CHAPTER
30

The “unfavorable” aesthetic results in abdominoplasty are usually correctable with revision procedures. With regard to actual complications, the more common ones are typically minor in nature and management is straightforward. The possible severe complications, including fatal pulmonary embolus, necrosis of the abdominal wall skin and soft tissues, and life-threatening infection, are rare.1 This chapter presents prevention concepts for the more common complications and the unusual challenging complications, along with their management. Also discussed are some tips and tricks that have resulted in enhanced outcomes in our hands.

Avoiding Unfavorable Results and Complications in Abdominoplasty

The ideal patient for an abdominoplasty is an otherwise healthy, nonsmoking patient with a normal body mass index, a lax abdominal wall with rectus diastasis, and excess abdominal skin. Patients that are at higher risk for complications or a suboptimal result include those who are morbidly obese (visceral fat precludes a tight plication), have lung disease including severe chronic obstructive pulmo nary disease (muscle plication will limit lung excursion), are currently smoking, or have a strong personal or family history of blood clots.

Primary Goals

Removal of Excess Soft Tissue

Although a patient may have abdominal wall laxity, it is typically the extra abdominal skin and fat that lead to patient desire for abdominoplasty. To this end, it is important to deliver a result that the patient will find satisfying. Although rectus plication will contribute to the “tight and flat” criteria, it is the removal of excess skin and fat that will cause the abdomen to be “thin” and eliminate redundant rolls and folds that are very bothersome to the patient.

Preoperative assessment of the location of excess abdominal skin is critical. Typically, the extra skin is located in the mid and lower abdominal regions, in which case a traditional abdominoplasty is indicated (Fig. 30.1). In some patients, particularly those who have undergone massive weight loss, there will be horizontal skin laxity in addition to a vertical component; in these cases, a fleur-de-lis abdominoplasty with a vertically oriented scar should be considered (Fig. 30.2). Although unusual, skin laxity can be located primarily in the upper abdomen. When asked by their surgeon to demonstrate what their desired abdomen would look like, these patients lift their upper abdominal wall toward the chest to give them the desired appearance (Fig. 30.3). In these cases, a reverse abdominoplasty is appropriate.

Following rectus plication, the patient is placed in the semi-Fowler (beach chair) position. The skin on the abdominal flap is demarcated precisely to create a closure that will be of the appropriate tension (Fig. 30.4) If patients have concerns regarding loose skin postoperatively, extra skin may be excised secondarily (the vertical resection of the fleur-de-lis can also be performed staged, but this is not optimal).

The abdominal wall has a superficial and deeper (subscarpal) fat layer. We have previously reported that the subscarpal fat appears to be “parasitic” to the overlying skin and fascial tissues in that blood supply progresses from lateral to medial and superficial to deep after perforator division. Therefore not only is trimming of the subscarpal fat helpful to reduce abdominal flap thickness, it removes fat with poor blood supply that is the most common site for fat necrosis postoperatively. Subscarpal fat resection is typically performed sharply at the level of the superficial fascia, taking care to preserve the integrity of the fascia to facilitate an excellent abdominal closure² (Fig. 30.5).

Fig. 30.1 Standard abdominoplasty. This 48-year-old woman was undergoing circumferential trunk liposuction with buttock fat grafting and abdominoplasty. The majority of skin laxity and striae are in the infraumbilical zone and would be resected as part of the standard abdominoplasty.

Fig. 30.2 Fleur-de-lis abdominoplasty. (a) This 37-year-old woman was undergoing a circumferential abdominoplasty with a fleur-de-lis component to remove the horizontal skin laxity. She also underwent an augmentation mastopexy, with gel implants placed submuscularly. (b) Result 6 months postoperatively.

Fig. 30.3 Reverse abdominoplasty markings. (a) This 50-year-old woman desired an improved abdominal contour. The skin laxity was primarily central and in the epigastric regions. (b) When the patient lifts the skin envelope upward, excellent contour of the abdomen is achieved. Thus the patient literally tells the surgeon the direction of skin excision. Patients will typically do this in the preoperative consultation standing in front of a mirror when a surgeon asks about the desired result.

Fig. 30.4 (a) Demarcating the abdominal flap. A Lockwood abdominal demarcator (or equivalent) is used to precisely mark the line of excision. Care must be taken to set the skin at the appropriate tension before resection. (b) Measuring the abdominal flap. After demarcation, the flaps to be excised are measured bilaterally to ensure equal amounts of skin are being resected to maximize symmetry.

