms of the country. Insights from a socio-economic study, carried out by Ms. Axelsson, gave a detailed insight in to the social opportunities and challenges of the region. Their vast understanding and the corporate ambitions from headquarters of Stora Enso served as key enabling factors for developing a best practice beyond legal requirements, as a counter weight to projects in other countries that had failed to meet expectations on social and environmental sustainability.
Due to the socio-economic conditions and the expectations from Stora Enso, the team, led by Mr. Fogde and Ms. Axelsson realized that the business model had to be built from the bottom up in the process of getting land concession, building a functional organization and finding employees. For example the administrative process started with a discussion with the village chief who communicated to members of the villages, and then to the office of the district. Also, an organization structure and a policy of hiring locally, from Laotian universities on senior level, and villages on junior level, were developed. To include village members they were offered to work and paid per hour during planting and harvesting season. Moreover, built in to the idea of organization structure was the possibility of communication through all the levels of the organization as the senior roles could handle English and Lao, and the junior roles could handle Lao and the local language of the villages. Also, in order to increase the direct communication the districts and plantations were visited by one of the head offices managers every ten days.
Agroforestry is not a new concept, but the use of agroforestry on an industrial scale is new. What started on a limited acreage is gradually scaled up to an industrial scale. This is in this process that the inclusive business model is developed. The agroforestry business model illustrates a rationale for the operationalization of triple bottom line [2] and how including stakeholders early in the development process can create what Porter and Kramer [4] refer to as shared values.
The critical factors and the inclusive aspects of the model are illustrated in Figure 3. These four critical factors can serve as a starting point when discussing the development and management of new business models in emerging economies (or BOP, as worded by [7]) . The factors can be seen as phases in a process of developing an alternative business model, as well as a process of internal acceptance of alternative corporate governance.
Critical factors for implementing an inclusive business model as a process of value creation in accordance with the triple bottom line ([11], p. 48).
A number of interdependent factors influence the implementation of the new business model. The first factor, corporate commitment, requires changing fundamental parts of the existing business model aiming for sustainable development. In this case the change was driven by the new corporate identity and experience from situations where the traditional model had led to conflicts and critique from external stakeholders.
Identifying key resources for the development of a new business model can not only be managed at a corporate level, as it requires a local and national connection as well. One of the most critical factors from this perspective is the involvement of social entrepreneurs and individuals who possess the local knowledge and have experience from running business in the country.
In the continued process, the inclusion of stakeholders in a dialogue to develop an understanding of shared values enables access to a network, for example with NGO’s, civil society and government departments. Hence, the identification of shared values is not only a strategy of developing the business model itself. The identification of shared values may also offer access to an inclusive network from other sectors and serve as grounds for legitimacy [10]. In this case the inclusive network supports the development of the business model and facilitates the exchange of knowledge between sectors.
This case supports the understanding that inclusive business models are characterized by high start-up and transaction costs [9]. It may, on the other hand, generate indirect values that can lead to long-term benefits for the company as suggested by Keijzers [24]. Typical benefits can be an enhanced corporate image, local support for continued operations, extended experience from new operational methods and ultimately competitive advantage.
One of the most critical factors is related to social entrepreneurship, the key roles of two social entrepreneurs with local knowledge and has experience from running a business operation in the country. The involvement of a social entrepreneur enables an effective identification of the most crucial points of intersection between the company and the community, what Austin et al. [26], calls the Social Value Proposition (SVP). These entrepreneurs also ensure the inclusion of various stakeholders in the process, aimed at benefiting the local community.
However, the traditional way of measuring the success of a business model is based on the economic efficiency and does not include long-term benefits and indirect values. This is a central problem as evaluations made in the early process can be crucial to the future of the development of a new business model. Therefore, an evaluation tool that takes the indirect values into account is a critical factor for the continued development of inclusive business models. The evaluation method is not only to evaluate traditional economic indicators but also to take into account the future values generated through the inclusion of social issues and the values associated with reputation and brand image. The evaluation method must not replace existing measures but serve as a complement in order to facilitate the communication with headquarters, the board of directors and investors.
