Examination of abdominal contour surgery candidates permits categorization of patients (the abdominolipoplasty system of classification and treatment) according to their treatable soft tissue layers of skin, fat, and muscle into the appropriate treatment level. Typically, postpartum abdominal wall changes are most thoroughly addressed by abdominoplasty. The indications and goals for abdominoplasty with liposuction (lipoadminoplasty) or without liposuction are presented. Surgical markings, technique, pain management, and postoperative care are described.
Key points
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Examination of the treatable layers of the abdominal wall (skin, fat, and muscle) and the nontreatable conditions in order to classify patients into the appropriate abdominal contour surgery procedure.
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Reconcile patients’ anatomic findings and their tolerance for the level of procedures, risks, recovery, and expected outcome.
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Recognize that downstaging patients from their appropriate anatomic level of treatment based on the examination to less invasive options do not yield equivalent results as more invasive options.
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Abdominoplasty in appropriate circumstances can be combined with other procedures. Length of surgery is an important consideration in determining the number of procedures that can be safely performed simultaneously.
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Abdominoplasty is the aesthetic surgical procedure associated with the greatest risk for systemic complications.
Introduction
Abdominoplasty is a commonly requested procedure for many reasons, including the concerns of an aging population determined to maintain a youthful physique, women intent on restoring their prepregnancy appearance, the rise in massive weight loss patients who are seeking to remove the stigmata of residual excess skin from weight loss. The goal of abdominal contour surgery is the aesthetic improvement of the affected soft tissue layers of skin, fat, and muscle through the least conspicuous incision feasible. Depending on the anatomic nature of the “disagreeable biologic condition,” the goal can be achieved through a range of procedures referred to as the abdominolipoplasty system of classification and treatment. These operations include liposuction alone (type I), the limited abdominoplasties (type II, mini abdominoplasty; type III, modified abdominoplasty), and a full standard abdominoplasty (type IV) with liposuction (lipoabdominoplasty) or without liposuction of the flap ( Fig. 1 , Table 1 ).
| Type | Skin | Fat | Musculofacial System | Treatment |
|---|---|---|---|---|
| I | Minimal laxity | Variable | Minimal diastasis | Suction-assisted lipectomy |
| II | Mild laxity | Variable | Lower diastasis | Mini abdominoplasty |
| III | Moderate laxity | Variable | Lower ± upper diastasis | Modified abdominoplasty |
| IV | Severe laxity | Variable | Complete diastasis | Standard abdominoplasty with or without suction lipectomy |
If additional abdominal, flank, or posterior skin needs to be resected, an abdominoplasty can be extended to address those regions (eg, Fleur di Lis, flankplasty, or extended–circumferential abdominoplasty).
The modern history of abdominal contour surgery and abdominoplasty can be traced back to the late 1960s and the contributions of several surgeons. Those procedures have evolved into present day abdominal contour surgery owing to advances in technique (eg, incision design, muscle treatment), technology (eg, liposuction), changing patient population (eg, massive weight loss), a better understanding of physiology (eg, wetting solutions), and anatomy (the ability to do combined procedures and flap liposuction). Similar to many scientific advances, in abdominoplasty these strides have been incremental. Numerous surgeons have provided varying degrees of contributions to present-day abdominoplasty surgery. Table 2 offers a brief, incomplete overview of milestones in abdominoplasty evolution.
| Time | Milestone |
|---|---|
| 1960s–1970s | Pitanguy, Regnault, Grazar: Classic abdominoplasty |
| 1982 | Introduction of S.A.L.: Illouz |
| 1987 | Greminger, Noone, Wilkinson, and Hakme: Mini abdominoplasty with Liposuction |
| 1988 | Matarasso, Psilakis: Abdominoplasty system classification and treatment |
| 1991 | Matarasso: Liposuction as an adjunct to full abdominoplasty |
| 1992 | Illouz: Abdominoplasty ‘mesh undermining,’ marriage abdominoplasty (Shestak- 1999) |
| 1995 | Lockwood: HLT abdominoplasty |
| 1995 | Matarasso: SA 1-4 goes based on Huger zones |
| 2001 | Survey of c/o ABD: Only 54% of board-certified plastic surgeons perform liposuction of abdominoplasty flap |
| 2001 | Hakme, Avelar, Saldahina, De Souza Pinto, Saltz: Lipo |
| 2000s | Rise in bariatric plastic surgery |
| Late 2010s | Persing/others: Validation studies of lipoabdominoplasty and measures to improve safety and including research and recommendation regarding DVT/PE |
| 2012 | Pannuci, et al, ASPS VTE Task force, Eric Swanson etc.: VTE prophylaxis |
This article focuses on abdominoplasty with liposuction (lipoabdominoplasty) or abdominoplasty without concomitant liposuction, in the most commonly encountered scenario of abdominoplasty, the postpartum abdomen.
