Lipoabdominoplasty: Saldanha’s technique

CHAPTER 62 Lipoabdominoplasty: Saldanha’s technique



Osvaldo Saldanha, Rodrigo Federico, Maurício Doi



History


When body contouring shows aesthetic and functional deformity by genetic or acquired characteristics because of obesity, weight loss, pregnancy or other causes, the abdomen is one of the most affected regions. It may present as cutaneous flaccidity, localized fat accumulation and diastasis of the abdominal rectus muscle, and this can lead to depression and loss of self-esteem.


Classical abdominal plastic surgery results in a high rate of morbidity, due to the necessity for a large undermining of the flap where the perforating vessels are sectioned, taking into account that according to the published evidence, they represent 80% of the blood supply of the abdominal wall. Consequently, the vascularity of the remaining flap is supplied by the intercostal, subcostal and lumbar perforating branches, situated in the back and flank regions. The occurrence of ischemic processes with tissue necrosis and dehiscence of the suture have been described, when abdominoplasty is associated with liposuction.


Since 1980, when Illouz developed liposuction, and mainly in the last decade, the evolution of abdominoplasty techniques has motivated surgeons to search for innovations to decrease surgical morbidity, obtain a faster recovery, better body shape, low rates of complication and a decrease in necrosis.


According to current records, lipoabdominoplasty was developed in 2000 and published for the first time in 2001 as a safer option for correcting aesthetic and functional abdominal deformity, achieving better aesthetic results with technical simplicity for surgeons. It combines two traditional techniques – abdominoplasty and liposuction. Its new and conservative concept is based on the preservation of the abdominal perforating vessels (subcutaneous pedicle), which are branches of the deep epigastric vessels. This conserves about 80% of the blood supply of the abdominal flap compared with traditional abdominoplasty. Also, the lymphatic nodes and nerves are preserved, maintaining the cutaneous sensibility of the flap to superficial pain and superficial touch by temperature, vibration and pressure, which is an improvement on traditional abdominoplasty.



Methods


We standardized steps to perform a safe combination of classical abdominoplasty with an entire abdominal liposuction plus infracostal areas. Using a selective undermining, it is possible to conserve at least 80% of the blood supply in the abdominal wall, resulting in little nervous trauma, preserving the majority of the lymphatic vessels. There are few complications compared with classical abdominoplasty, including post-bariatric patients.



Physical evaluation




• The principles of this technique can be used in any kind of abdomen presenting flaccid skin, fat adiposity and diastasis of rectus muscle.


• This technique should be performed initially in patients with flaccid skin and in those who are overweight.


• There is a short learning curve, because surgeons are used to performing abdominoplasty and liposuction separately.


• Observe the possibility of ventral, lumbar and/or femoral hernias. Preoperative ultrasound of the abdominal wall is required, systematically.


• Beware of previous liposuction.


• Beware of previous scarring and previous endoscopic procedure.


• In borderline cases, begin with a high suprapubic incision.


• Do not perform in cases with eventration.



Anatomy


Lipoabdominoplasty has aesthetic and reconstructive purposes. In order to achieve a complete reconstruction of the abdominal wall in the lower abdomen, we preserve the Scarpa’s fascia and partial deep fat layer in all of the lower abdomen (between the umbilicus scar and pubis). It will be completed when the superior flap comes down to the pubis (Fig. 62.1).


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Fig. 62.1 A, Lipoabdominoplasty anatomy. B, The preservation of the Scarpa’s fascia and partial. C, The superior flap extends to the pubis.


The undermining in the upper abdomen is performed exactly between the internal borders of the rectus muscles, corresponding to the diastasis area, preserving around 80% of perforating arteries, veins, lymphatic and nerves, as was shown by Alexandre Munhoz et al. in their study on comparative mapping evaluation in the pre- and postoperative periods.


The Doppler ultrasound study by Munhoz, performed after surgery, indicated that 81.21% of the perforating vessels mapped in the preoperative period were preserved, which validates the hypothesis that this technique results in a lower percentage of complications due to flap ischemia.


The innervation of the rectus abdominal muscle and of the skin is supplied by the anterior branches of the 6th to the 12th intercostal nerves that run along the abdominal perforating vessels. Many studies clearly indicate that the loss of sensitivity is significant after classical abdominoplasty.



Technical steps



Marking


The horizontal suprapubic line is 12 cm and the distance from the vulvar commissure is 6–7 cm (Fig. 62.2). Two oblique lines of 8 cm each are drawn in the direction of the iliac crest, completing the incisional line (Fig. 62.3). All the liposuction area is marked, including the dorsal area, when necessary. For better orientation at the beginning of tunnel undermining, diastasis is previously marked.


image

Fig. 62.2 Horizontal marking (12 cm).


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Fig. 62.3 Oblique marking (8 cm).



Infiltration


The tumescent technique is used by infiltrating the abdominal region with a 1 : 500,000 saline solution with adrenalin, using an average 1–1.5 L of the solution.



Upper abdomen liposuction


In order to perform liposuction safely, the patient is placed in a supine position on the surgical table. The liposuction begins on the supra-umbilical region with a 3 and 4 mm cannula, removing the fat of the deep and superficial layers, extending to the flank and reaching the sub-mammary fold (Fig. 62.4

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Mar 4, 2016 | Posted by in Aesthetic plastic surgery | Comments Off on Lipoabdominoplasty: Saldanha’s technique

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