This case study may provide an answer to the call for empirical examples of where social entrepreneurs “rise to the challenge” ([27], p. 446) and a transition of an enterprise ([24], p. 357) especially in identification and inclusion of key stakeholders in the process.
It illustrates that inclusive business model is tailored to the context in which it is developed and managed in order to be an inclusive business model. This shows that there are no simple answers to the question of how corporations may alter a traditional conduct to contribute to the society in which they operate, to alleviate poverty, raise educational levels, contribute to a more even distribution of wealth and serve as parts in creating shared values. An inclusive business model thus require corporate responsible intents and management is enacted in a dialogue with a wide set of stakeholders [3].
The entrepreneurship literature points to the importance of contextualization (e.g. [28]), and the importance of keeping the Social Value Proposition at the center of the context [26]. Our findings also show that the social entrepreneurs take the role as change agents, for example in the process of land concession with a wide set of stakeholders’ needs in mind and corporate hiring with gender awareness, which points to adaptation made by “the context” as well.
The Stora Enso case offers insights in challenges and opportunities perceived so far in their efforts to develop and implement an inclusive business model. So far the transformation of corporate conduct has transformed a local community but it has a potential value to an entire industry—and possibly with contextual adaptations to other industries on a world market in McElhaney [23] CSR landscape illustration (Figure 1). This project has neither investigated the internal or external assessment of the new business model, nor the consequences of what happens if the social entrepreneurs no longer are in office. Our suggestions for future research therefore include a call for other empirical studies of inclusive business models, the role of social entrepreneurs and the continued studies of various perspectives of corporate ambitions to “Rethink”.
We gratefully acknowledge the support and generosity of the Royal Swedish Academy of Agriculture and Forestry without which the present study could not have been possible to share with you. We would also like to thank SIDA for providing initial funding for the project, everybody at Stora Enso in Laos for generously sharing their TBL ambitions, especially Peter and Helena, and all the community interviewees that have generously shared their story with us in this project and encouraged us to communicate their entrepreneurship in developing an inclusive business model.
A surgery is an intervention that generates damage in an area of the human body in order to obtain a greater good. In cosmetic surgery, the objective of this controlled damage is to obtain greater beauty. But for this to happen, the damage will have to be controlled so that the body can recover. These procedures are usually performed on patients who must have optimal medical conditions. Therefore, recovery should be quick and smooth and is very desirable in all surgeries, especially in body contouring surgery. The goals of this work are to:
According to ISAPS latest global report, body contouring surgeries (BCS) are among the top four procedures worldwide [3], with a tendency to increase every year; different techniques and technologies have been implemented to optimize the surgical act and improve the patient’s esthetic outcome [4]. We recently searched for literature and realized that we could not find anything specific about optimizing the perioperative management in BCS, although we found some for breast augmentation and microvascular reconstruction [5, 6]. Therefore, we must first understand the problems and complications derived from BCS (mainly lipectomy and liposuction with buttock fat infiltration). By knowing the complications, we can develop strategies to prevent, mitigate, or avoid these complications. Fortunately, there are well-defined strategies for other surgery protocols, which can be used since they present similar complications [7].
The principles we used to select these strategies were that they could be grouped by systems (to facilitate their management), have a defined objective and scientific support, without interacting with the other recommendations, are cost-effective, and are easy to understand for patients. Based on the above principles, we consider that some points are highly relevant to achieve this rapid recovery, and we identified the following seven areas:
Nutrition
An excellent preoperative diet and a quick restart
Immunology
An adequate immunological function to decrease infections
Pain and inflammation
Avoiding pain with strategies that promote comfort and mobility
Hemodynamics
Hydration and response to bleeding, preventing thrombosis
Early mobilization
To avoid complications and rapid reintegration
Education and communication
Adequate patient education for active participation
Leadership
Effective decision making and re-evaluation for improvement
Body contouring surgeries sometimes require more than 3 hours of surgical time, management of large surgical areas, and a large exchange of fluids (as in the case of liposculpture). Therefore, it is important to consider the management of perioperative nutrition as a fundamental pillar for a good recovery, as well as the multimodal management [2, 5, 6, 7, 8]. Some of the possible benefits of adequate perioperative nutrition management such as decreased perioperative anxiety and thirst, controlled nausea and vomiting, decreased morbidity and mortality, and shortened hospital stay have been reported in different protocols [2, 5, 7, 9].