Introduction
Abdominoplasty is a commonly requested procedure for many reasons, including the concerns of an aging population determined to maintain a youthful physique, women intent on restoring their prepregnancy appearance, the rise in massive weight loss patients who are seeking to remove the stigmata of residual excess skin from weight loss. The goal of abdominal contour surgery is the aesthetic improvement of the affected soft tissue layers of skin, fat, and muscle through the least conspicuous incision feasible. Depending on the anatomic nature of the “disagreeable biologic condition,” the goal can be achieved through a range of procedures referred to as the abdominolipoplasty system of classification and treatment. These operations include liposuction alone (type I), the limited abdominoplasties (type II, mini abdominoplasty; type III, modified abdominoplasty), and a full standard abdominoplasty (type IV) with liposuction (lipoabdominoplasty) or without liposuction of the flap ( Fig. 1 , Table 1 ).
| Type | Skin | Fat | Musculofacial System | Treatment |
|---|---|---|---|---|
| I | Minimal laxity | Variable | Minimal diastasis | Suction-assisted lipectomy |
| II | Mild laxity | Variable | Lower diastasis | Mini abdominoplasty |
| III | Moderate laxity | Variable | Lower ± upper diastasis | Modified abdominoplasty |
| IV | Severe laxity | Variable | Complete diastasis | Standard abdominoplasty with or without suction lipectomy |
If additional abdominal, flank, or posterior skin needs to be resected, an abdominoplasty can be extended to address those regions (eg, Fleur di Lis, flankplasty, or extended–circumferential abdominoplasty).
The modern history of abdominal contour surgery and abdominoplasty can be traced back to the late 1960s and the contributions of several surgeons. Those procedures have evolved into present day abdominal contour surgery owing to advances in technique (eg, incision design, muscle treatment), technology (eg, liposuction), changing patient population (eg, massive weight loss), a better understanding of physiology (eg, wetting solutions), and anatomy (the ability to do combined procedures and flap liposuction). Similar to many scientific advances, in abdominoplasty these strides have been incremental. Numerous surgeons have provided varying degrees of contributions to present-day abdominoplasty surgery. Table 2 offers a brief, incomplete overview of milestones in abdominoplasty evolution.
| Time | Milestone |
|---|---|
| 1960s–1970s | Pitanguy, Regnault, Grazar: Classic abdominoplasty |
| 1982 | Introduction of S.A.L.: Illouz |
| 1987 | Greminger, Noone, Wilkinson, and Hakme: Mini abdominoplasty with Liposuction |
| 1988 | Matarasso, Psilakis: Abdominoplasty system classification and treatment |
| 1991 | Matarasso: Liposuction as an adjunct to full abdominoplasty |
| 1992 | Illouz: Abdominoplasty ‘mesh undermining,’ marriage abdominoplasty (Shestak- 1999) |
| 1995 | Lockwood: HLT abdominoplasty |
| 1995 | Matarasso: SA 1-4 goes based on Huger zones |
| 2001 | Survey of c/o ABD: Only 54% of board-certified plastic surgeons perform liposuction of abdominoplasty flap |
| 2001 | Hakme, Avelar, Saldahina, De Souza Pinto, Saltz: Lipo |
| 2000s | Rise in bariatric plastic surgery |
| Late 2010s | Persing/others: Validation studies of lipoabdominoplasty and measures to improve safety and including research and recommendation regarding DVT/PE |
| 2012 | Pannuci, et al, ASPS VTE Task force, Eric Swanson etc.: VTE prophylaxis |
This article focuses on abdominoplasty with liposuction (lipoabdominoplasty) or abdominoplasty without concomitant liposuction, in the most commonly encountered scenario of abdominoplasty, the postpartum abdomen.
Patient selection and screening
Females undergo the inevitable consequences everyone does: aging, weight fluctuations, and sun damage, in addition to the profound changes that accompany pregnancy. These issues manifest themselves as loose, damaged, and excess skin, rectus muscle diastosis and stretching, lipodystrophy, widened bony pelvic girth, potentially umbilical hernias and umbilical skin damage, and finally mons pubis alteration with distortion, widening, and ptosis. A full abdominoplasty is the procedure that most comprehensively addresses these changes. It can be supplemented with additional flap liposuction with hernia repair, additional skin removal (flankplasty) with hernia repair , or adjacent liposuction as well as other unrelated procedures.
