Applying art and science in lipoabdominoplasty: technical and safety considerations

INTRODUCTION

Abdominoplasty presents one of the most popular aesthetic operations performed worldwide^[1]. This fact is attributed to the constantly improved outcomes achieved due to the evolution of the concepts and techniques applied^[2-9]. Illouz^[3] in the 1990s supported the use of liposuction in combination with abdominoplasty. Matarasso^[4] proposed safe areas of liposuction during concomitant abdominoplasty, while Lockwood^[5] presented the high lateral tension abdominoplasty, using the Scarpa fascia to suspend the abdominal flap and thus decrease the tension of the skin closure. Shestak^[6] and Avelar^[7] presented similar techniques of abdominoplasty with liposuction, avoiding the flap undermining. In 2001, Saldanha et al.^[8] first used the term lipoabdominoplasty for his combined technique, which incorporated selective flap undermining. His results were corroborated by a following study in 2009, showing reduced incidence of complications and surgical revisions with lipoabdominoplasty compared to traditional abdominoplasty^[9]. In 2007, Hoyos et al.^[10,11] presented the vibration amplification of sound energy at resonance (VASER) liposculpture technique for high definition of the treated areas, extending its use in abdominoplasty to expedite fat extraction, preserve vascularization, and enhance the aesthetic outcomes. Wall^[12] combined abdominoplasty with circumferential liposuction of the trunk, using a three-step standardized liposuction method, with the aim to optimize the flap blood supply and eliminate contour irregularities. Further modifications of the lipoabdominoplasty have been presented over the years.

The objective of this article is to present a modern abdominoplasty approach, which combines technical elements from the aforementioned techniques based on the available evidence, aiming to improve the long-term outcomes and patient satisfaction while limiting the risk of complications following abdominoplasty.

METHODS

RESULTS

This surgical technique, combining liposuction with abdominoplasty, was performed on 93 female patients with an average age of 38 years (20-67 years). No other concomitant procedures apart from liposuction were performed during the surgery. The mean hospital stay and time of drain removal were 1.2 and 8.1 days, respectively.

This lipoabdominoplasty variation was associated with enhanced aesthetic outcomes, in terms of body contouring and definition, high satisfaction rate, and low rate of complications and/or surgical revisions. Common complications of traditional abdominoplasty, such as wound dehiscence and necrosis, never occurred, while minor seroma with no further sequala occurred once. No cases of hematoma or deep venous thrombosis were recorded. Minor surgical revisions, due to dog ears or scar hypertrophy, were performed in 12% of cases, under local anesthesia.

Patient examples are depicted in Figures 1-3.

Figure 1. A 36-year-old woman with BMI of 22 kg/m² and four caesarean sections, who underwent lipoabdominoplasty, before (A-D) and nine months after (E-G) surgery. Notice the correction of the large diastasis and the definition of the abdomen, waistline, and back.

Figure 2. A 41-year-old woman with BMI of 21 kg/m² who underwent lipoabdominoplasty, before (A-C) and one year after (D-G) surgery. Notice the diastasis and hernia repair and the definition of the abdomen, waistline, and back.

Figure 3. A 35-year-old woman with BMI of 24 kg/m² who underwent lipoabdominoplasty, before (A-C) and 2.5 years after (D-F) surgery. Notice the definition of the abdomen, waistline and back.

DISCUSSION

A plethora of abdominoplasty techniques have been used to address the anterior abdomen. Lipoabdominoplasty has transformed body contouring surgery, aiming not only to correct the musculofascial wall laxity and remove the excess skin and adipose tissue of the lower abdomen, but also to define the entire abdomen and flanks, enhancing the long-term aesthetic outcome. This technique is not simply the combination of liposuction with traditional abdominoplasty. It is a much wider concept, characterized by adequate preservation of the blood supply of the abdomen, focus on the pertinent anatomy, and use of relevant surgical algorithms and techniques to completely address each anatomical area and layer, namely excess skin and adipose tissue, rectus diastasis, inadequate abdominal, flanks, and waist definition, with safety and low complication risks.

The power of the lipoabdominoplasty technique has affected the aesthetic ideals towards a more defined abdominal contour, while the active and athletic modern lifestyle is literally mirrored to the applied techniques. Matarasso^[4] considered the flanks and the back as safe areas of liposuction based on Huger^[15]’s vascular anatomy of the anterior abdominal wall. Saldanha et al.^[8] showed improved aesthetic results incorporating liposuction of these areas to abdominoplasty. Hoyos and Millard^[10] analyzed the torso anatomy, visualized the changes induced by liposuction, in terms of natural superficial light and shadows, and applied his VASER abdominoplasty technique in a standardized fashion. In that respect, the waist is better defined and the waist-to-hip ratio ideal of 0.7 is approached^[16].The “high definition” concept, although not universally accepted, can be applied with this technique in the anterior abdomen of both genders to achieve body sculpting and shaping.

Liposuction of the thoracoabdominal area, superior and lateral to the flap, debulks an area which is not treated by abdominoplasty alone. In fact, cannula undermining has substituted the traditional flap undermining, preserving the vascular supply of the abdominal flap, while permitting its debulking, without increasing the risk of necrosis or complications. Sozer et al.^[17] showed in a series of 1000 patients that applying widespread circumferential liposuction with standard abdominal flap undermining up to the costal margins is safe and associated with improved aesthetic results. Similar results, concerning safety and patient satisfaction, have been also reported following concurrently performing liposuction and abdominoplasty^[18-20]. Roostaeian et al.^[21] conducted a prospective study in 18 patients, employing SPY fluorescent imaging (LifeCell Corp, Bridgewater, NJ), which showed that the rates of intraoperative abdominal flap perfusion or postoperative complications are not significantly different between lipoabdominoplasty and traditional abdominoplasty.

