Introduction

The concept of “lipoabdominoplasty”, the combination of lipoplasty and surgical techniques to excise loose skin and structurally tighten the abdominal wall has been ignored until recently in most of the world outside South America. This approach represents an evolution of technique in body contouring and a successful approach to safely combine excisional body contouring with a way to reduce fat deposits found within regional aesthetic units.

The conventional or “classic” abdominoplasty is a technique that is dependent on delamination of the abdominal skin and adjacent layers (lamina) from the deep abdominal wall (rectus abdominis muscle) fascia in order to accomplish maximum tightening of loose tissues. In most cases, this is a safe procedure, with acceptable risk of delayed healing and scarring. For some patients who have undergone massive weight loss, the conventional abdominoplasty is necessary. (Fig. 63.1).

Fig. 63.1 “Classic” abdominoplasty.

In a similar fashion, regarding “conventional” suction-assisted lipoplasty, we achieved fairly good results, with the acceptance of limitations of this technology in areas of fibrous tissue (epigastric region, flanks). An approach to re-engineer conventional lipoplasty technology regarding a reasonable level of precision and finesse was needed. The assistance of an energy-based technology (ultrasonic assisted lipoplasty [UAL]; VASER®-assisted lipoplasty [VAL]; or power-assisted lipoplasty [PAL]) appeared to improve the quality of outcomes over cannula-only techniques.

We as plastic surgeons make advances in surgical outcomes when we merge technologies. Often it comes down to making the anatomy work to our advantage by surgical measures that allow layers within the body to move without excessive delamination. The situation of innovation with the lipoabdominoplasty and its variations represents an area where such innovation occurred. Through the merging of technologies and the thoughtful knowledge of laminar anatomy, patients can safely undergo effective regional body contouring procedures.

Safety concerns over combining lipoplasty and excisional surgery

For years, the matter of combining lipoplasty and the “classic” excisional abdominoplasty was met with skepticism and safety concerns regarding the combined effect of raising a devascularized flap of abdominal tissue that had been first traumatized by a lipoplasty procedure. The “red zone” influence of the diagrams contained within articles written by Matarasso (1989, 1991, 2000)^1–3 greatly influenced our thinking about the potential for central abdominal skin necrosis when conventional lipoplasty was combined with classic abdominoplasty (Fig. 63.2).

Fig. 63.2 Matarasso abdominoplasty danger zones.

Innovations in abdominoplasty

Progress on how to improve the quality of outcomes in abdominoplasty occurred when tension on the flaps was directed laterally to help shape the waist.⁴ Ted Lockwood in the early 1990s recognized the importance of the superficial fascia (Scarpa’s fascia) of the abdominal area to take tension off the skin closure.^4,5 Avelar (1989) further refined the concept when he described a laminar approach to the abdominal wall, skin, subcutaneous fat, superficial fascia-fat matrix, and deeper fat layer⁶ (Fig. 63.3).

Fig. 63.3 Avelar’s laminar approach to anatomic layers of abdomen.

Other contributors to advanced concepts of abdominal contouring include Saldanha (2001), Shestak (1999) and Illouz (1992).^7–10 The concept of safely combining lipoplasty with excisional surgery in order to improve the aesthetics of the entire abdominal region was demonstrated. Brazilian surgeons appear to have innovated the “lipoabdominoplasty”, although it is difficult to exactly credit one inventor, as several surgeons reported their own individual variations on the procedure. Matos and Ribeiro recently published an excellent review and classification of lipoabdominoplasty and its variants.¹¹ Other surgeons, including Cardenas-Camarena and Brauman were some of the first to report lipoabdominoplasty in the American plastic surgery literature.^12–13

VASER® ultrasonic lipoplasty combined with excision

When Dr Fodor, Dr Souza Pinto and I wrote the original VASER paper in 2002, I noted the capabilities of VASER® technology to deliver safe, effective, and precise outcomes that heretofore were not available with “conventional” lipoplasty or second-generation ultrasonic lipoplasty devices. The VASER® was able to safely treat all layers of tissue in areas such as the abdominal region and did not appear to inflict collateral damage to skin, vascular, lymphatics, or sensory nerves. It was possible to be selective for fat removal from the tissue matrix and still leave supporting structures largely intact, provided simple clinical guidelines were followed. The use of ultrasonic lipoplasty was initially reported by Abramson^14,15 (Figs 63.4–63.6).

Fig. 63.4 Vaser lipoplasty of abdomen.

Fig. 63.5 Photo of aspiration after fragmentation.