Patients are examined and classified based on their anatomy to the appropriate abdominoplipoplasty level of treatment. Their physical concerns are addressed and this information is reconciled with their tolerance for incisions, discomfort, healing time, and so on. They are then offered the abdominal contour procedure most suitable to their needs. It cannot be overemphasized that less invasive procedures (downstaging), although associated with less operative time, faster recovery, and lower costs, do not provide the same outcome as a full abdominoplasty.
Anatomic conditions that can be identified and cannot be improved with abdominoplasty, such as intraabdominal fat, spinal disfigurements, uterine malposition, and “bloating,” are clearly communicated to the patient.
Preoperative planning and preparation
Preoperative preparation begins from the time of the initial consultation and is a multidimensional process based on a series of conversations with the physician, their staff, the anesthesiologist, ancillary personnel, and the patient.
Patients receive an extensive informational brochure package at the time of the consultation. Before surgery, they receive a detailed package outlining their anticipated preparations and care, which includes a copious list of products that adversely affect coagulation. For all abdominal contour surgery procedures, patients are instructed to cease nicotine-containing products and compounds that affect clotting before the procedure. All patients are evaluated by an internist and undergo appropriate blood and diagnostic testing. Consideration is given to “special” hematology testing for genetic prothrombogenic factors because patients who have these factors are at an increased risk for blood clots (a history of miscarriages can be a marker for these hypercoagulable risk factor situations). Abdominoplasty, in general, has the highest incidence of venous thromboembolism of all aesthetic procedures and one half or more of abdominal fatalities are owing to thromboembolism. Thromboembolism deterrent stockings and Venodyne compression devices are always used. The use of pharmacologic intervention for venous thromboembolism prophylaxis (eg, enoxaparin sodium [Lovenox, Sanofi Aventis US, Bridgewater, NJ] 40 mg subcutaneously every 12 hours from onset of surgery) is an unresolved and evolving concept. Many surgeons who advocate anticoagulation utilize a risk base model such as the Venturi modification of the Davision-Caprini system to determine the need for anticoagulation.
Patients begin antimicrobial skin washes, including the area above and beyond the surgical site, 3 days preoperatively. No shaving of body hair is done. Broad-spectrum perioperative antibiotics are employed and may be continued until any drains that are used are removed. However, evidence-based information, which confirms that antibiotics may reduce surgical site infections in abdominoplasty, suggests that a single preoperative antibiotic is as effective as preoperative and postoperative doses.
The arms are symmetrically placed on arm boards while avoiding pressure points and secured with Kerlix wraps. Preoperatively, the operating room table is checked to verify that it can reach a maximum beach chair position, which is necessary for wound closure and removing the old umbilical site ( Fig. 2 ). A Foley catheter is inserted for all open abdominal contour procedures. Abdominoplasty is generally performed as an outpatient procedure and it is usually the last procedure in a multisurgical operation (eg, breasts, or liposuction, or face).
Surgical markings
Surgical markings are made in conjunction with the patient so that stab wound incisions for liposuction are well hidden and abdominoplasty incisions are confined to their undergarments. The abdominal excision is essentially an ellipse of tissue removal between the umbilicus and mons pubis ( Fig. 3 ).
Markings begin with the patient comfortably fitted in their preferred undergarments. The upper and lower edges of the garment are marked, and it is then removed. While the patient is in a bent over, sitting position, the length of the abdominoplasty incisions is then determined by locating the ends of the pannus’ skin creases, and by placing a mark on either side. After this marking, the patient gently elevates their pannus while the surgeon joins these lateral marks, with the midline position, approximately 6 to 8 cm above the vulva cleft. We try to incorporate the removal of any old scars, such as cesarean sections, in our excision. The upward pull helps to avoid a scar that is too high by accounting for eventual upward scar contraction or migration.
A flexible ruler can then be used on the lower incision and reversed to demarcate the upper limb of the ellipse as a mirror image of the lower incision. The upper incision is then drawn across the top of the umbilicus from hip-point to hip-point, joining the lower incision and completing the ellipse. The ability to remove the lower abdominal skin pannus from umbilicus to pubis is then reverified by the surgeon grasping the skin and confirming that the upper and lower incision meet and therefore can be closed (see Fig. 3 ). In an abdominoplasty, it is preferable to remove enough tissue so that the old umbilicus site is removed with it. In the operating room, the markings are verified by placing long silk sutures (after any liposuction is performed) in the midline at the xyphoid and pubis and overlapping them at multiple points on the upper and lower incision to ascertain symmetry between sides of the incision ( Fig. 4 ).
