Traditional abdominal plastic surgery results in a high rate of morbidity because of the necessity for a large undermining of the flap. In 2001, Saldanha using the term “lipoabdominoplasty” for the first time, standardized a selective undermining, corresponding to 30% of the traditional undermining, between the medial borders of the rectus abdominal muscles. This procedure combines 2 traditional techniques, abdominoplasty and liposuction.
Most people are concerned about their physical appearance. When body contour shows aesthetic and functional deformity because of a genetic condition or as an acquired characteristic resulting from obesity, weight loss, pregnancy, or any other cause, the abdomen is one of the most frequently affected regions. Deformities may present as cutaneous flaccidity, localized fat accumulation, or diastasis of the rectus abdominal muscles, and this can lead to depression and loss of self-esteem.
Traditional abdominal plastic surgery results in a high rate of morbidity stemming from the necessity for a large undermining of the flap in which the perforating vessels are sectioned. According to published evidence, these vessels 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, which are situated in the back and flank regions. The occurrence of ischemic processes with tissue necrosis and dehiscence of the suture has been described when abdominoplasty is associated with liposuction.
History shows that from 1899 to 1957 progressive undermining of the abdominal wall was performed. Thereafter, the extensive undermining was standardized by Vernon to facilitate umbilicus transposition.
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 and to obtain a faster recovery, a better body shape, low rates of complications, and a decrease in necrosis.
In 1985, Hakme presented a new approach for abdominal lipectomies, called miniabdominoplasty technique, consisting of liposuction of the abdomen and flanks, associated with elliptical resection of the suprapubic skin and plication of the supra- and infraumbilical muscles, without relocating the umbilicus.
In 1991 and 1995, Matarasso focused on the complications of combined liposuction and abdominoplasty, presenting 2 articles that recommended safe areas of liposuction. In those articles he considered the back and the flanks safe areas, did not regard the lateral region of the abdomen as a safe area, and considered the central region of the abdomen prohibited for liposuction.
In 1995, Lockwood reported “high lateral tension abdominoplasty” in which he used Scarpa fascia to decrease the tension of the skin closure.
Since the 1990s, the undermining has decreased in extent because of the large number of complications (seroma, hematoma, and most of all, necrosis), reaching zero in 1992 with the publication of “abdominoplasty mesh undermining” by Illouz. The trend of abdominolipoplasty with or without small undermining continued up to 1999, when Shestak presented the partial abdominolipoplasty method, with no undermining, associated with liposuction.
According to current records, lipoabdominoplasty was developed by Saldanha in 2000 and published for the first time in 2001 as a safe option to correct aesthetic and functional abdominal deformity while achieving better aesthetic results with technical simplicity for surgeons. In that publication, Saldanha standardized a selective undermining between the medial borders of the rectus abdominal muscles and used the term “lipoabdominoplasty” for the first time. Lipoabdominoplasty combines 2 traditional techniques, abdominoplasty and liposuction. The 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 technique conserves about 80% of the blood supply of the abdominal flap compared with traditional abdominoplasty. The lymphatic nodes and nerves are preserved, maintaining the cutaneous sensitivity of the flap to superficial pain and superficial touch caused by temperature, vibration, and pressure, which is an improvement on traditional abdominoplasty.
Principles of the technique
Superficial liposuction described by De Souza Pinto was one of the fundamental principles of lipoabdominoplasty because it facilitated implementation of the latter. This procedure gives more mobility to the abdominal flap so that it can slide down easily and reach the suprapubic region.
The second principle is the anatomic study of the exact localization of the perforating abdominal vessels so that they can be preserved during the procedure. Using selective undermining, it is possible to conserve at least 80% of the blood supply of the abdominal wall, reduce nerve trauma, and preserve most lymphatic vessels.
Fewer complications are observed when compared with traditional abdominoplasty, including bariatric surgery. All patients with indications for traditional abdominoplasty may undergo lipoabdominoplasty.
Physical evaluation
The principles of this technique can be used for any kind of abdomen presenting with flaccid skin, fat accumulation, and diastasis of the rectus muscle, but initially, to gain experience, it should be performed in patients with excessive flaccid skin and in those who are overweight, so that the surgeon develops confidence with this procedure. There is a short learning curve because surgeons are used to performing abdominoplasty and liposuction separately.
Ventral, lumbar, and femoral hernias should be ruled out. In the authors’ practice, preoperative ultrasonography of the abdominal wall is routinely performed on all patients.
Warning
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Previous abdominal liposuction could cause difficulty in the mobility of the flap.
