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AMERICAN ACADEMY
OF COSMETIC SURGERY
THE AMERICAN JOURNAL
of COSMETIC SURGERY
Five and a Half Years' Experience With the Avelar
Lipoabdominoplasty Procedure: Analysis of
Complication Rates
Quita Lopez, MD
181
The American Journal of Cosmetic Surgery Vol. 30, No. 3, 2013
ORIGINAL ARTICLE
Five and a Half Years' Experience With the A velar
Lipoabdominoplasty Procedure: Analysis of
Complication Rates
Quita Lopez, MD
Introduction: The Avelar lipoabdominoplasty procedure
has been described in the literature as a safe procedure with
fewer complications than traditional abdominoplasty
because oflimited upper abdominal dissection, which spares
the superior neurovascular bundles along with the lymphatics. In the author's published article in 2008, 80 patient
charts were evaluated retrospectively, and the complication
rates were compared with other studies presented in the
literature. The purpose of this study is to compare the complication rates of the first 2 years to the subsequent 3 ~
years since the procedure was adopted. The Avelar minilipoabdominoplasty procedures were also reviewed, and
the complication rates were compared with those of the full
Avelar procedures.
Materials and Methods: A retrospective review was performed of records of patients who underwent a full or miniA velar lipoadominoplasty procedure from July 1, 2007 to
December 31,2010.
Results: A total of89 patient charts were reviewed. There
were 73 fulllipoabdominoplasty and 16 mini-lipoabdominoplasty procedures peiformed by the author. The mean age of
the patients was 42 years; 46% had general anesthesia and
54% had conscious sedation. In the 89 patients who underwent both types of procedures, there was 1 case of skin
necrosis ( 1.1% incidence compared with a 3. 7% incidence
the first 2 years), 4 seromas (4.5% incidence compared with
12.5% incidence in the original study), and no deep venous
thromboses or hematomas. For the fulllipoabdominoplasty
procedures, the skin necrosis rate was 1.4% compared with
3.9% in the 2008 study, and the seroma rate was 5.5% compared with 13.0%. There were 9 small skin dehiscences
( 10% incidence), and there were 4 postoperative infections
( 4.5% incidence). The mini-lipoabdominoplasties had none
of these complications.
Received for publication December 5, 2012.
From the Aesthetic Laser Center, Fresno, Calif.
Corresponding author: Quita Lopez, MD, Aesthetic Laser Center, 6081
N First #101, Fresno, CA 93710 (e-mail: [email protected]).
DOl: 10.5992/AJCS-D-12-00060.1
Conclusions: The complication rates have decreased in
the subsequent 3~ years compared with the first 2 years.
This is probably due to increased surgeon experience, not
operating on smokers in the second part of the study, and
using the Erchonia EML (Erchonia Medical Inc, Mesa, Ariz)
on all patients pre- and postoperatively. The rates were
lower than those reported for traditional abdominoplasties.
There were none of the above complications for the miniabdominoplasties using the Avelar technique.
bdominoplasty is a common procedure for
abdominal contouring. Since Avelar 1•2 described
his technique of combining liposuction with lipectomy
and avoiding large upper flap undermining, the complication rates for the procedure have been shown to
be lower than with traditional abdominoplasty. Lipoabdominoplasty and A velar abdominoplasty are terms
that are often used synonymously by some surgeons.
There have been subtle variations on the technique
described by various surgeons. A common theme
among all is liposuction along with limited dissection
in the upper abdomen and sometimes lower abdomen
when a mini versions are performed. The Avelar
lipoabdominoplasty technique is becoming more popular among surgeons who do abdominal contouring
procedures. It is possible to salvage at least 80% of
the blood supply to the abdomen. 3 Graf et al4 showed
that 60% of the perforators were preserved with a
modified technique that involved limited upper flap
dissection with full en bloc dissection of the lower flap
where there was transection of the inferior epigastric
and external iliac vessels. The size and flow rate are
increased in the remaining vessels due to hypoxic
stimulation. This is a technique that the author employs
with patients with larger body mass index (BMI) who
have a large inferior pannus. Patients with smaller BMis
A
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The American Journal of Cosmetic Surgery Vol. 30, No. 3, 2013
have only the dermis excised, salvaging most of the
blood supply along with the lymphatics and nerves.