Surgical technique
All procedures are undertaken with systemic anesthesia (spontaneous ventilation general anesthesia, or spinal/epidural) administered by an anesthesiologist. The operative field is injected with approximately 1 L of superwet anesthesia (1 L of Ringer’s lactate, 20 mL of 1% lidocaine, 1 mL of 1:1000 epinephrine). Limiting the volume of wetting solution to the abdomen provides a margin of safety to allow infiltration of additional operative sites, by avoiding potentially toxic doses of lidocaine or epinephrine (the toxic dose is 0.07 mg/kg of 1:1000 epinephrine). Moreover, excess injectate would ultimately encumber electrocauterization during surgery.
The operation begins by liposuctioning as indicated ( Fig. 5 ). The surgeon then changes gloves and rechecks the abdominal excision markings. The umbilicus is again cleansed with betadine. The abdominoplasty proceeds by incising and freeing the umbilicus. The pannus is then prepared for preexcision in a vest-over-pants fashion (after Jaime Plannas). This maneuver is accomplished by incising the upper limb of the ellipse to the level of the rectus fascia while beveling the cut inwards at approximately a 45° angle. The upper abdominal flap is then completely undermined in a narrow tunnel resembling an inverted “v” corresponding with the zone of complete undermining ( Fig. 6 ), maintaining the intercostal blood supply (Huger zone III, Figure 7 ) sufficiently to achieve rectus muscle repair and anterior sheath plication. Preservation of the blood supply in this manner allows for appropriate liposuction of the flap. Dissection is done by scalpel and electrocautery. Moreover the inverted ‘V’ undermining may actually preserve Zone 1 DSEA (Huger Zone 1, Figure 7 ) the preoperative predominant blood supply.
An intact zone surrounding this tunnel or zone of selective undermining is undermined as needed to diminish the inevitable skin bunching that occurs after muscle closure. This action maintains a broad intact subcostal perforator blood supply ( Fig. 7 ) by discontinuous undermining (from liposuction) of the axial blood supply ( Fig. 8 ). Consequently, the flap can be suctioned when performing a full abdominoplasty, hence the term lipoabdominoplasty. This operative technique serves as a standard template and is adjusted according to individual patient needs unless they do not require liposuction.
The operating room table is flexed and the upper skin flap is then advanced over the pannus to the proposed lower skin marking to verify that it reaches. If it does not reach, the flap can be stretched, appropriately undermined more, Scarpa’s fascia scored, or adjustments in the height of the lower incision can be made, if necessary. Once it is determined that the upper flap reaches the lower skin incision, the skin island is grasped with Allis clamps on the side of the surgeon and excised en bloc from side to side. This vest-over-pants preexcision of the pannus has the following advantages: leaving the pannus that will later be resected in place preserves heat and blood, it is faster than elevating a flap that will ultimately be excised, and it avoids the tendency of wide upper flap undermining ensuring upper flap tunneling in an inverted “v” fashion, thereby maintaining the lateral intercostal blood supply (Zone III and possibly Zone I).
Some authors recommend leaving a thin layer of fibro-fatty tissue on top of the fascia (and/or quilting sutures when closing), which may reduce the incidence of seromas. In massive weight loss patients, a large pannus can distort the anatomy and bring the spermatochord into the surgical field, therefore, care must be taken as the incision proceeds down to the rectus fascia.
A plastic button (ocular conformer) is sutured to the umbilicus to be used for subsequent identification by palpation through the skin and removed when the umbilicus is later exteriorized. At each step, the surgeon and assistants achieve hemostasis with electrocautery, and particularly before perforators retract below the fascia.
The rectus muscle diastasis, which begins as early the second trimester of pregnancy, is marked so that it closes without excessive tension while in the supine position, with ink in a long vertical ellipse from xyphoid to pubis. The section above and then below the umbilicus is closed in layers with running 0-loop nylon suture. A second layer of buried interrupted 2-0 Neurolon sutures is used to further imbricate and reinforce the first layer. In thin patients with minimal intraabdominal adiposity, additional waistline narrowing can be performed by placing one or two 2-0 Neurolon sutures horizontal to the umbilicus (Ian Jackson). No further fascial muscle tightening is necessary or desirable. Once appropriately closed, the amount of flattening achieved with rectus plication cannot be predicted or increased. Furthermore, some relaxation and stretching of the fascial repair is likely to occur over time. Certain sites along the rectus fascia plication from xyphoid to pubis warrant consideration ( Fig. 9 ).