In order to properly apply the recommendations, a patient undergoing body contouring surgery must be selected according to specific parameters [4] and preferably without comorbidities. Increased metabolic stress and insulin resistance are closely associated with fasting long periods [10], which may result in nausea, vomiting, and increased morbidity and mortality, including prolonged hospital stay and longer recovery period [1]; there are several perioperative guidelines and protocols published in order to avoid them [5, 6, 8]. In the case of body contouring surgeries, they are particularly useful and can be divided into:
perioperative nutrition;
fast to solid food; and
fluid and carbohydrate loading.
The patient who undergoes elective body contouring surgeries must comply with the specific indications to improve his postoperative period, optimize recovery times, provide optimal conditions for healing, and prevent possible complications. Obese patients can also be malnourished; we suggest a complete nutritional evaluation, and the patient follows the appropriate and specific indications before surgery [9]. It is important to work on the patient’s good eating habits and physical activity, since obesity is undoubtedly a factor that increases perioperative morbidity and mortality, wound dehiscence and infections, venous thromboembolism, and other complications. We would even recommend the surgeon to postpone surgery if the patient’s weight is not adequate, seeking to perform elective surgeries on body mass indexes below 30 kg/m2 ideally [11, 12]. It is important to integrate a group of professionals that includes a nutritionist and a psychologist, working together to improve our patient’s behaviors and bad habits.
Alcoholic beverages should also be avoided. An intake of five or more alcoholic beverages in 1 day or five or more days in the last 30 days is considered high consumption and should be recommended to be suspended 1 month before surgery, since it is considered a risk factor frequently associated with wound infection [11].
Adequate preoperative intake should be monitored, and foods rich in protein and energy can be recommended 7 to 10 days before surgery [13, 14]. Supplements rich in arginine, fatty acids, and nucleotides have been shown to be effective in improving tissue oxygenation by promoting healing and overall recovery [13].
Preoperative fasting is intended to prevent perioperative bronchoaspiration, which has a relatively low incidence but high mortality [15]. But fasting along with surgery can trigger increased insulin resistance and catabolic stress. Catabolic stress produces homeostasis alterations leading to an increase in the occurrence of nausea, vomiting, pain, and general postoperative discomfort that prolongs hospital stay [5, 13].
To avoid this, we recommend patients with BCS, a 6-hour fast for solid foods may be considered. Patients with underlying gastroduodenal pathology [5, 13, 14] and with evidence of delayed gastric emptying will need an 8-hour fast or an overnight fast.
Preoperative administration of carbohydrates (loading) is an option that should be considered 2 hours before the procedure and may be administered in clear liquids (maltodextrin, 12.5%, 285 mOsm/kg, 800 ml the evening before surgery and 400 ml 2–3 hours before induction of anesthesia) [5, 8, 9, 14]. In patients with delayed gastric emptying, carbohydrate loading should be avoided. These measures have been reported to decrease preoperative anxiety, in addition to suppressing thirst and postoperative discomfort [13, 14].
Resuming an early oral intake after major surgery has shown many benefits, such as decreased nausea, faster return of bowel motility, and shorter hospital stay. It is generally recommended to start 4 hours after surgery, preferably with a low-residue diet. The addition of high-calorie and high-protein supplements will compensate for post-metabolic surgical stress [14].
Undoubtedly, nutrition is an important factor in improving critical postoperative aspects such as wound healing and infection prevention [5, 8, 13, 16]. Once the patient is at home, it is important to start a diet with supplementation of amino acids such as arginine and glutamine in addition to fatty acids, antioxidants, and nucleotides, since these are the most necessary nutrients for the body’s metabolic response to surgical stress.
