Chapter 18 Aesthetic classification of the abdomen
• The abdominolipoplasty system of classification and treatment (type I-suction-assisted lipectomy (SAL); Type II & III – limited abdominoplasties; Type IV abdominoplasty with or without liposuction) provides the framework on which procedure selection is based (Fig. 18.1 and Table 18.1).
• The appropriate procedure is based on reconciling the patient’s anatomic findings with their goals; and taking into considering such factors as their tolerance for the length of the lower abdominal scar and an umbilical scar.
• Overall, liposuction of the abdomen is the most frequent abdominal contour procedure. As surgeons have become familiar with incorporating liposuction with a full abdominoplasty, abdominoplasty with liposuction referred to as Lipoabdominoplasty has become more mainstream. This and abdominoplasty alone without liposuction (conventional abdominoplasty) represent the most common types of “open” options for the abdomen.
• Lipoabdominoplasty is an operation based on the principles of preserving the maximum blood supply to the anterior abdominal wall (Fig. 18.2) and of creating a narrow tunnel of undermining (zone of complete undermining) to the xiphoid in order to access the rectus diastasis with a surrounding zone of selective undermining and a zone of discontinuous undermining (Fig. 18.3).
FIG. 18.1 The abdominoplasty system of treatment and classification is based on evaluating the treatable soft tissue layers of the abdomen. Type I (upper lift) is liposuction alone; Type II (upper right) is mini-abdominoplasty; Type III (lower left) modified abdominoplasty (or lower abdominoplasty or marriage abdominoplasty); Type IV (lower right) a full abdominoplasty without or with (lipoabdominoplasty) liposuction. (Pink = liposuction, yellow = undermining, green = excision).1
FIG. 18.3 Lipoabdominoplasty is based on the principle of undermining to the xiphoid in a narrowed tunnel leaving intact intercostal (Huger zone III) blood supply. Surrounding this is a zone of selective undermining that is done sharply to free any excessive skin bunching that occurs after rectus fascia plication. The zone of discontinuous undermining results from the blunt dissection of the liposuction cannula.3
The goal of abdominal contour surgery is the esthetic improvement of the abdomen with the least conspicuous scar feasible. Depending on the procedure performed, improvement can be achieved in varying degrees to the appearance of loose, damaged skin, rectus muscle diastasis, and excess fatty deposits, in order to create a firmer, flatter abdomen.
More than ever, today’s society emphasizes youthfulness and vitality, particularly as the first wave of the populous “Baby Boomer” generation passes 65. They are a population that has attempted to defy aging by being more health-conscious than any preceding demographic. However, from the age of the mid 30s onward in males and beginning in the premenopausal years in females the abdomen begins to change with the accumulation of intra-abdominal fat (apple), loosening skin, and widening of the rectus muscle diastasis. These problems are magnified following pregnancy in women, or in both genders with massive weight loss or fluctuations and are only self-controlled or rectified by the patient to a limited degree. For example, a fit male runner running 20 miles per week in his 20s would need to run over 50 miles a week in his 50s just to maintain his prior weight and appearance (even with maintenance most people report that their abdomen never looks the same as in earlier years). Otherwise, they might expect to gain approximately 1.5 kg (3.3 pounds) per decade and 1.5 cm ( of an inch) on their waistlines. Women over 40 years old would need to exercise over 1 hour a day to just retain the appearance of their earlier figure.
Females, in addition to the inevitable consequences of aging, are plagued by the changes that occur from pregnancy, which invariably and almost universally ravage the abdomen and breasts. (Hence the idea of breast and abdominal surgery being referred to as the “mommy makeover”. The male equivalent for improving the abdominal and chest area has been dubbed the “daddy do over”.)
In males and females the abdomen represents the region with the largest surface area of the body and a patient’s perception of its appearance often acts as a surrogate barometer for how an individual perceives their ideal weight, their level of fitness, their overall health and their physical appearance or attractiveness.
Suitable candidates for abdominal contour surgery have had an in-depth discussion with their surgeon regarding their concerns and the appropriate procedures available to them based on those anatomic characteristics that can be improved (skin, subcutaneous fat, and rectus muscle diastasis) and those factors that cannot be (quality of the remaining skin, visceral fat, scars, spinal or uterine issues that affect the appearance of the abdomen). Factored into this discussion is their tolerance for risk and recovery, their expected goals and outcome, and their willingness to accept lower abdominal or periumbilical scars. Based on this information an appropriate procedure is selected, with a firm understanding that different techniques will yield different outcomes.
