23 Liposuction of the Abdominal Wall Followed by Abdominoplasty

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23 Liposuction of the Abdominal Wall Followed

by Abdominoplasty

Giorgio Fischer

23.1

Introduction

The history of cosmetic surgery of the abdomen starts back in the nineteenth century. Between 1890 and 1910, several authors described the technique of dermolipectomy. In 1957, Vernon [1] baptized the modern era of abdominoplasty using a combined technique of a low transverse abdominal incision together with an umbilical transposition [2]. Callia, in 1967 [3], described a similar technique with an incision that passed under the inguinal line. In the same year, Ivo Pitanguy [4]

published his work on abdominal lipectomy. It was his experience that gave us the opportunity to understand the basic principles of abdominoplasty. Pitanguy’s principles were simple and precise: small incision of the inferior abdomen and down through the inguinal line, transverse umbilicoplasty, reinforcement of the fascia, and postoperative bandages. In 1975, Regnault [5] introduced the “W technique”. The incision started above the mons pubis and laterally went down following the inguinal line.

This shows that abdominoplasty techniques have varied throughout the years, and that with time the goal has been to achieve maximum results with scars that could have easily been covered by bikinis or by natural anatomical lines.

Unfortunately, the only concern of the patient seems to be the remaining scar. It has to be kept in mind that we are not general surgeons. Lives are not being saved and the patients are hardly able to accept evident scars.

It is for this reason that the concept of modeling the abdomen has radically changed after the introduction of liposuction techniques. The abdomen is one of the areas that has most benefited from the introduction of liposculpture [6]. Until then the only option that was giv- en to patients was dermolipectomy.

Besides the scar, which is sometimes very difficult to accept, abdominoplasty in the traditional manner is a very big operation. It probably needs hospitalization and several days of recovery. Medical preoperative evaluation is very important in order to detect the presence of hernias and possible diastasis of the rectus abdominal muscles. Another important fact to evaluate is

the degree of intra-abdominal, visceral, or omental fat.

This, in fact, will determine the outcome of the operation since only the abdominal wall fat will come out.

Last, but certainly not least, abdominoplasty is not free from complications. The most frequent are certainly the formation of hematomas and seromas. These complications make the recovery period even longer and uncomfortable for the patients. Necrosis of the skin is the most unfavorable complication. Fortunately its in- cidence is low and occurs when the vascularization of the flap has been damaged during the operation. Super- ficial necrosis is, however, quite frequent especially me- dially in the suprapubic incision when closure is performed under great tension. Smokers are obviously high-risk patients for this complication.

23.2

Anatomical Considerations

The anatomical characteristics of the abdomen are very important to take into consideration. The surface anatomy of the abdomen can be subdivided into the epiga- strium or upper abdomen, the hypogastrium or lower abdomen, and the mesogastrium or midabdomen, which contains the periumbilical and waist areas. The lower abdomen is delimited by two imaginary lines running one superiorly through the belly button, and one inferiorly through the mons pubis.

The anatomy of the subcutaneous fat can be subdivided into an apical layer which is very thin and extends into the deep reticular dermis, a mantle layer which is quite large but varies in thickness throughout the body, and a deep fat compartment layer [7]. This latter layer is responsible for the uncosmetic areas of fat excess.

The distribution of the subcutaneous fasciae is also very important in order to understand why certain areas of the abdomen appear so difficult to defat. The septae are the major responsibility for the presence of very fibrous areas, especially in the waist area and in the upper abdomen.

Camper’s fascia is defined as the superficial layer of superficial fascia of the abdomen. It extends over the

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entire area of the abdomen. Scarpa’s fascia instead only exists in the lower abdomen with the upper insertion coinciding with the waistline fibrosis.

The upper abdomen appears to be more fibrous and harder to penetrate with a cannula probably because of the presence of numerous fibrous septae. This is why the upper abdomen, above all of the other areas of the body, has a high risk of postoperative wrinkles. Scarpa’s fascia does not exist in the upper abdomen; therefore if too much fat is taken away there is no possibility that this

a b

Fig. 23.1. a Preoperative pa- tient with large fat deposit and excess skin. b Postopera- tively good results with liposuction alone. Patient could have had an abdominoplasty but she was satisfied with the results

a b

Fig. 23.2. a Preoperative type D patient with localized fat deposit and no skin excess.

b Postoperatively excellent results with liposuction alone

fascia, existing only in the lower abdomen, may allevi- ate the adherences of the fibrous tissue to the skin.