Several studies attribute benefits to arginine supplementation, which is associated with an improvement in vasodilation and oxygenation, in addition to normalizing T-lymphocyte function in tissues, enhancing the body’s immune response, and accelerating biological recovery processes [13, 14].
Consuming protein-rich supplements has also been observed to reduce infection rate and hospital stay [13]. Similarly, supplementation with protein, iron, and vitamin B12 and supplementation with vitamin A, C, as well as zinc, calcium, and magnesium should be considered [17].
The consumption of coffee when started orally and gum (three times a day for 1 hour) has been widely studied to quickly reactivate the intestinal function, being these measures inexpensive and available in any recovery environment. Attempts have also been made to counteract the effect of opiates on intestinal motility by using alvimopan for its antagonistic effect on u-blockers in the gastrointestinal tract, as well as mosapride and its serotonin agonist action to enhance recovery from ileus [5, 13].
It is important to note that surgical infections are rare in body contouring procedures [11, 18, 19], but adequate prophylaxis covering both aerobic and anaerobic bacteria is mandatory [20].
The appropriate time for antibiotic administration, according to current guidelines, is intravenous administration 60 minutes before the surgical procedure. The use of first-generation cephalosporins (Cefazolin 1 g) is preferred because of its wide coverage, low cost, and low allergenic potential [20, 21, 22].
The administration of oral antibiotics in the subsequent postoperative period lacks scientific support to demonstrate its efficacy in preventing infections, and its role in eliminating intestinal bacterial flora can be questioned [11, 20, 22].
It is recommended to clean the skin with alcohol and chlorhexidine solutions to eliminate the bacterial flora. Its use decreases the presence of surgical site infection by up to 40%. Studies have shown that they are more effective compared to povidone-iodine [11].
Preoperative bathing with chlorhexidine-based soaps remains questionable [20]; however, it can be considered useful as BCS works in large surgical areas, and this theoretically allows for more adequate preparation before the surgical procedure [11, 21].
One of the pillars of the comprehensive approach to surgical patient recovery is the management of analgesia. With this in mind, the first step is precisely to establish an appropriate analgesia management scheme even before the procedure. There is evidence that reducing pain during the intraoperative and postoperative processes will allow patients to have a faster nutritional, psychological, and motor recovery [23]. Among the results, a significant decrease in postoperative pain from day 0 to day 3 has been found. Another reason within rapid recovery protocols is to limit the use of opiates, thereby achieving the goal without increasing complications. On the other hand, opioids reduction is also part of the postoperative strategy to limit nausea and vomiting and avoid postural hypotension. These symptoms are a common cause of longer hospitalizations [11, 23, 24]. Among the recommendations for postoperative analgesia, treatment with ketorolac and then with paracetamol, nonsteroidal anti-inflammatory drugs, and gabapentin are recommended [25, 26].
Multimodal management is chosen to act on the different pain mechanisms and thus reduce them in the postoperative period [25]. As preoperative planning, celecoxib (200–400 mg), gabapentin (300–600 mg), and ondansetron (8 mg) are started as premedication one night before surgery and the surgery morning. Intraoperatively, dexamethasone (8 mg) and promethazine (25 mg) are added after induction, either intravenously or in suppository [26], in addition to fentanyl and propofol per kilogram of weight [23]. In breast surgery, the protocols also include regional anesthesia by paravertebral blocks [25] and in abdominoplasty the use of liposomal bupivacaine [27] (0.25–0.5%) below the rectus abdominis sheath [25] or transverse abdominal plane block. Ropivacaine as a pain control measure within the breast pocket in breast surgeries has also been reported efficiently by Durán-Vega [28]. In all cases, 1 g of paracetamol is applied intravenously at the end of surgery and just before extubation. In the recovery area, gabapentin can be used before discharge or during the hospital stay. For outpatient management, celecoxib and gabapentin are indicated for 5 to 7 days (Table 1) [26].