With the mini-lipoabdominoplasty procedure, liposuction is performed in the deep and superficial layers,
and the excess skin in the lower abdomen is excised
just below the dermis. There is usually no dissection
of the lower flap except when lower diastasis is present. The midline is then dissected up to the umbilicus
to allow plication for correction of a diastasis. The
umbilicus is not transposed; hence, a small amount of
dead space is created, and there is the preservation of
an even greater amount of blood supply, nerves, and
lymphatics; this probably accounted for there being no
complications in the parameters studied.
Methods
A retrospective review of medical charts was performed between July 2007 and December 2010. There
were 73 full Avelar lipoabdominoplasties and 16 minilipoabdominoplasties performed. All of the patients
were women. The mean age was 42 years, with a
range from 21 to 72 years. The average BMI was 28.6
kg/m2 (range, 20-41 kg/m2). The mean BMI for
patients undergoing mini-lipoabdominoplasty was
25.8 kg/m2 (range, 20-31 kg/m2). Forty-four patients
had liposuction of other body parts along with the
abdominoplasty, and 14 patients had concomitant
breast surgery. This included implant placement,
implant with simultaneous lift, or just mastopexy. Fat
grafting to the face was done in 9 patients, and 5 had
simultaneous fat grafting to the buttocks. One patient
had a labioplasty procedure at the same time, and
another had a brachioplasty procedure. Hence, all of
the patients undergoing mini-lipoabdominoplasty had
other procedures performed. The overall incidence of
concomitant procedures was 75%. All surgery was
performed in an accredited office surgery center.
Surgical Technique
The patient was marked preoperatively, and tumescent anesthesia consisting of 0.05% lidocaine was
used. In a liter of normal saline, 0.8 mg of 1:1000
epinephrine and 10 mg of 8.4% bicarbonate were also
placed. Forty-six percent of the patients had general
anesthesia, and 54% had conscious sedation. In the
original study, 41% had general anesthesia and 59%
had conscious sedation. The Erchonia EML Laser
(Erchonia Medical Inc, Mesa, Ariz) was used during
infiltration to facilitate liquefaction of fat prior to liposuction. The Mangubat disruptor was also used before
liposuction was initiated. Liposuction was performed
below and above Scrapa' s fascia in the upper abdomen to allow sliding of the flap. Liposuction is also
performed aggressively in the lower flap, and Scarpa
fascia is usually not well preserved in the author's
opinion. Patients with larger BMis who have significant fat in the lower flap had an en bloc dissection of
the lower abdomen and drain placement horizontally
in the lower abdomen. Here, the inferior epigastric
and external iliac vessels, which are zone 1 and 11
vessels as described by Huger, 5 are transected, and
there is also injury to the lymphatics in this region.
The excess skin is then measured and marked, and it
is tested before excision by pulling together with
Koeker clamps. The excess skin is excised, the umbilicus is released, and the stalk is tagged. The vertical
midline is also released up to the xyphoid process if
needed. This vertical tunnel is mostly limited to the
internal borders of the rectus abdominal muscles. A
Saldanha retractor is placed in the midline, and the
author has made more aggressive releases in the latter
3¥2 years to better plicate the superior fascia for better
correction of a diastasis defect. The retractor stretches
the midline and allows for better visualization of the
fascia. The vessels will be located more laterally on
stretched-out abdominal muscles; hence, a larger
tunnel can be dissected safely. Fat is resected in the
lower midline to expose the fascia, and it is plicated
if needed. The incision is closed in 2 or 3 layers, and
the umbilicus is transposed. A Jackson-Pratt drain is
placed horizontally in patients with full-thickness
excision of the lower flap. Activated platelet-rich
plasma (PRP; Harvest Technologies, Plymouth, Mass)
is sprayed in the flap prior to closure and along the
incision after closure. PRP has been shown in the literature to promote wound healing. 6--11 All patients
wear pneumatic compression stockings if they have
general anesthesia, and they also have their knees
flexed during surgery. All patients wear knee-high
compression hose for 14 days, and Lovenox (Aventis
Pharmaceuticals Inc, Bridgewater, NJ) is given to
high-risk patients for 3 days. Compression garments
are worn for a minimum of 2 weeks.