23.3

Surgical Treatment (Figs. 23.1 – 23.6)

The choice of surgical treatment depends on the sur- geon and obviously on the type of deformity of the patient. With the introduction of liposuction, the original 196 23 Liposuction of the Abdominal Wall Followed by Abdominoplasty

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a b Fig. 23.3. a Preoperative mid-

dle-aged patient (type B) who could have liposuction or abdominoplasty. b Post- operatively following liposuction only

a b

Fig. 23.4. a Preoperative pa- tient with excess fat and skin. b Postoperatively fol- lowing liposuction. Skin retraction is not complete and patient can have a small abdominoplasty as a secondary procedure

abdominoplasty is now rarely required. The differences between patients have to be taken into consideration because abdominal liposuction is not ideal for every patient, especially when little fat is present with a large skin apron, extended stretch marks, and/or the presence of muscle diastasis. To these patients, whom I call Type A patients, I recommend an ordinary abdominoplasty. My Type D patient is a patient with no muscular laxity and an excess of fat in the abdominal area. This

patient will undergo a simple liposuction of the abdomen.

Type B and C patients are those patients whom I call

“boundary patients”. My first approach is always liposuction, but I tell the patients that if the skin will not retract in the 6 – 8 months following the operation, they will need a mini tummy-tuck. It is very important to in- form the patients of the various technical possibilities.

It is very surprising to see that many patients to whom

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a b

Fig. 23.5. a Sixty-year-old pa- tient with localized excess fat. b Postoperatively follow- ing liposuction with good skin retraction despite age

a b

Fig. 23.6. a Preoperative pa- tient with moderate excess fat and no loose skin. b Post- operatively following liposuction with excellent results

I had advised this two-stage operation were already satisfied with liposuction only. The abdomen in fact has excellent retraction capabilities, especially in young patients.

I never practice a one-stage operation. The first stage is always liposuction, and the second one, if needed, is a mini-abdominoplasty. The second stage operation is quite simple, and since the only remaining thing is the excess skin, there is no need for a very long scar,

nor is there any risk of vascular damage as when large dermolipectomies are performed.

23.4

Liposculpture

Liposuction technique for the abdomen does not differ very much from that of other areas of the body. The ab- 198 23 Liposuction of the Abdominal Wall Followed by Abdominoplasty

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domen is a very challenging area to operate upon and the silhouette can really be changed in a person. There are areas in which we must be very careful, such as the upper abdomen, where excessive defattening might result in rugosity after the postoperative edema has passed. This happens most often in older patients with decreased skin elasticity.

Preoperative evaluation of the patient is very important. The first thing to do is to make the patient lie down and lift her/his legs up, so that the abdominal muscles can be evaluated. In the case of severe diastasis of the rectus abdominal muscles, liposuction is not performed. Also, it is important to know whether the patient has a hernia, since there is a higher risk of intesti- nal perforation. It is also important to know whether the patient has breast protheses. After the examination, preoperative pictures are taken and the skin marked.

Once in the operating theatre, the anesthetist starts sedating the patient. General anesthesia is never used.

All through the operation they must be able to contract their abdominal muscles if asked to do so. Too much re- laxation will cause loss of the perception of the area being worked on.

Infiltrating of tumescent fluid is done using a modi- fied tumescent technique. The amount infiltrated is as much as is determined will be removed. Real tumescent anesthesia infiltration [7] gives an excessive distortion of the fat, making it very difficult to sculpt the body. Li- posuction is a sculpture of the body. I have fought for years against the force of gravity that kept me making the same mistakes, making it hard to see what the final result could be. When I invented the orthostatic bed, the statue in front of me could finally be seen as she would appear in everyday life. Infiltrating twice or three times as much, as I have seen many of my colleagues do, is a wrong approach for the technique. There is no need to do so. One should never lose sight of what is under one’s hands. Therefore, if 1,000 cc of fat is estimated to require removal, only 1,000 cc is infiltrated.

It is important that the patient lie on the orthostatic bed. The abdomen, especially in young people, is one of those areas that must be treated in the orthostatic position. Many patients will tell you that when they are lying down, their tummy looks fine. Patients, neverthe- less, never look at themselves lying down; therefore, you should always operate in the most natural and physiological manner. In the upright position you will have no false effects due to the force of gravity. The re- finements are, therefore, carried out in an orthostatic manner. The first part of the operation may be carried out in with an oblique method.

When liposuction represents the first stage of a two- stage operation, most of the fat is taken away from the very deep fat compartment. It is only later that a superficial liposculpture is performed in order to help the skin retract.

Criss-cross tunnels are used for liposculpture. Gen- erally four or five incisions are enough for the whole abdominal area. Do not be concerned about the num- ber of incisions made. The only important thing is to work comfortably and to tunnel in the correct direc- tions. Tunnelling should always be performed in a ver- tical manner. Two incisions are suprapubic. From the left one the cannula is criss-crossed onto the right side of the abdomen in a clockwise direction, and the opposite happens for the right incision. Remember to place the incisions in a non-symmetrical manner to give the appearance that they are other types of scars. Another incision is placed over the umbilicus. From this incision the cannula is criss-crossed right and left. Other incisions can be placed under the breast so as to tunnel in an opposite direction to the umbilical incision. Of course different situations require different incisions.