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Previous scarring or an endoscopic procedure could permit the cannula to cross through the abdominal muscle aponeurosis.
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In borderline cases where it is not clear whether the proposed superior extent of resection can be reached, begin with a high suprapubic incision.
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Do not perform in patients with eventration.
Physical evaluation
The principles of this technique can be used for any kind of abdomen presenting with flaccid skin, fat accumulation, and diastasis of the rectus muscle, but initially, to gain experience, it should be performed in patients with excessive flaccid skin and in those who are overweight, so that the surgeon develops confidence with this procedure. There is a short learning curve because surgeons are used to performing abdominoplasty and liposuction separately.
Ventral, lumbar, and femoral hernias should be ruled out. In the authors’ practice, preoperative ultrasonography of the abdominal wall is routinely performed on all patients.
Warning
- •
Previous abdominal liposuction could cause difficulty in the mobility of the flap.
- •
Previous scarring or an endoscopic procedure could permit the cannula to cross through the abdominal muscle aponeurosis.
- •
In borderline cases where it is not clear whether the proposed superior extent of resection can be reached, begin with a high suprapubic incision.
- •
Do not perform in patients with eventration.
Anatomy
Lipoabdominoplasty has aesthetic and reconstructive purposes. To achieve a complete reconstruction of the abdominal wall in the lower abdomen, the authors preserve Scarpa fascia and the partial deep fat layer in the lower abdomen (between the umbilicus and the pubis). The procedure is completed when the superior flap comes down to the pubis ( Fig. 1 ).
The undermining in the upper abdomen is performed exactly between the medial borders of the rectus muscles, corresponding to the diastasis area, preserving around 80% of perforating arteries, veins, lymphatics, and nerves, as shown by Munhoz and colleagues in their study about comparative mapping evaluation in the pre- and postoperative periods. Their Doppler ultrasound study indicated that 81.21% of the perforating vessels mapped in the preoperative period were preserved postoperatively, which validates the hypothesis that this technique results in a lower percentage of complications caused by flap ischemia.
The rectus abdominal muscle and the skin are innervated by the anterior branches of the 6th to 12th intercostal nerves that run along the abdominal perforating vessels. Many studies indicate that the loss of sensitivity is significant after traditional abdominoplasty, but sensitivity is probably preserved when they undergo lipoabdominoplasty.
Surgical steps
Marking
Marking is done by drawing a 12-cm horizontal suprapubic line that is 6 to 7 cm from the vulvar commissure ( Figs. 2 and 3 ). Two oblique lines of 8 cm each are drawn in the direction of the iliac crest, completing the inferior incision line ( Fig. 4 ). The abdominal flap and the liposuction areas are marked, including the dorsal region, when necessary. For better orientation at the beginning of tunnel undermining, the diastasis area is previously marked ( Fig. 5 ).
Infiltration
The tumescent technique is used by infiltrating the abdominal region with a 1:500,000 saline solution with adrenalin, using an average of 1 to 1.5 L of the solution ( Fig. 6 ).
Upper Abdomen Liposuction
The patient is placed in a hyperextended position on the surgical table so that liposuction can be performed safely. Liposuction begins on the supraumbilical region with a 3- and 4-mm cannulas, removing the fat of the deep and superficial layers, extending to the flank as far as the submammary fold ( Fig. 7 ). As in classical liposuction, the fat thickness is maintained to about 2.5 cm to avoid vascular impairment and contour deformities.
Lower Abdomen Liposuction
Scarpa fascia is an important anatomic structure of the abdomen and should be preserved in lipoabdominoplasty. To facilitate its visualization and its preservation, the superficial fat layer and part of the deep layer need to be aspirated in the lower abdomen using a 6-mm cannula ( Fig. 8 ). After evaluation of the flap mobility and descent ( Fig. 9 ), umbilicus isolation and total resection of the infraumbilical skin are performed, as in traditional abdominoplasty ( Fig. 10 ). If necessary, complementary open liposuction is performed to remove fat above and below Scarpa fascia and to create a homogeneous surface to accommodate the superior flap, which becomes thinner in its descent ( Fig. 11 ).
Related posts:
Anatomic Considerations in Abdominoplasty
Editorial Comment on “Traditional Abdominoplasty”
Editorial Comment on “ SAFECircumferential Liposuction with Abdominoplasty”
SAFECircumferential Liposuction with Abdominoplasty
Editorial Comment on “Concepts on Correction of the Musculoaponeurotic Layer in Abdominoplasty”
Revision Abdominoplasty and Proper Umbilical Positioning
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