The mini-lipoabdominoplasty procedure is similar,
but the umbilicus is not translocated, and there is
almost no dissection of the lower flap. Only the midline is dissected up to the umbilicus if plication is
needed for lower diastasis repair. Drains are not placed
in these procedures.
Prior to performing the skin excision, liposuction is
performed in the other areas, usually the flanks. As
The American Journal of Cosmetic Surgery
183
Vol. 30, No.3, 2013
Table 1. Postoperative Complication Rates (%)
2008 study (n = 77)
Current study (n =73)
Skin Necrosis
3.9
Seromas
13.0
1.4
5.5
noted, 50% of the patients had liposuction of other
areas done in addition to the Avelar lipoabdominoplasty. All of the mini-lipoabdominoplasty patients
had additional liposuction for improved body contouring. Patients undergoing other procedures had those
procedures performed prior to the abdominoplasty,
except for fat grafting to the face, which was done
last.
Results
In the original study, 12 the author performed a retrospective review of the charts between June 2005 and
June 2007. There were 80 patients, with 77 having full
lipoabdominoplasties and 3 having mini-lipoabdominoplasties. The mean age of the patients was 44 years
(range, 24-76 years). The average BMI was 30.1 kg/m2
(range, 20-42 kg/m2) . There was an overall 3.7% skin
necrosis rate, and the full lipoabdominoplasties had a
3.9% rate, which was lower than most studies found
in the literature (range, 1.2-20% ). In the second part
of the study, the overall rate decreased to 1.1% and to
1.4% for the fulllipoabdominoplasties (Table 1). This
occurred despite more aggressive release of the stromal structures in the midline to allow for better fascial
plication. No smokers were operated on in the second
study.
The overall seroma rate decreased from 12.5% to
4.5%. The full lipoabdominoplasty rate decreased
from 13.0% to 5.5% (Table 1). The decreased rate
probably reflects better selection of patients who need
drain placement. With full-thickness excision of the
lower flap, the lymphatic tracks in this area are usually
damaged along with the lower part of zone 1 and zone
2 vessels. Hence, the author now places drains routinely in these patients. The Erchonia 635-nm lowlevel laser was also used on all patients postoperatively
in the second series. Most patients were not treated
with the low-level laser in the 2008 study. Only
patients in the last 2 months of the first study were
treated, which amounted to about 12 of 80. The lowlevel laser has been shown to enhance wound healing
and increase vascularization after surgery. 13• 14 This
might also have contributed to the decreased skin
necrosis rate in the second series as all the patients
Deep Venous Thromboses
0
0
Hematomas
0
0
were treated with the low-level laser. Jackson 15 used
PRP on his adominoplasty procedures and showed
less seroma formation, and drains were used for a
shorter amount of time. PRP was used on most patients
in the first and second study.
There were no deep venous thromboses or hematomas in either series (Table 1). There was an overall
4.5 % infection rate and 10% dehiscence rate in the
second series. Most of the infections were minor and
were treated with oral antibiotics, and all dehiscences
were small. Please see Figures 1 to 9 for before and
after photos.
Discussion
The lipoabdominoplasty procedure as described by
Avelar 1•2 has been shown to be safe and have decreased
complications compared with traditional abdominoplasty procedures. Avelar started performing these
procedures in 1998 after doing cadaver studies and
research for 10 years. In his studies, he found that liposuction below Scarpa's fascia allowed sliding of the
superior flap and that the neurovascular bundles were
able to be preserved because of limited dissection. He
Figure 1. Sixty-year-old patient (height: 150 em; weight:
84 kg) had liposuction of waist and hips with an Avelar
abdominoplasty (side view).
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The American Journal of Cosmetic Surgery
Vol. 30, o. 3, 2013
Figure 4. Thirty-nine-year old (height: 165 em; weight:
74.5 kg) had liposuction of waist, hips, inner thighs, and
knees and an Avelar mini-abdominoplasty (front view).
Figure 2. Sixty-year-old (height: 150 em; weight: 84 kg)
had liposuction of waist and hips with an A velar abdominoplasty (front view).
measured the length of the preserved vessels and
found them to stretch 4 times their length. Fat above
Scarpa's fascia was retained to maintain a uniform
thickness and avoid irregularities. He also closed
Scarpa's fascia to avoid indentations and decrease the
tension on the scar. Initially, the excess skin was
removed suprapubically and in the inframammary
region. The fascia was not plicated in his original
studies. Avelar later modified his procedure and plicated in the midline and transposed the umbilicus.
