Abdominoplasty

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Chapter 20 Abdominoplasty

The modern history of abdominal contouring began in 1899 with Kelly1,2 performing an abdominal apronectomy or dermolipectomy to eliminate a large abdominal pannus. In 1957, Vernon 3 described umbilicus transposition. Gonzalez-Ulloa 4 in 1959 popularized the abdominoplasty technique describe by Somalo 5 in 1946 where he resected a circular skin pattern from the lower abdominal region extending around the waist in a belt lipectomy fashion. In 1967, Pitanguy 6 presented his technique consisting of inconspicuous scars in the lower abdomen and groin, wide superior dissection up to the costal margins and xiphoid, plication of the transverse abdominal rectus muscle and umbilicoplasty. Regnault, 7 in 1972, introduced the concept of abdominoplasty in a ‘W’ pattern, and in subsequent years described modifications of the technique including a fleur-de-lis and modified belt lipectomy. Grazer, 8 in 1973, reported 44 cases of abdominoplasty hiding the incision in the bikini line. The concept of miniabdominoplasty was introduced by Elbaz and Flageul 9 in 1971, and later modified by Glicenstein 10 in 1975. The introduction of liposuction in the late 70s added a significant tool to abdominoplasty and body contouring in general. 11 Matarasso, 12,13 in the late 80s, made a significant contribution by introducing his classification scheme and by describing the incorporation of liposuction with modified abdominoplasty procedures. Lockwood, 14 in 1991, described a new concept – the superficial fascial system (SFS), which is a highly organized collagen structure responsible for anchoring the skin of the body and for supporting the weight of the fat throughout life. In 1995 he introduced a high lateral tension abdominoplasty (HLTA), which was designed to create more lateral abdominal improvement and anterior thigh elevation. 15 Within the past decade Saldanha 16 introduced and popularized ‘lipoabdominoplasty’, which has become fairly popular in South America and Europe. It is a technique that utilizes extensive liposuction of the entire abdomen combined with minimal undermining in the hope of reducing the risks of tissue necrosis and seroma formation.

Summary

Introduction

The modern history of abdominal contouring began in 1899 with Kelly1,2 performing an abdominal apronectomy or dermolipectomy to eliminate a large abdominal pannus. In 1957, Vernon3 described umbilicus transposition. Gonzalez-Ulloa4 in 1959 popularized the abdominoplasty technique describe by Somalo5 in 1946 where he resected a circular skin pattern from the lower abdominal region extending around the waist in a belt lipectomy fashion. In 1967, Pitanguy6 presented his technique consisting of inconspicuous scars in the lower abdomen and groin, wide superior dissection up to the costal margins and xiphoid, plication of the transverse abdominal rectus muscle and umbilicoplasty. Regnault,7 in 1972, introduced the concept of abdominoplasty in a ‘W’ pattern, and in subsequent years described modifications of the technique including a fleur-de-lis and modified belt lipectomy. Grazer,8 in 1973, reported 44 cases of abdominoplasty hiding the incision in the bikini line. The concept of miniabdominoplasty was introduced by Elbaz and Flageul9 in 1971, and later modified by Glicenstein10 in 1975. The introduction of liposuction in the late 70s added a significant tool to abdominoplasty and body contouring in general.11 Matarasso,12,13 in the late 80s, made a significant contribution by introducing his classification scheme and by describing the incorporation of liposuction with modified abdominoplasty procedures. Lockwood,14 in 1991, described a new concept – the superficial fascial system (SFS), which is a highly organized collagen structure responsible for anchoring the skin of the body and for supporting the weight of the fat throughout life. In 1995 he introduced a high lateral tension abdominoplasty (HLTA), which was designed to create more lateral abdominal improvement and anterior thigh elevation.15 Within the past decade Saldanha16 introduced and popularized ‘lipoabdominoplasty’, which has become fairly popular in South America and Europe. It is a technique that utilizes extensive liposuction of the entire abdomen combined with minimal undermining in the hope of reducing the risks of tissue necrosis and seroma formation.