Moment | Drug |
---|---|
Night before surgery | Celecoxib |
Gabapentin | |
Ondansetron | |
Morning of surgery | Celecoxib |
Gabapentin | |
Ondansetron | |
Induction | Dexamethasone |
Promethazine (suppository) | |
Intraoperative | Acetaminophen |
Bupivacaine injection or ropivacaine pocket irrigation site (Duran’s technique) [28] | |
Recovery | Gabapentin |
Postoperative | Acetaminophen |
Celecoxib | |
Gabapentin | |
Methylprednisolone | |
Tramadol (rescue) |
Options for pain management.
The accelerated recovery protocol after surgery originated in the 1990s after findings from major research groups in elective surgery [29] demonstrated improved hydration, reduced incidence of bleeding, transfusions, and complications of thrombosis [1].
The strategies carried out in the perioperative period emphasize the application of management in the different stages of surgery, and one of the main objectives is to avoid the non-rational use of fluids to avoid water overload [30]. It has been shown that water overload is one of the main risk factors that increase morbidity and mortality. Inadequate use of intravenous fluids in quality and quantity favors tissue edema, increased body weight, and fluid leakage into the third space. This also translates into cardiorespiratory complications and, at abdominal level, into a delay in the recovery of adequate peristalsis, since it favors the presence of mesenteric edema and ascites.
Fluid restriction and the use of adequate intravenous fluids have resulted in less interstitial and visceral edema; however, the beneficial effects of such water restriction have not been fully demonstrated through various studies. Some meta-analyses even concluded that there is no decrease in complications or hospital stay [31]. Other randomized controlled studies report a decrease of up to 59% in complications in abdominal surgeries [32]. Optimizing water balance begins with the intake of clear liquids up to 2 hours before surgery [32]. Regarding solid food, it is recommended to be 6 hours before surgery.
But what is the volume that they consider ml/kg/hour within the (non-standardized) definition of water restriction? The range is from 4 to 9 ml/kg/hour compared to non-restriction of 18 ml/kg/hour. It is also important to consider the type and quality of the liquids used for a proper hydroelectrolyte balance ideally with balanced crystalloid solutions instead of saline solutions. Most of the studies are still inconclusive in this topic. Some multicenters report a 20% decrease in postoperative complications and others report a 40% decrease. However, a key element in the success of trans- and postsurgical care continue being continuous hemodynamic monitoring, including surveillance of variables as simple as urine volume per hour, being a very effective and minimally invasive tool. Hydration must always adjust the insensitive losses and the blood losses with crystalloids in each surgical procedure. It is recommended to keep IV fluids at a rate of 6 to 8 ml/kg/hour, the mean arterial pressure above 60 mmHg and the urinary output greater than 0.5 ml/kg/hour.
Patients treated with target-administered fluid therapy (TAFT) has shown in meta-analysis significantly lower morbidity (p = 0.002); therefore, the decrease in hospital stay, hospital costs, as well as lower mortality specifically due to major cardiovascular complications, in this case without being statistically significant (p = 0.370). It was demonstrated in all cases that managed with TAFT globally, less intraoperative fluids were administered compared to their controls [33]. We all recognize the need to replace water in surgery; however, the exact amount for a given procedure remains unknown, and the ideal volume should be identified in an attempt to avoid postoperative complications. Optimal management using conventional heart rate, blood pressure, and urine output parameters is difficult; so, TAFT was proposed; however, the beneficial effect is inconsistent. Nevertheless, TAFT is currently recommended in the context of protocols to improve postoperative recovery. The use of vasopressors is recommended to support fluid management and has no negative effect in the case of free flap surgery [12].
Regarding bleeding, studies by Zakhaleva and others, relate the use of less fluid, with less surgical morbidity [34]. Hemoglobin before surgery should ideally be greater than 13 g/dl [35] in an attempt to decrease morbidity and mortality from bleeding in our elective surgeries. In the case of anemia identified preoperatively, it should be corrected regardless of whether the cause is due to iron deficiency or some previously unidentified disorder [36].