Fig. 30.5 Subscarpal fat resection. The subscarpal fat is parasitic at this point, because it now relies on vessels that are more superficial. Therefore this fat may be trimmed sharply without worrying about vascular compromise to the remainder of the skin flap. The integrity of Scarpa’s fascial layer must be preserved, because it is important for closure.

Fig. 30.6 (a) This 50-year-old woman had a prior abdominoplasty, with residual adiposity of the abdomen, flanks, back, and hip rolls. She underwent SmartLipo MPX followed by suction-assisted lipectomy of these areas. (b) Result 4 months postoperatively. Despite the previous abdominoplasty, the patient was able to be aggressively liposuctioned without compromised bloodflow to the skin (even when including laser energy with the SmartLipo MPX). Although aggressive liposuction can be used at the time of initial flap elevation during abdominoplasty procedures, laser energy should not be included at that stage.

If excess adiposity exists postoperatively, thorough abdominal liposuction may be performed to significantly thin the flap without concern for vascular compromise (Fig. 30.6). To prevent postoperative excess adiposity, we routinely perform thorough tumescent liposuction of the entire abdominal flap, flanks, and hip rolls before flap elevation during the initial abdominoplasty.³ Although still somewhat controversial, thorough circumferential body liposuction in combination with abdominoplasty has been repeatedly demonstrated to be highly successful with a minimal risk of vascular compromise when proper thorough tumescent infiltration has been performed. The addition of liposuction enhances the final outcome, delivering an overall circumferential body thinning that is perceived by patients very positively (Video 30.1).

The abdomen is not a structure in isolation, but is only one side of a cylindrical trunk. This is why we routinely perform circumferential liposuction. If there is excess skin posteriorly, this may be resected. If the excess skin is inferior, a circumferential abdominoplasty should be performed. If the excess skin is on the upper back, a bra-line back lift or other upper back excisional technique may be performed. The result will be a significant circumferential improvement with a reduced anteroposterior dimension and a more pleasing profile.

Correction of the Rectus Diastasis

Rectus diastasis may be congenital or acquired. In acquired cases, increased intra-abdominal volume stretches the muscles apart. Two of the more common reasons for increased abdominal volume are pregnancy and weight gain with a significant intra-abdominal distribution. After childbirth or weight loss, the contributing intra-abdominal volume is decreased, but the diastasis remains. Exercise is not effective in reducing the diastasis; the treatment is surgical plication.

Fig. 30.7 Abdominal wall hernia. This woman was undergoing an abdominoplasty when a true abdominal wall hernia was discovered at the right extent of her prior cesarean section scar. One must be especially cautious of these occult hernias when performing liposuction.

The amount of diastasis is typically easily assessed at the time of initial consultation by abdominal palpation during abdominal wall loading maneuvers. Evaluation for true hernias should also be conducted at this time. The most common locations are in the periumbilical and midline regions, but they may be found in scar tissue from previous abdominal operations (Fig. 30.7). Patients who still maintain a significant amount of intra-abdominal fat should be encouraged to lose weight beforehand, because this will allow for a tighter operative muscle plication and therefore a more ideal contour. Operating on a patient with significant intra-abdominal visceral fat will yield disappointing results for both the patient and surgeon.

Fig. 30.8 (a) Markings for the rectus plication. The medial borders of the rectus abdominis muscles are marked with methylene blue, and the outer markings represent the desired extent of the plication suture. There are myriad methods of plication; we prefer a looped 0 Ethilon suture run from xiphoid to pubis without interruption. (b) After the rectus plication. A wide rectus abdominis plication (WRAP) has been performed. The extent of the plication is adjusted (in this case, brought in) based on the tension of the closure to prevent “cheese-wiring” of the fascia.

A stable preoperative weight is important. A patient’s weight should be stable for at least 3 months before the operation. Lifestyle changes contributing to weight gain preoperatively will lead to weight gain postoperatively if continued, and the result will be suboptimal. For patients who have undergone bariatric surgery, nutritional analysis preoperatively is important to ensure satisfactory healing.4 Postoperatively, the patient’s weight should remain stable to maintain the favorable result accomplished surgically. Typically, if patients lose weight after surgery, the operative result is even more dramatic.

Several maneuvers are helpful to prepare the patient for the tight muscle plication. We suggest that patients wear an abdominal binder tightly, day and night, for 2 weeks, which simulates the muscle plication and allows the body to adjust physiologically before surgery. We also request the patients begin a clear liquid diet 2 to 3 days before the procedure to decompress the bowel, which will reduce intra-abdominal volume.