Indications

Patients seeking abdominoplasty most often complain of excess skin and subcutaneous tissue in the abdomen and abdominal protrusion due to laxity of abdominal wall caused by previous pregnancy, weight fluctuations and/or aging. Many of these patients will present with lipodystrophy of the hips and lateral thighs as well.17 A traditional abdominoplasty is indicated when the deformities involve both the supra and infraumbilical regions whereas a mini-abdominoplasty is usually indicated if the problems are limited to the infraumbilical region. Although most patients are female, males do present with similar problems, but often complain of adiposity in the flank areas and supraumbilical rectus diastasis.1820

The ideal candidate for abdominoplasty is a young healthy woman who is a nonsmoker and whose weight is within, or slightly above, the normal range. In many cases, especially in middle-aged and older women, patients present with concomitant lipodystrophy of the hips and lateral thighs, as well as the abdominal deformities. These patients are still amenable to abdominoplasty in combination with liposuction of the areas of lipodystrophy. However, if the deformities involve the lower trunk circumferentially, as in the massive-weight-loss patient or some overweight patients, abdominoplasty can have disappointing results. These patients usually require a circumferential truncal dermatolipectomy to treat their deformities.

Obese patients are not good candidates for abdominoplasty because they have excess intra-abdominal or visceral fat. The intra-abdominal cavity can be thought of as a balloon that fits inside a second external skin balloon. If the internal balloon is overly inflated by visceral fat, it cannot be effectively flattened by musculoaponeurotic plication. Thus it will maintain a convex profile, which is translated to the external balloon and will lead to a convex appearance for the entire abdomen. This defeats the major reason why most patients seek abdominoplasty surgery.

As with any elective plastic surgery procedure patients who have unrealistic expectations of the potential results should either be advised by their surgeon to change their expectations or should not be operated on. Similarly patients who present with unstable psychiatric or medical conditions should be avoided. The question about whether the risk of carrying out an abdominoplasty in an individual who has well-controlled diabetes mellitus is too high is controversial. Many surgeons consider the risk posed by the decreased ability to fight infection, potential vascular compromise, and decreased wound healing ability too high.

Smoking has been implicated in occlusive microvascular thrombosis and delayed wound healing and when associated with a procedure that already compromises the blood supply of the abdominal skin flap, can result in tissue necrosis and jeopardize the outcome. Active smokers are excluded by most surgeons, but some surgeons are willing to operate on them utilizing techniques that reduce abdominal flap elevation to reduce the risk of vascular compromise.2123

Abdominal wall plication can increase intra-abdominal cavity pressure and this can potentiate certain problems.

Although it is always best for women to undergo abdominoplasty after they have had children and when they do not plan any more, many patients do become pregnant and have children after the procedure. Some of the benefits of abdominoplasty may be reduced or eliminated by pregnancy, thus it is wise to postpone the procedure if a pregnancy is anticipated in the near future.

Previous abdominal scars

Patients with previous abdominal scars may require special considerations if abdominoplasty is contemplated.

Mini-abdominoplasty

Indications for mini-abdominoplasty are limited to patients who present with abdominal laxity restricted to the infraumbilical region.24 The laxity has to be minimal and may be of the abdominal wall and/ or of the skin/fat envelope. Physical examination of the abdomen in the supine position will demonstrate infraumbilical rectus diastasis, which can be confirmed by the ‘diver’s test’ (see Fig. 20.1). These patients are usually young women who have had one or two pregnancies, have good skin elasticity, and are not overweight. Mini-abdominoplasty, with any of its modifications, is not a procedure that is often employed because it is the unusual patient that will fit its required criteria.

Lipoabdominoplasty

Lipoabdominoplasty was introduced and popularized by Saldanha16 from Brazil. This technique, with a variety of its forms, is becoming more popular around the world especially in South America and Europe. For the surgeons who espouse lipoabdominoplasty, it is an alternative technique that accomplishes many of the same goals as traditional abdominoplasty but maybe safer and associated with less complications (Box 20.1). Currently many American plastic surgeons are starting to utilize the technique in its entirety or at least in some of its main aspects. Lipoabdominoplasty has some similarities to HLTA.

Preoperative Considerations

Preoperative evaluation of potential abdominoplasty patients includes a good history and physical examination, and determination of their primary concerns and expectations. Special attention should be paid to weight fluctuations, any history of pregnancy, diet and exercise regimens, and previous abdominal surgery and/or hernias. A careful medical history should be obtained along with a smoking history.

Physical examination

On physical examination the patient’s weight and height should be determined. The body mass index (BMI), should be calculated based on the formula: weight in kg/(height in m)2. The patient is initially examined circumferentially in the standing position to evaluate the abdominal contour from the rib cage to the mons pubis. However it is also important to pay attention to the surrounding contours of the posterior trunk, thoracic region, and thighs.