Every patient will prove to be a different challenge in relation to bleeding. This can be related to factors like age, sex, medical history, comorbidities, type and duration of surgery, intraoperative and especially postoperative bleeding, drains use, etc. Also, anesthesia-related factors will have to be analyzed, such as hemodynamic monitoring technique, hemodynamic optimization, and fluid infusion solutions selected, among others [37].
The protocolization of the approach to fluid management will result in adequate perioperative water management, which will reduce costs, morbidity, and mortality, as well as the prompt recovery of our patients, avoiding high rates of postoperative morbidity and mortality dependent on water management by the anesthesiologist [38].
A fundamental element for the prevention of complications and an adequate perioperative evolution is venous thromboembolism prophylaxis. This becomes more relevant when the surgery includes abdominoplasty, a surgery that is usually known to have a higher risk of deep vein thrombosis and pulmonary embolism [18]. In these cases, it is essential to carry out a risk scale from the first contact in the office before elective surgery. There are several scales, and each team must determine which is the most appropriate to work with, although the best known is the scale of Caprini and Davidson [39]. The use of low-molecular-weight heparins is recommended in high-risk patients, unless the procedure is contraindicated and there is a high risk of postoperative bleeding. Among prophylactic measures, the use of graduated compression stockings, as well as intermittent mechanical pneumatic compression devices until the patient’s discharge, is confirmed in different meta-analyses. Early ambulation is undoubtedly one of the main objectives of the rapid recovery process. Mobilization within the first 24 hours after the end of surgery is imperative.
Early mobilization after any surgery is the key to rapid recovery from any surgery. This is desirable even in those surgeries where such mobilization would normally be thought to be contraindicated (for example, in the case of skin grafting) [40]; but in the case of body contouring surgery, mobilization is highly indicated. It is considered the most important general care measure in postoperative care to avoid complications [41]. Early mobilization also reduces hospital stay and hospitalization costs and improves the psychological well-being of patients; it promotes circulation, improves muscle tone, adds coordination and independence, improves bowel and urinary functions, and reduces the risk of pulmonary embolism and pneumonia. We owe this knowledge to Dr. Canavarro since World War II, who made the wounded walk from day 1, reporting a 50% reduction in complications in general [40].
Complications from not having early mobilization include muscle weakness, predisposition to lower extremity thrombosis and embolism, and impaired lung function [42]. For this reason, it is always desirable for the patient to move quickly. Also, mobilization is in full relation with the rest of the indications. For example, if anesthesia does not result in adequate recovery, the patient will not be able to mobilize properly. Or if the patient is in a lot of pain, mobilization will be extremely restricted. Similarly, nausea, cold, and other factors may prevent early mobilization.
One of the fears any doctor may have after surgery is that early mobilization will cause more bleeding. However, studies have shown that it is possible and indicated after surgeries even though when the risk of bleeding is thought to be higher. Southwell showed that there was neither any difference in graft integration nor was it necessarily associated with a higher risk of bruising, bleeding, infection, or slower integration [40]. Similarly, Yang after reconstructions [43] with maxillofacial free flap, considered mobilization as safe and that it could even have a better impact on patient comfort and sleep. Shakil [44] after orthopedic surgeries demonstrated that mobilization is not only desirable but also necessary, as it significantly reduces the rate of wound infection. Miyamoto [45] showed that early mobilization is possible after free anastomosis of the lower limbs. And Krauss [46] mentioned that in patients after hip arthroplasty surgery, it is possible to use tranexamic acid as an adjuvant to prevent bleeding and promote early mobilization.
A very important element is the adequate communication and information of patients through education and counseling of patients throughout the perioperative process. Human, physical, and digital resources can be used for this purpose. Knowing the complete perioperative procedure will help the patient to make the best decisions and to prepare physically and mentally in an adequate way for the surgery, as well as to know the process that will be presented during the recovery phase that starts from the postoperative recovery area.