At the time of the procedure, the abdominal skin and subcutaneous tissue is typically separated from the abdominal wall fascia inferiorly up to the rib margin and xiphoid process superiorly. We recommend a strong and complete muscle plication be performed between the xiphoid and pubic symphysis. We typically overcorrect the diastasis and perform a tight muscle plication to create an elegant waistline laterally and a flat abdominal contour (Fig. 30.8). Suture selection and technique vary; we prefer a 0 looped Ethilon in a running fashion from the xiphoid to the pubis without interruption at the level of the umbilical stalk. This technique is time-efficient and creates a strong fascial plication. We have never had this suture fail.

Unfavorable results can often occur if there is residual epigastric fullness, the waistline remains straight, or abdominal wall laxity returns after the procedure. Residual epigastric fullness, especially on abdominal loading maneuvers, can occur if the plication is not complete from the xiphoid to the symphysis. Failure to recognize that the plication should be performed in a bone-to-bone fashion commonly leads to an unfavorable return of epigastric fullness that will result in patient dissatisfaction. Every effort should be made to ensure the abdominal flap is elevated to the level of the xiphoid and the plication started at the most superior aspect of the dissection. A waistline that remains convex postoperatively is often disappointing for both the patient and physician.

For women, the waistline should be concave, and flowing in a sinusoidal fashion from the chest to the waist to the hips. To create this shape, a wide plication should be performed to create a tight, flat abdominal wall. In individuals with significant abdominal laxity, this plication can actually bring together the medial borders of the external oblique muscle and fascia. Such a wide plication will invert the rectus muscles; however, because most women do not desire a chiseled “six-pack abs” look, a flat abdomen and a concave waistline will be viewed quite favorably.

For men the waistline should be essentially straight. The medial edges of the rectus muscles should be reapproximated, with a wider plication performed if it will result in a decreased anterior-posterior distance (any tighter of a plication will cause a decrease in the lateral distance, which will feminize the waistline).

The return of abdominal wall laxity after abdominoplasty is suboptimal.⁵ Repeat plication is indicated, and often the scar plane of the rectus fascia holds sutures well and allows for a strong plication during secondary procedures. If the fascia is of poor quality and cannot adequately support the plication suture, the abdominal wall may be reinforced with mesh—an acellular dermal matrix, permanent mesh, or resorbable mesh that promotes tissue ingrowth. We prefer to use GalaFLEX (Galatea Surgical) or Phasix (Bard), which is a monofilament poly-4-hydroxybutyrate mesh (Fig. 30.9). A mesh for reinforcement should be available in the surgical center in case it is needed.

Fig. 30.9 Rectus fascial plication reinforcement. During plication in this 54-year-old woman’s abdominoplasty, her fascia was found to be weak. The abdominal wall was reinforced with a prosthetic mesh to prevent a return of abdominal wall laxity.

Fig. 30.10 Strong cephalad pull during marking by the same patient as in Fig. 30.1. The strong pull upward mimics the pull of the abdominal flap after the abdominoplasty. Marking with the patient pulling strongly upward helps prevent superior migration of the scar postoperatively into an unfavorably high position.

Secondary Goals

Scar Placement and Quality

Abdominoplasty cannot be performed without a scar. Even if a great abdominal contour is achieved, an unsightly scar will be bothersome to the patient. An unsightly scar can result from suboptimal placement or scar quality.

If the patient desires to hide the scar within a particular article of clothing, the patient should bring that article of clothing the day of surgery; the boundaries of the clothing are marked, and the incision is placed inside those marks. The ideal incision placement is usually low and easily hidden in even the lowest cut garments. The patient should strongly lift up on the abdominal flap, and the incision should be marked at the level of the pubic bone (Fig. 30.10). If the patient does not strongly lift the abdomen superiorly while it is marked, the incision will migrate cephalad as a result of the pull of the abdominal flap during healing and ultimately leave it in a higher and more visible position. The ideal abdominal incision is placed low enough that it usually removes the upper third of the hair-bearing mons. Correction of a high-riding scar involves a scar revision to lower the final scar (Fig. 30.11).

A common tactic for patients with a long infraumbilical skin segment is to cheat the low transverse incision higher to ensure that the umbilical hole is fully resected and no vertical T is created. This can be a mistake. If the final scar is low and easily hidden in clothing, patients will tolerate a small vertical T segment. They should be informed of this possibility preoperatively, however. If the small vertical segment continues to be bothersome (unusual), it may be excised secondarily when the infraumbilical skin has healed and relaxed.