Three main components need to be evaluated in the physical examination of the abdomen: the skin, the subcutaneous fat, and the abdominal wall.

Skin

The overall quality of skin, including scars and stretch marks should be noted. The skin should be examined to determine its vertical excess and the extent of its laxity in the different regions of the abdomen. Often multiparous women present with stretch marks that involve the infra and supraumbilical regions.26 The patient needs to understand that infraumbilical skin will most often be removed, but supraumbilical stretch marks will not. These remaining stretch marks are often less unattractive when stretched by the procedure and can be hidden by some bikini patterns because of their transference to the lower abdomen.

Abdominal wall laxity

A third reason for a protruding abdomen is abdominal wall laxity. It is essential to ascertain the integrity of the abdominal wall, whether there are any hernias present, and the extent of intra-abdominal or visceral fat. The exam is fairly easy in thin patients, but can be more cumbersome and difficult in the overweight or obese patient.

A number of tests can be performed, which alone or in combination, can give the examiner a feel for the degree and extent of any laxity. Initially the patient is asked to stand and relax their abdominal wall completely. For many this is not easy and they must be coaxed into cooperating. An appreciable amount of abdominal protrusion in this position usually indicates significant abdominal wall laxity. To confirm the result of this simple test, the patient is asked to perform the classic ‘diver’s test’ (Fig. 20.1).

To get a more accurate estimation of abdominal wall laxity, the patient is placed in the supine position and asked to lift the head and upper back off the table while the examiner palpates the abdominal wall. The extent of generalized laxity and the separation between the rectus muscles should be noted. Most patients presenting for abdominoplasty will demonstrate at least some degree of rectus diastasis. Men have a propensity toward a supraumbilical diastasis, whereas women most often present with infraumbilical muscle separation.

Abdominal wall laxity can be difficult to examine in patients with thick panniculi. A distinction between subcutaneous and visceral fat must be made because none of the techniques of abdominal contouring are designed to address excess intra-abdominal fat. A helpful test for these patients is to place them in the supine position and observe their abdominal contour. If it dips below the level of the ribs, it is likely that rectus fascia plication will be effective; if not, it can be presumed that there is an excessive amount of intra-abdominal adipose tissue. Attempting to perform an abdominoplasty on a patient with excessive intra-abdominal content most often yields an unfavorable outcome.

Operative Approach

Relevant anatomy

In young, healthy men and women the waist is the narrowest circumference of the torso, usually 2.5 cm cephalad to the umbilicus, which lies on the midline at about the level of the iliac crests. Ideally, the distance from the umbilicus to the anterior vulvar commissure is 18-21 cm, and the pubic hair line is 5-7 cm cephalad to the anterior vulvar commissure.

The anterior abdominal muscle wall may be considered to have two parts:

The rectus muscle is enclosed in a stout sheath formed by a bilaminar aponeurosis, which passes anteriorly and posteriorly around the muscle, decussating in the midline to form the linea alba. Anteriorly the sheath is made up of the external oblique fascia and the anterior portion of internal oblique fascia. Posteriorly the sheath is made of the posterior portion of the internal oblique fascia and the transversus abdominis muscle fascia. Halfway between the umbilicus and the pubis, the posterior sheath layers pass anteriorly at the arcuate line of Douglas. The lack of support below the line of Douglas leads to a natural tendency toward lower abdominal fullness.

The umbilicus lies in the midline at varying distances between the xiphoid and the pubis symphysis, but usually level with the anterior superior iliac spines (ASIS). It has a dual blood supply, from the deep layer and from the skin, and it is able to survive on either. Caution is warranted in patients with large umbilical hernias and previous transections of the umbilicus.

Subcutaneous abdominal fat is compartmentalized into superficial and deep layers divided by the superficial fascial system, which in this region of the body is called Scarpa’s fascia. In patients who are relatively thin, the two layers of fat are fairly close to each other in thickness. In patients who have a large BMI the superficial fat layer is often much thicker than the deep layer (Fig. 20.3). The superficial fat layer is compact, dense with fat cells contained within well organized fibrous septa, whereas the deep fat is a loose areolar layer.

Vascular zones

Regardless of the technique used when performing abdominoplasty, vascular territories are interrupted and should be taken into account especially when upper abdominal scars are present.27 Thus a thorough knowledge of the blood supply of the abdominal skin and fat is essential. Huger28 studied the blood supply to the abdomen and designated three vascular zones (Fig. 20.4):

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