Within this information, it is fundamental to inform the aspects that can interfere in the evolution and the result of the surgery, as well as those elements and factors that can increase the risk of some complications. The patient must change or suspend some behaviors like the habit of smoking, suggesting the complete abstinence from tobacco, both actively and passively, 4 weeks before the date of the surgery and at least 4 weeks after surgery [11].
Education and information about the perioperative process will allow the patient to collaborate with behaviors and attitudes that seek early recovery and the best outcome, since they will understand in detail the key elements that can prevent complications. The patient must know the importance of immediate ambulation (within the first 24 hours after surgery), the need and procedure for physical therapy, and postoperative rehabilitation.
Immediate postoperative follow-up with clear and precise indications and recommendations promotes early physical and emotional recovery. Adequate follow-up have been shown to promote better mobility, decrease pain scales, and promote the overall quality of life in the recovery process [47]. Appropriate follow-up includes supervised physical activation programs and other care and support initiatives to be implemented after discharge, which have been shown to accelerate recovery and mobility and improve patient self-confidence [48].
The central objective of educating a patient about the process he will face in surgery will be to have a proactive patient who understands what is happening. This patient will be able to differentiate between what is normal and what is not and will know the alarm data so that he can communicate with the surgeon on time in case of any eventuality. This will allow the surgeon to avoid or treat complications in a timely manner thanks to the cooperation of the patient, eliminating ignorance as an impediment to timely treatment.
For the correct application of these protocols, it is essential to establish a lead director of the indications, who within his functions will also ensure the socialization and compliance with the steps, and will monitor and establish the improvements or changes necessary for each group. Therefore, it is of great importance that the processes and successes are audited by a professional and multidisciplinary team [27].
As a major milestone, it is proposed that the patient can be discharged when the following conditions are met: oral fluid and solid tolerance, audible peristalsis, controllable pain with oral medications, assisted or independent mobilization, and absence of complications requiring hospitalization [27].
Rapid recovery protocols after surgery have shown that, even with variable surgeries and different populations, perioperative care determines outcome and success more than the surgical procedure itself [18]. The principles of these practices allow shorter stays and early mobility without increased morbidity [27]. Despite the numerous reports and solid literature on the benefits of rapid recovery protocols, differences in populations and access to resources and elements described above, patient comorbidities [27] involving behavioral changes among so many other variables should be identified by the team leader who should be sensitive to these differences and seek a solution for the different usual scenarios.
Lack of willingness to implement changes, non-standardization of processes and the execution without inspectors [49] are barriers that prevent the proper implementation of these strategies. For this reason, it is very important to be a leader who can work with barriers, such as general resistance to change, lack of time and team availability, and poor communication, collaboration, and coordination between departments [50].
The implementation of these fast recovery strategies is the best approach for our patients, with cost-efficiency optimization, a better experience, and a high overall satisfaction during the whole process [27]. It constitutes a paradigm shift from the traditional steps [24] around the well-being of the patient. It is possible to develop a management protocol that, although standardized, can be adapted to the different surgical groups performing BCS. In the area of nutrition, appropriate support should be sought to adequately nourish the patient so that the patient can have the least amount of fasting and a rapid tolerance to food. In the area of immunology, care must be taken to ensure that the patient has adequate immunological competence to keep inflammation under control and reduce infectious complications. Maintaining and taking care of an adequate hemodynamic function will help to avoid problems of postural hypotension, besides taking care of hemorrhage and adequate hydration, without it being minor or major. In the area of pain, try to make the patient feel as little discomfort as possible so that he or she can move and recover. Early mobilization will bring immediate benefits to the entire body. Proper patient education will help you understand the challenges you will face and communicate properly with the team to achieve a rapid response and avoid complications. And having a team leader who monitors the processes and implements the changes needed to make them truly effective will give the patient success for rapid recovery after BCS.
We would like to acknowledge Dra. Diana Cecilia Popoca for the translation of this document.
None of the authors declare any conflict of interest.
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