For example, liposuction is often the first choice of patients, though liposuction does not tighten skin, but rather skin can be expected to contract, albeit to an unpredictable degree, after fat removal, in contrast to the excisional procedures that actually remove loose skin. Moreover, it should be recognized that the more skin that is removed the larger the incision that is required and that the remaining skin is not improved but just pulled tighter. Preoperative preparation begins from the time of the initial consultation and is an evolving process that is based on a series of conversations with the physician, their staff, the anesthesiologist and any ancillary personnel and the patient.
Patients receive an extensive informational package at the time of the consultation and are mailed a detailed perioperative package that includes a copious list of products that affect coagulation. For all abdominal contour surgery procedures patients are instructed to cease nicotine-containing products and compounds that affect clotting prior to the procedure. All patients are evaluated by an internist, and have appropriate blood or diagnostic testing. Consideration is given to “special” hematology testing for prothrombogenic factors because patients that are genetically susceptible dramatically increase their potential for blood clots. Abdominoplasty, in general, has the highest incidence of thromboembolism of all esthetic procedures. Half or more of deep vein thromboses (DVT) result in pulmonary embolism fatalities frequently. 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 often 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 pre- and postoperative doses.
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 the limits of their undergarments. The abdominal excision is essentially an ellipse of tissue removal between the umbilicus and the mons pubis (Fig. 18.4). The length of the abdominoplasty incision is determined by locating the ends of the pannus’ skin creases, which are determined in a sitting position and noting the ends of the skin folds.
The lower incision is then marked between those two points, approximately 6 to 7 cm superior to the vulva cleft and incorporating removal of any lower (Pfannenstiel, cesarean, etc.) scars. 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 verified by the surgeon grasping the skin and their fingers meeting. 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 xiphoid and pubis and overlapping them at multiple points on the upper and lower incision in order to ascertain symmetry between sides of the incision (Fig. 18.5).
FIG. 18.5 Surgical markings are made confining the incision to reasonable undergarments. This is verified intraoperatively with underlying criss-crossed silk sutures. Marking for excision. The upper markings demonstrate the suction areas (red = terrible triangle – the area most in danger of devascularization; yellow, safer; green, safest.
All procedures are undertaken with systemic anesthesia (spontaneous ventilation GA, or spinal/epidural) administered by an anesthesiologist. The operative field is injected with approximately 1 liter of super-wet anesthesia (1 liter of Ringer’s lactate, 20 ml of 1% lidocaine, 1 ml of 1 : 1000 epinephrine). Limiting the wetting solution allows safe injections to any additional operative sites, by avoiding potentially toxic doses of lidocaine or epinephrine (0.07 mg/kg of 1 : 1000 epinephrine) and excess fluid would ultimately encumber electrocautery use during surgery. In “open” procedures 20 ml of 1% Marcaine is injected at various points in the muscle layer. A Foley catheter is inserted for open (non-SAL only) procedures. The arms are symmetrically placed on arm boards while avoiding pressure points and secured with curlex wraps. Preoperatively the bed 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. 18.6).
Abdominal contour surgery procedures are generally performed as an outpatient and usually they are the last part if a multisurgical operation (e.g., breast surgery, liposuction, facialplasty, etc.) operation is performed.
All patients receive TED stockings and sequential pneumatic compression devices (SCD). Pharmacologic intervention is considered on a case-by-case basis and is determined with the assistance of the Davidson–Caprini model or Venturi modification and considering the unique circumstances of each patient and procedure.
|Skin||Laxity, striae gravidum, tone, thickness|
|Muscle||Extent of rectus muscle diastasis and the quality of the muscle|
Hernia (peri/umbilical or hernias elsewhere)
|Prior surgery||Circumscribed umbilicus, limited abdominoplasty with a floated umbilicus, liposuction, presence of nonmidline upper abdominal scars, flank scars or inframammary scars|
Sample of Factors that Commonly Influence the Procedure that Patients Select