Updates_in_Aesthetic_Surgery_0512_Article.13

COSMETIC
Lipoabdominoplasty
Osvaldo R. Saldanha, M.D.
Rodrigo Federico, M.D.
Presper F. Daher, M.D.
Andrey A. Malheiros, M.D.
Paulo R. G. Carneiro, M.D.
Sérgio F. D. Azevedo, M.D.
Osvaldo R. Saldanha Filho
Cristianna B. Saldanha
Santos, São Paulo, Brazil
Background: Abdominoplasty is one of the most common aesthetic operations. Wide bibliographic research has revealed that there is a safe method
whereby two techniques-liposuction and abdominoplasty-can be associated
in the same procedure. The authors present a new abdominoplasty technique
combining a selective undermining with complete abdominal liposuction.
Methods: The authors standardized steps with which to perform a safe
association of traditional abdominoplasty with liposuction of the entire
abdomen and infracostal areas. Using selective undermining, it is possible
to preserve at least 80 percent of the blood supply in the abdominal wall,
causing little nervous trauma, preserving the great majority of the lymphatic
vessels, and resulting in few complications compared with traditional abdominoplasty, including post-bariatric surgery procedures. In this study,
lipoabdominoplasty was performed on 445 patients: eight male patients and
437 female patients, from 2000 to 2007.
Results: The authors consider the results good and excellent, especially regarding
patient evaluation, better body contour, abdominal rejuvenation, shorter scars, the
form of the umbilicus, and a decrease in the abdominal measures.
Conclusion: With a progressive adaptation of this technique, it is possible to achieve
a harmonious body contour using a safe liposuction method on the abdominal and
costal areas, with fast recovery and good to excellent results. (Plast. Reconstr. Surg.
124: 934, 2009.)
T
he evolution of techniques in abdominal surgery, with low postoperative morbidity and
lower complications rates, has always motivated surgeons to search for innovations in plastic
surgery.1–16 Lipoabdominoplasty was developed
and patterned as a safe and functional option with
which to perform liposuction and abdominoplasty
during the same surgical procedure, promoting
the benefits of both techniques. This technique
generates a better aesthetic result and can be
learned quickly because surgeons are accustomed
to performing each procedure, liposuction and
abdominoplasty, separately.
This technique is not simply using liposuction
while we are performing abdominoplasty. It has a
much wider concept, respecting the complete abdominal anatomy. The traditional undermining
has been substituted with canula undermining. As
From the Plastic Surgery Department, Santa Cecı́lia
University.
Received for publication December 6, 2007; accepted April 9,
2009.
Reprinted and reformatted from the original article published
with the September 2009 issue (Plast Reconstr Surg. 2009;
124:934 –942).
Copyright ©2012 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e318250a549
a consequence, we do not stop the blood supply
coming from the abdominal perforating vessels.
HISTORY
Undermining Evolution
History shows a progressive undermining of the
abdominal wall from 1899 to 1957, when the extensive undermining was standardized by Vernon1–3 to
facilitate umbilicus transposition. Hakme, in 1985,
presented a new approach for the abdominal lipectomies, called the miniabdominoplasty technique
and consisting of liposuction of the entire abdomen
and flanks, associated with the elliptical resection of
the suprapubic skin, and plication of the supraumbilical and infraumbilical muscles, without relocating the umbilicus.8
In 1991 and 1995, Matarasso focused on the
complications of combined liposuction and abdominoplasty methods, presenting two articles
that recommended safe areas of liposuction.9,10 In
those articles, he considered the back and the
Disclosures: None of the authors has a financial
interest to declare in relation to the content of this
article.
www.PRSJournal.com
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Plastic and Reconstructive Surgery • Spring 2012
flanks safe areas and did not regard the lateral
region of the abdomen as a safe area; the central
region of the abdomen was considered prohibited
for liposuction.17
In 1995, Lockwood reported the high lateral
tension abdominoplasty, in which he used the
Scarpa fascia to decrease the tension of the skin
closure.12,13 Since the 1990s, the undermining has
decreased in amplitude because of a large number
of complications (seroma, hematoma, and most of
all, necrosis), reaching zero in 1992 with the publication regarding abdominoplasty mesh undermining by Illouz.11,18,19 The trend of abdominolipoplasty
without or with small undermining continued until
1999, when Shestak14 and Avelar15 presented the
partial abdominolipoplasty method, with no undermining, associated with liposuction.