Always work on a wet surface. Only in this way can one really appreciate what is under one’s hands.

I work with my left hand flat on the surface of the abdomen until I am concerned about the diminishment of the volume. Then I start pinching it in order to evaluate the thickness. A certain amount of subcutaneous fat should always be left; otherwise after the postoperative edema has passed, adherences to the muscle may be seen. You should always feel unhappy at the end of your operation thinking that you could have taken away more. Remember that a certain amount of fat reabsorp- tion occurs after the operation; therefore the final result will not be seen at the operating table. As Illouz has said,

“it is not so much what is removed that is important, but what is left behind” [8]. Good and expert surgeons are only able to imagine what the final result will be.

Because of the particular anatomy of the abdomen, I do a heavier liposuction on certain areas of the abdomen in order to give the patient a better silhouette. The midline between the costal margins contains a lot of fibrous tissue and fat and, at times, can be difficult to remove, but when possible more fat in that area is removed than in the surrounding ones in order give a

“depression” effect. Patients want to look like body builders, and this turtle-effect of the abdomen makes the patient look thinner. Also, more fat is removed in the triangle above the mons pubis, beneath the umbilicus. This gives more roundness on the left and right sides of the lower abdomen, which gives a very nice feminine look to the abdomen. Accentuating the waist is a very important aspect of abdominal liposuction.

Suction of the lateral upper hips can really change the silhouette of a person.

Recently I have started using a very simple instru- ment at the end of my operation. Before applying Re- ston foam, I smooth the treated areas with an iron steel tube. I roll the tube for about 10 min all over the abdomen with a certain amount of pressure. This smooth- ens and evens up the surface very well.

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After the operation is completed, Reston foam is ap- plied. I disagree with my colleagues who believe in the unsatisfactory results of Reston foam. It creates a uni- form distribution of the pressure and prevents bruising very well. If you do not infiltrate too much you will not need loose garments which permit open drainages; in fact, I always suture the incisions. Over Reston, I make my patients wear a normal pair of elastic garments (70 den tights). Reston is removed on the third postoperative day. Patients are immediately sent to massage sessions that will continue for over a month, and even longer if needed. At the beginning they will have mas- sages three or four times a week. This is very important especially when the abdomen is treated. The postoperative edema of the abdomen takes more time to resolve than that of other areas of the body. It is very important to massage the areas to reduce the probability of per- manent lumps and long-lasting edema.

Patients are told not to sit at a 90 degree angle or to bend forward for too long. Sitting straight up or bent forward for a long time can cause wrinkles on the surface of the abdomen that will be very difficult to remove later on.

23.5 Conclusions

I believe that in the majority of our patients liposuction alone is able to give good satisfactory results. Liposuc- tion has proved to be so effective that routine abdominoplasty is now rarely required. Only in the case of excessive skin, little fat, diastasis of rectus abdominal

muscles, or extensive stretch marks, is abdominoplasty required. In all other cases, liposuction alone, if performed correctly, will give excellent results.

When liposuction alone is not enough, I never per- form abdominoplasty at the same time. I carry out what is called a two-stage operation. When indicated, the second-stage abdominoplasty is carried out 6 – 8 months after liposuction. Generally there is no need for large scars if the flap has been well defatted. The operation can be carried out using local anesthesia.

Abdominoplasty alone is rarely indicated except for particular cases. The first approach should always be liposuction and the patient should be informed that another operation may have to be performed. Perfection needs time.

References

1. Vernon S (1957) Umbilical transplantation upward and abdominal contouring in lipectomy. Am J Surg 94:490 2. Rees-La Trenta (1998) Chirurgia Plastica Estetica. Verducci

Editore, Rome, pp 1113 – 1114

3. Callia WEB (1967) Una plastica para o cirurgia geral. Med Hosp (Sao Paulo) 1:40 – 41

4. Pitanguy I (1967) Abdominal lipectomy: An approach to it through an analysis of 300 consecutive cases. Plast Reconstr Surg 40:384 – 391

5. Regnault P (1975) Abdominoplasty by the W technique.

Plast Reconstr Surg 55:265

6. Fournier P (1991) Liposculpture: the syringe technique. Ar- nette, Paris

7. Klein J (ed) (2000) Tumescent technique: tumescent anesthesia & microcannular liposuction. Mosby, St. Louis 8. Illouz Y-G, De Villers YT (1989) Body sculpturing by lipo-

plasty. Churchill Livingstone, Edinburgh, p 67 200 23 Liposuction of the Abdominal Wall Followed by Abdominoplasty