Liposuction has allowed the surgeon to improve
Figure 3. Thirty-nine-year-old (height: 165 em; weight:
74.5 kg) had liposuction of waist, hips, inner thighs, and
knees and an Avelar mini-abdominoplasty (side view).
patient contouring along with salvaging the neurovascular bundles and lymphatics. This allows the flap to
be closed without the usual undermining up to the
costal margins. Saldanha et al 3 showed that the upper
flap was undermined only 30% compared with standard abdominoplasties. In their article, Brauman and
Capocci 16 discussed skin-retaining ligaments, which
caused skin creases on patients in the upper abdomen.
They felt that these were vertical layers of fascia that
attach the skin to the deep fascia and make the downward advancement more difficult. The skin will usually retract back later, making the result less
aesthetically pleasing. They used scissors or blunt dissection in lateral tunnels to release the ligaments
selectively. With their experience, they were able to
preserve the perforators while releasing the ligaments.
The authors also felt the release of the skin-retaining
ligaments decreased the tension on the skin incision,
which is a cause of flap necrosis. They showed a 1.7%
necrosis rate in their series of 337 patients (Table 2).
Figure 5. Forty-five-year-old (height: 160 em; weight: 72
kg) had an Avelar abdominoplasty.
The American Journal of Cosmetic Surgery
Vol. 30, o. 3, 2013
185
Figu~e
6. ~ifty-year-old (height: 165 em; weight: 84.5 kg)
had lzposuctwn of the lower back, waist, and hips and an
A velar mini-abdominoplasty (side view).
Samra et al 19 compared complication rates in 161
patients who underwent a lipoabdominoplasty (n =
93) versus a traditional abdominoplasty (n = 68). They
found the lipoabdominoplasty had a complication rate
of 4.30% compared with 11.76% (P = .126). These
were what they called perfusion-related complications,
including skin necrosis, wound infection, and wound
dehiscence. In the patients who were at high risk,
which included smokers and patients with significant
upper abdominal scars, the complication rates were
not statistically significant.
There are numerous studies in the literature in which
wound healing, postoperative pain, and inflammation
are improved with the low-level laser. 16.zO-zz.zs.z6 Bensadoun and Naif2 3 performed a meta-analysis on 33
relevant articles, which showed that low-level laser
therapy reduced the risk of oral mucositis (relative
risk, 2.45). Treatment also reduced the severity of oral
mucositis and decreased the duration to 4.38 days.
This was clinically significant (P < .0009). The authors
concluded that there was moderate-to-strong evidence
Figure 7. Fifty-year-old (height: 165 em; weight: 84.5
kg) had liposuction of the lower back, waist, and hips and
A velar mini-abdominoplasty (front view).
Figure 8. Forty-six-year-old (height: 155 em; weight: 79
kg) had liposuction of the lower back, waist, and hips and
an Avelar abdominoplasty along with breast augmentation
(side view).
in favor of low-level laser therapy for treating cancer
therapy-induced oral mucositis. It was well tolerated
and relatively inexpensive.
The author's decreased skin necrosis rate during the
second study probably reflects the use of the low-level
laser, which has shown to improve flap survival by
50% in rats. Tenehaus et al 24 produced random-pattern
skin flaps on mice. Since the low-level laser at 635 nm
is known to increase mitochondrial activity and adenosine triphosphate production in cells, it was used to
treat half the animals. Perfusion was measured by
laser Doppler before and after surgery. Mean flap loss
was 25% in the nontreated group and 9% in the treated
group. There was more than a 50% reduction in ischemia or apoptosis in the zone of stasis in the lowlevel laser-treated group. This was statistically
Figure 9~ For~-six-year-old (height: 155 em; weight: 79
kg) had lzposuctwn of the lower back, waist, and hips and
an Avelar abdominoplasty along with breast augmentation
(front view).
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The American Journal of Cosmetic Surgery
Table 2.