In 2001, using the term lipoabdominoplasty
for the first time and with the publication of this
technique, Saldanha standardized a selective undermining along the internal borders of the rectus
muscles, corresponding to 30 percent of the traditional undermining, thus preserving the abdominal perforating vessels, because of the use of liposuction and abdominolipoplasty during the
same surgical procedure safely.20 –23 This selective
undermining is maintained to this day. Figure 1
shows the evolution of undermining in abdominoplasty from 1899 to 2007.
LIPOABDOMINOPLASTY SURGICAL
TECHNIQUE
Fundaments of the Technique
Superficial liposuction introduced by Souza
Pinto was one of the fundamental principles of
lipoabdominoplasty because it made possible and
facilitated its execution.24 This procedure gives more
Fig. 1. Abdominoplasty: evolution of undermining from 1899 to
2007.
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mobility to the abdominal flap so that it can slide
down easily and reach the suprapubic region. The
second principle is the anatomical study of the exact
localization of the perforating abdominal vessels so
that they can be preserved during the procedure.
Patient Selection
All patients for whom traditional abdominoplasty is indicated may undergo lipoabdominoplasty. From the year 2000 to 2007, lipoabdominoplasty was performed on 445 patients (eight
male patients and 437 female patients), with an
average age of 36 years.
SURGICAL STEPS
Surgical Marking
We mark the abdomen in the shape of a “bicycle handlebar,” with 12 cm horizontally (Fig. 2,
above) and 8 cm obliquely, with approximately 40
to 45 degrees of inclination on each side (Fig. 2,
center), in the direction of the iliac crests. The
distance from the vaginal furcula to the horizontal
marking is 6 to 7 cm (Fig. 2, below).
For better orientation at the beginning of tunnel undermining, we mark the diastasis in advance. If necessary, we mark the dorsal areas we are
going to aspirate.
Infiltration
We use the wet technique, infiltrating the abdominal region with saline solution and adrenaline (1:500,000), with an average 1 to 1.5 liter total.
Epigastric and Subcostal Liposuction
To safely perform liposuction, we place the
patient in a hyperextended position on the surgical table. We start liposuction on the supraumbilical region with a 3- and 4-mm cannula, removing the fat of the deep and superficial layers, going
on to the flank. As in classic liposuction, we maintain enough fat thickness to avoid vascular impairment and contour deformities.
Lower Abdomen
Before removing the excess skin, to facilitate
visualization and preservation of the Scarpa fascia,
we aspirate all of the fat in the superficial layer and
some of the fat in the deep layer in the lower
abdomen using a 6-mm cannula. We evaluate the
flap descent and proceed with isolation of the
umbilicus and total resection of the infraumbilical
skin, as in traditional abdominoplasty. When necessary, we perform complementary open liposuction to remove more fat below the Scarpa fascia,
Volume 129, Number 5S • Lipoabdominoplasty
tasis, the wider the tunnel, because the perforating
vessels follow the separation of the muscles.
Tunnel undermining may reach the xiphoid,
depending on the necessity of the plication. For a
better view of the anatomical structures and to
facilitate the plication, we created a retractor that
amplifies the surgical area and avoids trauma on
the edge of the flap (Fig. 5).
Preservation of the Scarpa Fascia
In the lower abdomen, all of the superficial fat
layer should be aspirated to facilitate visualization
and preservation of the Scarpa fascia, leaving it
intact after removal of the lower abdominal skin.
The preservation of the Scarpa fascia is very important for many reasons. It causes less bleeding, because of the preservation of the inferior perforating
Fig. 3. Selective undermining, diastasis demarcation, preservation of the Scarpa facia, and the inferior fuse demarcation to be
removed.
Fig. 2. (Above) Horizontal marking (12 cm), (center) oblique
marking (8 cm), and (below) initial distance from the pubis (6
to 7 cm).
to create a homogeneous surface to accommodate
the superior flap.
Selective Undermining
We start the undermining of the tunnel in the
median line of the upper abdomen, between the
internal borders of the rectus abdominal muscles,
with care taken to not overpass them, because in
this area we might cut off the abdominal perforating vessels (Figs. 3 and 4). The wider the dias-
Fig. 4. Perforating vessels.
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Plastic and Reconstructive Surgery • Spring 2012
Fig. 5. The Saldanha retractor.
Fig. 6. Resection of the infraumbilical fuse.
vessels; it is a homogeneous support for the upper
flap, which becomes thinner on its descent; and it
provides smaller scars laterally and offers better adherence between the flap and the deep layers.