Fig. 30.11 (a) This 47-year-old woman had a high scar after an abdominoplasty. She was displeased with the high position of the scar. She desired a lower umbilicus instead of the presence of a vertical scar in the lower midline. She also wanted excess tissue removed posteriorly, along with the creation of a more full buttocks. (b) Result 6 months after revision abdominoplasty to lower the scar, an umbilical float procedure to lower the umbilicus, and a purse-string gluteoplasty. The scar has been significantly lowered, and her hip and thigh shape has improved with the circumferential abdominoplasty with purse-string gluteoplasty.

An innie umbilicus is facilitated by a wide rectus plication, which will shorten the umbilical stalk by pulling it inward as the rectus muscles are plicated. Because of this, sutures to deepen or “tack down” the umbilicus are not necessary. Midline placement is achieved by dropping a plumb-line string from the xiphoid to the pubic symphysis after skin flap demarcation and temporary stapled closure, then using a Lockwood demarcator to mark the umbilical location on the abdominal flap. If the preoperative umbilicus is lateral to the midline, asymmetric rectus plication is performed to place the umbilicus in the midline. Once the proper position of the umbilicus is identified on the abdominal flap, a vertically oriented ellipse is resected of skin and subcutaneous tissue and the umbilicus is delivered through the abdominal wall. The ellipse should be kept small, because the umbilicus usually enlarges with time. It is far easier to secondarily revise an umbilicus to make the aperture larger, and quite difficult to undergo umbilicoplasty to reduce the size (Fig. 30.12).

Fig. 30.12 (a) This 40-year-old woman who had a previous abdominoplasty presented with a high scar and a superiorly placed umbilicus. A revision abdominoplasty to lower the scar, repeat the muscle plication to tighten the abdominal wall and shorten the umbilical stalk, and an umbilicoplasty were planned. (b) After the rectus plication was performed, the previous umbilical aperture was cinched using 2–0 Ti-Cron in a purse-string fashion. (c) Rewidening of the umbilical aperture 17 months postoperatively. The patient was displeased with this appearance and desired a revision. (d) Preoperative markings. A repeat purse-string cinching technique was planned. The umbilicus was incised, and undermining was performed to the extent of the outer circle to mobilize the tissue centrally. (e) After the abdominal wall was undermined, a 2–0 Ti-Cron suture was placed in a purse-string fashion to cinch the aperture. Unfortunately, the patient was lost to followup before postoperative pictures were obtained.

Minimizing soft tissue trauma by meticulous surgical technique and avoidance of excessive electrocautery, along with precise hemostasis, will decrease trauma to the surgical surfaces and therefore decrease the release of reactive fluid. Drain placement after abdominoplasty has been the standard of care for many years. When concurrent circumferential body tumescent liposuction is performed, the drainage output can be very significant in the early postoperative phase. Dead space may be obliterated with a combination of internal space-obliterating (or progressive tension) sutures and external compression such as an abdominal binder, which will facilitate adhesion of the abdominal flap to the underlying abdominal wall, or at a minimum compartmentalize any fluid collections for quicker absorption6,7 (Fig. 30.13). The introduction of TissuGlu Surgical Adhesive (Cohera Medical), placed as discrete drops, holds great promise and was recently approved by the U.S. Food and Drug Administration⁸ (Fig. 30.14).

Regardless of these techniques, a seroma can still occur.⁹ When a seroma is detected, percutaneous drainage should be initiated and performed several times weekly until the seroma is no longer detectable (Fig. 30.15). External compression is critical during this time to reduce fluid reaccumulation. Although various sclerosing agents have been described (e.g., ethyl alcohol, doxycycline, bleomycin, talc), we have not found these agents to be very useful.

Fig. 30.13 Space-obliterating sutures in a 44-year-old woman undergoing a circumferential abdominoplasty. Quilting sutures were placed to coapt the skin envelope and rectus fascia and obviate the need for a drain.

Fig. 30.14 Cohera’s TissuGlu Surgical Adhesive was used on this 43-year-old woman undergoing an abdominoplasty as part of the initial U.S. Food and Drug Administration trials. The unit dispenses three drops of product at a time directly onto the rectus fascia, spaced out a certain distance. The abdominal flap is then placed onto the rectus fascia in the desired location and held in place until the glue cures. The product was recently approved for the approximation of tissue in abdominoplasty.

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