Fig. 63.6 VASER ultrasonic solid probe lipoplasty.

VASER® ultrasound-assisted lipoplasty (VAL) became a powerful adjunct to excisional surgery when we realized that there appeared to be less damage to the underlying tissue matrix, less risk of burns, seroma, and dysesthesia. The VASER®’s unique qualities for treating fibrous tissue, such as the epigastrium, mons pubis, and flanks, made it possible to simultaneously achieve contour enhancement on a regional basis versus the traditional removal of blocks of skin and fat. Wide undermining was no longer necessary, the superficial fascia could be left intact, and even deep fat could be thinned, elements that could not be reliably and predictably achieved to the same level with conventional liposuction.

The effect of VASER® ultrasonic lipoplasty on the lamellae of the abdomen appears to go far beyond that of volume reduction, producing a “shrink wrap” effect on overlying tissue through a proposed tightening of the collagen rich mid-lamellar layer. Competing superficial technologies that utilize radiofrequency energy, infrared, or mechanical rollers lack a substantive effect at this depth. According to a prospective randomized study that compared conventional lipoplasty to the adjunct of laser energy delivered to the tissues done by Prado,¹⁶ there was not a substantive benefit noted.

Ultrasonic cutting devices

Additional innovation was made by Richter¹⁷ regarding how dissection above the superficial fascia could be performed to limit interruption of vascular and lymphatic structures where tissue excision is planned. Suture fixation of the superficial fascia to the deeper rectus fascia has been shown to stabilize the mons pubis and inguinal regions. Variations on this approach with resection of a midline strip of superficial fascia in the lower abdomen to access the deeper fascia for tightening have been reported by Jewell.¹⁸ Once the deeper tightening has been accomplished, the superficial fascia is closed with PDS suture (Ethicon Inc., Somerville, NJ USA). This approach works well with both procedures that require umbilical transposition or limited tissue excision from the lower abdominal region only.

Alternatives to electrosurgical dissection for tissue resection and creation of a central tunnel for tightening of the upper rectus muscle diastasis have been developed with the Ethicon EndoSurgery Synergy® ultrasonic scalpel Jewell¹⁹ and Richter¹⁷) (Fig. 63.7). This device allows for precise, rapid dissection above the level of the superficial fascia following the lipoplasty component of the procedure (Figs 63.8–63.10).

Fig. 63.7 Synergy® ultrasonic scalpel.

Fig. 63.8 Dissection above Scarpa’s fascia.

Fig. 63.9 Resection of strip of superficial fascia.

Fig. 63.10 Tightening of lower abdominal wall.

Upper abdominal dissection to expose the diastasis of the rectus abdominis is accomplished with the use of a fiberoptic retractor to provide upward traction. Hemostasis with this device is acceptable; it is possible to perform a lipoabdominoplasty without electrosurgery (Figs 63.11, 63.12).

Fig. 63.11 Creation of tunnel.

Fig. 63.12 Tightening of upper abdomen.

Specifically, the surgical principles used in the many variations of lipoabdominoplasty include dissection and sculpturing of the subcutaneous deep layer and superficial layer with lipoplasty (conventional and VASER®-assisted), selective undermining and plication of the anterior rectus sheath, preservation of the perforator vessels, preservation of Scarpa’s fascia and deep fat, skin resection, and umbilical transposition. Successful re-contouring of the abdominal region involves more than just excision of blocks of skin and fat.

The future in the field of abdominal body contouring procedures will probably take two pathways: (1) that of external high-intensity focused ultrasound (HIFU) for smaller volume corrections; and (2) that of the combination of ultrasonic surgical devices (VASER® and Ethicon EndoSurgery Synergy® ultrasonic scalpel) combined with any number of variations of lipoabdominoplasty.

Technical considerations for Ethicon EndoSurgery Synergy® ultrasonic scalpel in lipoabdominoplasty

The learning curve for incorporation of ultrasonic cutting devices into lipoabdominoplasty is straightforward:

Steps for lipoabdominoplasty

Discussion

There are a variety of elements regarding technology, physics, and process of abdominoplasty that could be improved to change the quality of patient outcomes. These consist of precision, finesse, safety, and technology. Success in performing contemporary lipoabdominoplasty involves the following elements:

Fig. 63.C1 A–F, Before/after standard lipoabdominoplasty.

Fig. 63.C2 A–F, Before/after limited lipoabdominoplasty.

Fig. 63.C3 A–F, Standard lipoabdominoplasty.