Resection of the Infraumbilical Fuse and Rectus
Muscle Plication
In the median infraumbilical line, we remove
a vertical fuse that contains the Scarpa fascia and
adipose tissue to expose the internal edges of the
rectus abdominal muscles and to perform the plication from the xiphoid to the pubic symphysis
(Figs. 6 and 7).
Omphaloplasty
We use the star-shaped omphaloplasty technique, which is a cross-demarcation on the abdominal wall and a rectangular demarcation on the umbilical pedicle. The cardinal points of the umbilical
pedicle are sutured, accommodating themselves on
the cruciform incision of the abdominal wall. We
perform the resulting scar in continuous Z-plasty
that offers little possibility of retraction (Fig. 8).
Suture of the Layers
We perform the suture of the abdomen in two
layers using 3-0 Monocryl (Ethicon, Inc., Somerville, N.J.) on the deep layer and 4-0 Monocryl on
the subdermis, attempting to take the tension off
the midline skin closure by placing more tension
laterally, as recommended by Lockwood.17 We suture the skin with 5-0 mononylon, with separate
stitches (Fig. 9). We use a continuous aspiration
drain (4.2 mm) for 1 or 2 days (Fig. 9). The operation takes approximately 2 hours and the patient stays in the hospital for 1 day.
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Fig. 7. Rectus abdominal muscle plication.
Fig. 8. Star-shaped omphaloplasty closure.
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Fig. 9. The two-layer suture.
Dressing
To dress the wound, we use Micropore surgical tape (3M, St. Paul, Minn.) on the suture,
which is changed on the third and eighth days
after surgery, when we remove the stitches, except those on the umbilicus, which are removed
on the twelfth day after surgery. The patient
needs to use compressive mesh for 20 days after
surgery.
Postoperative Period
Patients who undergo lipoabdominoplasty
present an intermediary recovery between an
abdominoplasty and a liposuction because the
lipoabdominoplasty is less invasive and causes
little vascular and nervous trauma other than
presenting a discrete dead space. These factors
together result in less morbidity. With this
method, patients return to their social and professional activities earlier.
RESULTS
The safe association of liposuction and abdominoplasty during the same surgical procedure improves the results, including a greater
reduction in abdominal measures and better
body contour. The patient satisfaction resulting
from abdominal rejuvenation leads to an increase in surgical demand and a decrease in the
need for surgical revisions.
We compared the incidence of complications
with traditional abdominoplasty to that with lipoabdominoplasty. The 940 patients who underwent
abdominal surgery, as mentioned in this article,
were operated on and followed by the senior author (O.R.S.) from 1979 to 2007.
From 1979 to 2000, the senior author performed 494 traditional abdominoplasty operations. In 2000, the senior author began to develop
lipoabdominoplasty and in 2001 it was standardized, corresponding to 445 procedures until 2007.
In that year, there was only one traditional abdominoplasty because it was a specific case of skin
excess in a post-bariatric surgery patient.
In the first 8 years of technique implementation, there was an increase of 100 percent in the
abdominal interventions made by the senior author (before 2000, there was an average of 35
patients per year; in 2007, there was an average of
70 patients per year). The same does not occur to
interventions in other parts of the body. There was
a 50 percent reduction in the need for surgical
revisions in the same period.
We observed a decrease in the final scar extension when compared with the initial marking
in 30 percent of patients. The initial line always
measured 28 cm in length: 12 cm horizontal and
8 cm oblique on each side. In the 445 patients, 134
had a final scar between 25 and 27 cm, with an
average reduction of 2 cm from the initial marking. This is attributable to the traction that the
Scarpa fascia makes on the skin. The graceful
shape of the umbilicus scar has been evaluated by
the team and the patients as good or excellent
(Figs. 10 and 11).
COMPLICATIONS
Following the surgical steps systematically and
carefully reduces considerably such complications
as abdominal flap ischemia and skin necrosis,
which are difficult to treat and which can jeopardize the doctor-patient relationship (Fig. 12).
The reduced incidence of seroma (from 60
percent to 0.4 percent, p ⬍ 0.0001), epitheliolysis
(from 3.8 percent to 0.2 percent, p ⫽ 0.0003),
dehiscence (from 5.1 percent to 0.4 percent, p ⬍
0.0001), and necrosis (from 4 percent to 0.2 percent, p ⫽ 0.0002) has statistical significance. Although the incidence of hematoma was reduced
(from 0.6 percent to 0.2 percent) and the incidence
of deep venous thrombosis/pulmonary embolism
remained the same (0.2 percent), we cannot consider these findings as statistically significant because
of the small number of cases. All of these rates can
be observed if we compare traditional abdominoplasty with lipoabdominoplasty.
