Chapter 28 Lipoabdominoplasty
• Lipoabdominoplasty was developed and patterned as a safe and functional option with which to perform liposuction and abdominoplasty during the same surgical procedure, promoting the benefits of both techniques.
• This technique is not simply using liposuction while we are performing abdominoplasty. It has a much wider concept, respecting the complete abdominal anatomy by performing a selective undermining and preserving the Scarpa fascia. This will be studied in this chapter.
3. Surgeons have always been motivated to offer the best results with a lower complication rate. In the 1990s, many papers were published relating to the decrease in undermining and the avoidance of performing full liposuction in abdominoplasty because of increasing complications. Patient safety was our major objective when developing lipoabdominoplasty. This technique patterned the limits of abdominal flap undermining, making it safe and generating a better esthetic result. It can be learned quickly because surgeons are used to performing each procedure, liposuction and abdominoplasty, separately.
According to published evidence, the perforator vessels represent 80% of the blood supply of the abdominal wall.5,6 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.7 The occurrence of ischemic processes with tissue necrosis and dehiscence of the suture has been described when abdominoplasty is associated with liposuction (this is without a selective undermining).8
4. 1985, Hakme and Shestak presented a new approach for abdominal lipectomies, the “Mini-abdomiplasty technique” of liposuction of the abdomen and flanks, associated with an elliptical resection of the suprapubic skin and the plication of the supra and infraumbilical muscles, without relocating the umbilicus.11,12
1. 1991 and 1995, Matarasso focused on the complications of combined liposuction and abdominoplasty, presenting two articles recommending the 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.8
Since the 1990s, the undermining has decreased in extent because of the large number of complications (seroma, hematoma, and most of all, necrosis),14 reaching zero in 1992 with the publication of “abdominoplasty mesh undermining” by Illouz.10
4. 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.12
Lipoabdominoplasty was developed by Saldanha in 2000 and first published in 2001as a safe option to correct esthetic and functional abdominal deformity while achieving better esthetic results with technical simplicity for surgeons.15 In that publication, a selective undermining between the medial borders of the rectus abdominal muscles was presented and use of the term “Lipoabdominoplasty” was standardized for the first time. Lipoabdominoplasty combines two 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.5–7 This technique conserves about 80% of the blood supply of the abdominal flap compared with traditional undermining. The lymphatic branches 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 over traditional abdominoplasty.15–19
2. Surgeons who wish to adopt this technique should perform the lipoabdominoplasty first in patients with excessive skin flaccidity and in those who are overweight; surgeons can then develop more confidence with this procedure, which has a short learning curve.
3. Assessment of the entire abdomen must be performed, especially looking for hernias. Ventral, lumbar, and femoral hernias should be ruled out. In the authors’ practice, preoperative ultrasonography of the abdominal wall looking for hernias is routinely performed on all patients.
Preservation of Scarpa’s fascia and the deep fat layer partially in the lower abdomen (between the umbilicus and the pubis) allows a complete reconstruction of the abdominal wall in the lower abdomen to be performed (Fig. 28.1).
Tunnel undermining is performed exactly between the medial borders of the rectus muscles, corresponding to the diastases area, preserving at least 80% of the perforating vessels, and also preserving lymphatics and nerves. Graf et al,20 using echo Doppler, showed the flow of the periumbilical perforating vessel 15 days after the procedure, and Munhoz and colleagues,21 through a Doppler ultrasound study, found that about 80% of the perforating vessels mapped in the preoperative period were maintained. This validates the hypothesis of lesser complication rates due to flap ischemia when performing lipoabdominoplasty.
The study of the exact localization of the perforating abdominal vessels led us to perform a selective undermining (tunnel undermining), preserving at least 80% of the blood supply of the abdominal wall, also reducing nerve trauma and maintaining lymphatic drainage. This produces fewer complications when compared to traditional abdominoplasty, even in post-bariatric surgery.
Performing liposuction in the upper abdomen not only removes fat, producing a better body contour, but also undermines the abdominal flap (cannula undermining) to facilitate flap descent. This stage of the surgery is mandatory and is one of the keys to successful outcomes.
3. Assessment of the descent and mobility of the abdominal flap (Fig. 28.9). (If safe, the next step can be performed – “incision”.)
Many surgeons think that liposuction of the lower abdomen is not necessary and a waste of time when the lower abdomen is going to be excised. However, doing liposuction of the entire superficial layer of the lower abdomen provides a better visualization of Scarpa’s fascia (this is important and one of the main principles of the surgery) and doing a partial liposuction of the deep layer of the lower abdomen reduces the fat thickness, to give a better contour.
1. Undermining is performed in the midline of the upper abdomen, between the internal edges of the rectus abdominal muscles (Figs 28.12 and 28.13). Neglecting to limit the dissection in this manner may result in damage to perforating vessels, which increases morbidity and the risk of abdominal flap necrosis.