The technique presented herein, SAFElipo, accomplished the safety issue, in terms of the flap vascular supply^[12]. Suction is not used during the fat separation and equalization phases, which diminishes the risk of avulsion injury to the vessels. Fat equalization also minimizes the risk of contour irregularities by creating a layer of separated fat, which acts as a buffer zone during the healing phase. Consistent results can be achieved following the SAFELipo steps meticulously. Of note, our approach involves standard cannulas instead of the power-assisted cannulas by Wall or VASER system by Hoyos, exemplifying the importance of the technique and the surgical artistry instead of the device use.

Following the completion of liposuction, lipectomy is performed based on the principles set by Saldanha et al.^[8,9]. The width of dissection above the umbilicus is limited, preserving perforators from the deep superior epigastric artery, as confirmed by the Doppler flowmetry color study of the abdominal wall of Graf et al.^[22]. Smith and Smith^[20] reviewed 300 consecutive cases and showed that abdominoplasty with abdominal liposuction is safe when a perforator vessel is spared. These perforators are expected in a 2 cm radius located 4 cm from the midline and 6 cm from the subcostal margin.

Contrary to the Saldanha’s technique with sub-Scarpa’s fat preservation, we prefer excision of most of this deep fat, reducing both the thickness of the flap and its metabolic needs, which also improves the blood supply. Swanson^[23] in 2015 used intraoperative laser perfusion imaging to show that the perfusion of the abdominoplasty flap following limited dissection abdominoplasty with sub-Scarpa’s fat preservation is not significantly different from that of full abdominoplasty with sub-Scarpa’s fat removal. Tourani et al.^[24] conducted an anatomic study, which showed that the lymphatic drainage of the lower abdomen lies superficial to Scarpa’s fascia and the transition to the infra-Scarpa fascial plane occurs within 2-3 cm of the inguinal ligament. Interestingly, a systematic review of four studies concluded that Scarpa’s fascia preservation is associated with significantly decreased seroma rate, drain output, time to drain removal, and hospital stay^[25]. In a meta-analysis, we showed that certain preventive measures, namely Scarpa’s fascia preservation, tissue adhesives, and use of progressive tension sutures (PTS), significantly reduce the seroma and infection rates, time to drain removal, and the length of hospital stay^[26]. Based on this evidence, we prefer to leave a thin layer of fat and the loose areolar layer above the deep fascia intact.

In addition, PTS, as first described by Pollock and Pollock^[27], are used prophylactically to minimize the dead space and shearing forces between the flap and the underlying fascia. In their study of 597 consecutive abdominoplasty cases without drains, PTS use facilitated abdominal flap advancement, while the seroma rate was only 0.8%^[28]. Similarly, Antonetti and Antonetti^[29] reviewed 516 consecutive cases and showed that the adoption of PTS was associated with a dramatic decrease in the seroma rate (from 24% to 1.7%). Gould et al.^[30] also reported significantly lower seroma rates with PTS usage in 619 patients who underwent either drainless lipoabdominoplasty with PTS or drain-based lipoabdominoplasty. Α clinical trial showed that the seroma rate was reduced to 3.5% by placing PTS and 11 sutures were as efficient at preventing seroma as the usage of 22 PTS, with the additional benefit of reduced surgical time (13 min vs. 30 min)^[31]. Based on the above, we use a continuous PTS to enhance the midline from the xiphoid down to the umbilicus instead of 3-4 interrupted PTS and 7-8 interrupted PTS to stabilize the remaining abdominal flap. Interestingly, neither our results nor other studies associate PTS practice with increased rates of complications.

Apart from the technical aspects of abdominoplasty, consideration should also be given to VTE prophylaxis due to the inherited risks of operations. Increased intraabdominal pressure following muscle plication, binder use, and postoperative patient positioning and immobilization are known risk factors. In a recent review, obesity, circumferential procedures, and hormone replacement therapy were independent risk factors for VTE in abdominoplasty patients^[32]. These findings are corroborated by a previous systematic review of VTE risk in abdominal contouring procedures, which demonstrated that circumferential abdominoplasty and abdominoplasty performed in combination with intra-abdominal procedures had increased risk for VTE (3.4% and 2.17%, respectively)^[33]. Abdominoplasty alone had the lowest rate (0.35%), which was doubled in abdominoplasty with concomitant plastic surgery procedures (0.79%). Based on this evidence, we avoid the routine combination of lipoabdominoplasty with other procedures. Furthermore, preoperative risk stratification based on the Caprini score is applied. A score greater than 7 or 8 necessitates chemoprophylaxis^[34]. Despite the concerns that chemoprophylaxis increases bleeding complications, recent studies refute this notion and support its use in the prevention of VTE risk^[35,36]. Surgeons should choose VTE prophylaxis taking into consideration the patient and operative risk factors. Our VTE prophylaxis protocol also comprises preoperative patient optimization, compression stockings, and use of a sequential compression device intraoperatively and early ambulation postoperatively.

In conclusion, this paper presents a safe and efficacious variation of lipoabdominoplasty, using standard liposuction cannulas. Despite the marketing and innovations of liposuction devices, such as radiofrequency-, laser-, and vibration-assisted liposuction devices, consistent results can be achieved by standard liposuction devices, using a meticulous technique based on the accumulated evidence, thorough anatomical and surgical knowledge, and applied surgical skills.