In the same way, the percentage of surgical
revisions decreased from 20 percent to 10 percent
when only lipoabdominoplasty was performed, remaining so for 7 years. The cases of surgical revision resulting from complementary liposuction
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Plastic and Reconstructive Surgery • Spring 2012
Fig. 10. Case 1. (Left) Preoperative views; (right) postoperative views.
and postoperative skin flaccidity (1.8 percent)
corresponded to patients who had undergone
previous bariatric surgery and who presented a
great amount of flaccidity (Table 1). There was
a need for surgical revision of scars in 6.5 percent, which represents 63 percent of surgical
revisions. Because of that, since 2001, we have
been performing only lipoabdominoplasty
(Table 2).
DISCUSSION
Lipoabdominoplasty has been performed with
a significant reduction of complications such as
seroma, hematoma, and flap necrosis. This technique avoids two-stage procedures (abdominoplasty
and isolated liposuction) in most of the abdomino-
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plasty procedure indications. Using the conservative
approach, we can safely perform liposuction in the
abdominal and in the costal regions to obtain a
harmonious body contour, providing excellent aesthetic results, with low morbidity. Lipoabdominoplasty results in a greater reduction of the abdominal
measures and better body contour, not only because
of the traditional removal of skin but also because of
a decrease in the fat layer located in the abdomen
and flanks by using liposuction.
The 100 percent increase in the demand for
abdominal surgery, unlike with other procedures,
shows patient acceptance of the technique and
how patients have recognized the improvement it
has brought. The decrease in the need for surgical
revisions is another fact that motivates other sur-
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Fig. 11. Case 2. (Left) Preoperative views; (right) postoperative views.
geons to perform this technique. The use of vacuum drainage is important for draining the liquid
injected during liposuction.
In addition, the technique results in the preservation of suprapubic sensibility, quicker healing,
faster postoperative recovery, lower morbidity,
and a better appearing shape of the umbilicus
scar. It also proves to be particularly indicated for
smokers because of the preservation of the perforating abdominal vessels.
CONCLUSIONS
Traditional abdominal plastic surgery is associated with a high rate of morbidity, because of the
necessity for undermining of large areas of the flap
where the perforating vessels are sectioned, taking
into consideration that they represent 80 percent of
the blood supply of the abdominal wall, according to
the literature on this subject.25–30 Lipoabdominoplasty is based on the selective undermining of the
abdominal flap on the superior medial line, preserving the great majority of the arteries, lymphatic vessels, veins, and nerves, which reduces the incidence
of complications. However, a progressive adaptation
of this technique is necessary, starting with cases in
which there is a large amount of skin flaccidity and
sufficient adipose accumulation to permit liposuction and easy liberation of the flap.
This technique is not simply using liposuction
while performing abdominoplasty. It represents a
much wider concept, respecting the complete
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Plastic and Reconstructive Surgery • Spring 2012
Fig. 12. Complication rates.
Table 1. Surgical Revision in Lipoabdominoplasty
Total primary cases (n ⫽ 445)
Scars
Insufficient liposuction
Excessive liposuction
Skin flaccidity
Infection
Other causes
Total (%)
2000
2001
2002
2003
2004
2005
2006
2007
15
3
—
—
—
—
—
3 (20)
45
5
—
—
—
—
—
5 (11)
55
4
1
—
1
—
—
6 (11)
64
3
2
—
2
—
—
7 (11)
62
4
2
—
1
—
1
8 (13)
65
3
1
—
1
—
—
5 (8)
68
3
1
—
1
—
—
5 (7)
71
4
1
—
2
—
—
7 (10)
Table 2. Personal Statistics of Abdominal Surgery
Abdominoplasty
Lipoabdominoplasty
1979 –1999
2000
2001
2002
2003
2004
2005
2006
2007
Total
469
—
25
15
—
45
—
55
—
64
—
62
—
65
—
68
1
71
495
445
abdominal anatomy. Lipoabdominoplasty is
based on the selective undermining of the
abdominal flap in the superior medial line, resulting in the preservation of arteries, veins, lymphatic vessels, and nerves. The classic undermining was replaced with cannula undermining.
As a result, we preserve the blood supply from the
abdominal perforating vessels. This represents an
important way of ensuring patient safety.
Osvaldo R. Saldanha, M.D.
Clinica Osvaldo Saldanha
142 Washington Luis Avenue
Encruzilhada
Santos 11050-200, Brazil
[email protected]
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