Lonergan and Mangubat 17 (n =67)*
Rodriguez and Borsand 18 (n =100)*
Saldanha et al 3 (n =445)*
Brauman and Capocci, 16 (n =337)t
Current study (n =150)*
Vol. 30, No. 3, 2013
Complication Rates (%) as Reported in the Literature
Skin Necrosis
3
2
0.2
1.7
2.6
Seroma
6
9
0.4
1.4
9.3
Infection
7
4
n/a
1.4
4.0
Deep Venous Thromboses
0
0
0.2
0
0
Hematomas
0
5
0.2
.29
0
*Lipoabdominoplasty performed.
tLipoabdominoplasty with selective release of skin-retaining ligaments.
significant (P < .01). The perfusion measured at the
distal flap showed an upregulation at day 4, which was
statistically significant between the tested group and
control group (P < .05). There was about a 50%
increase in blood perfusion in the group treated with
the low-level laser.
No smokers were operated on in the second series.
The mini-lipoabdominoplasty maintains the most
blood supply; hence, there were no cases with skin
necrosis.
Overall seroma rates decreased from 12.5% to 4.5%,
and fulllipoabdominoplasty rates decreased from 13%
to 5.5% (Table 1). Modification of Avelar's original
technique involving en bloc dissection of the lower
flap causes more dead space formation and injury to
the inferior vessels and lymphatics. Huger5 noted that
the lymphatic drainage follows the vascular blood
supply pretty closely. When a full-thickness excision
is performed, there is routine placement of drains in
the lower abdomen. The Avelar mini-lipoabdominoplasty procedures have limited dissection and almost
no injury to the vessels and lymphatics. There were no
seromas in the 16 cases the author performed. In summary, the potential mechanisms for a decreased seroma
rate in the second series is probably due to avoiding
injury to the upper and lower abdominal lymphatic
vessels. When the lymphatics are injured during an en
bloc dissection in patients with larger BMis, drains are
Table 3.
now placed routinely until the serous output is less
than 30 mU24 h. Reducing the exposed rectus fascia
and having a fat-to-fat interface during closure of the
flap might also help. Eliminating the amount of dead
space is also a factor. The use of PRP in the lower flap
has been shown by Jackson 15 to decrease seroma formation. The low-level laser10•11 •13 has been shown to
improve wound healing. This might also have contributed to the decreased rate, but more studies are needed
to confirm this.
There were no deep venous thromboses or hematomas in either series (Table 1). This is probably in part
due to the use of the tumescent solution that contains
epinephrine, which causes vasoconstriction, and to the
use of compression garments after surgery, along with
meticulous dissection and careful control of bleeding.
Patients also ambulate the evening of surgery and are
mobile and wear compression stockings. Lovenox
prophylaxis is also given to high-risk patients.
Table 3 is a statistical analysis of the complication
rates between the 2 studies. Even though they are not
statistically significant to the P > .05 level, there is a
trend toward decreased rates. Having a higher sample
size might have shown statistical significance.
Please review Table 2 for complication rates published by different authors on the abdominoplasty
procedure.
Results of the z Test Comparing the Complication Rates in the Current Study to
the Complication Rates in the 2008 Study*
Complication
Proportion for Current
Study (n =73)
Proportion for 2008
Study (n =77)
ZScore
P Value (2-Tailed)
All
Skin necrosis
Seromas
.068
.014
.055
.169
.039
.130
-1.89
-0.96
-1.58
.059
.337
.114
Statistical
Significance
P>.05
P>.05
P>.05
*Statistical analysis of the complication rates from the 2 studies showed that the complication rates between the 2 studies were
not statistically significant to the P > .05 level, but there was a trend for decreased rates in the current study.
The American Journal of Cosmetic Surgery Vol. 30, No.3, 2013
Conclusion
The Avelar lipoabdominoplasty has been shown to
be a safe and effective procedure for treating skin
laxity and localized adiposity and for correcting diastasis recti. In the author's first published study, she
showed a decreased complication rate compared with
traditional abdominoplasty procedures reported in the
literature. Comparing a similar case number in the
subsequent 3~ years showed a further decrease in
complication rates, probably due to the author's
increased experience with the procedure and the use
of PRP and the low-level laser to increase skin perfusion after surgery.
Mini-lipoabdominoplasty procedures using the
Avelar technique were performed with other concomitant procedures for better body sculpting, and there
were no noted complications in this series. The author
opines that most blood supply is spared since there is
very little undermining with the procedure. The additional procedures performed on these patients did not
increase the complication rates.
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