Introduction

Many surgeons over the last century have increased our understanding of abdominal surgical anatomy, especially with regard to the vascularization and lymphatic drainage of the abdominal wall. These advances have resulted in surgeons able to perform safer, more efficient and faster abdominoplasty procedures with good and consistent results.

Surgeons such as Callia,² Pitanguy,³ Pontes,⁴ Baroudi,⁵ Avelar,⁶ Matarasso,⁷ Lockwood,⁸ Guerrero Santos,⁹ and many others around the world have contributed to the development of surgery in the abdominal area.

Concerning vascularization studies, contributions from El Mrakbey,¹⁰ Boyd and Taylor¹¹ and others have highlighted the associated morbidity related to the extension of the undermining in these procedures.

The classifications of the pathology, according to Pitanguy¹² and Bozola,¹³ allowed more precise and correct surgical indication by choosing the technical options and the extension of each procedure.

Baroudi’s⁵ stitch technique greatly diminished the occurrence of seroma formation by plicating the abdominal flap to the aponeurosis. Seroma formation, together with infection and skin necrosis, are the major complications of this procedure in the postoperative period.

Bozola¹³ described the umbilical position, which can be measured in a geometric proportion of 1 for the infraumbilical portion and 1.5 for the supraumbilical area, giving a harmonic relationship to the abdomen (Fig. 22.1). The umbilical position will be the parameter for our assessment concerning the removal of the infraumbilical flap, so we must be extremely careful with those patients having a high umbilical scar position.

FIG. 22.1 Geometrical position of the umbilical scar described by Bozola.

However, the greatest advancement in the evolution of abdominoplasty was the use of liposuction. The liposuction studies by Illouz,¹⁴ Avelar,⁶ Saldanha,¹⁵ Hunstad¹⁶ and Klein¹⁷ highlighted the safety of this procedure in regular association with traditional abdominoplasty. Liposuction decreases fat thickness and reduces the undermining required. This results in both harmonious and satisfactory outcomes for the patients and their respective surgeons.

In our clinical practice we are in favor of the previous resection of the abdominal flap as proposed by Pontes⁴ since 1964. The ease of the resection, the absolute control of bleeding, scar symmetry, and improved speed and efficiency of the procedure are our critical points to advocate the abdominoplasty with previous flap resection as our routine technique. In addition, improved flap handling is another distinct advantage and further emphasizes our preference for this procedure.

Preoperative Preparation

Once the patients have disclosed their expectations about the surgery, we carefully analyze the deformity to indicate the best technical option for the case. The surgery must be clearly discussed with the patient beforehand so as to avoid any misunderstandings with regards to scarring and the final esthetic results.

Surgical Technique

In a standing position we draw an area corresponding to a bikini shape (Fig. 22.2). The lateral lines are parallel to the inguinal crease, reaching a point demarcated on the natural crease of the abdomen on the hips (Figs 22.3 and 22.4).

FIG. 22.2 Marking the area corresponding to a bikini shape.

FIG. 22.3 Marking the natural crease of the abdomen on hips.

FIG. 22.4 The lateral lines are parallel to the inguinal crease into the area limits.

The central inferior line delineates the upper pubis and is located approximately 5–6 cm from the vulvar commissure, with a soft caudal concavity.

The opposite side will be drawn in the same way and confirmed with a ruler and a compass.

In sequence we draw a semicircle bordering the inferior pole of the umbilical scar, and another one passing the superior border, creating a safety area (Fig. 22.5).

FIG. 22.5 Final demarcation forming an elliptical design, the safety area (above the umbilical scar) and the regions for liposuction.

At the moment of traction and suture of the flap to the pubic area, we assess the tension of the flap.

If the superior border is considered the ideal one, the remaining skin in the safety area will be resected. This situation corresponds to about 95% of the cases.

If there is too much skin tension we can change our surgical plan, closing the umbilical scar and stretching it to the suprapubic region, leaving a small 2–3 cm longer vertical scar as a release tension maneuver (Fig. 22.6).

FIG. 22.6 An eventual suprapubic vertical scar.

All the measurements are checked and tattooed in the key points with methylene blue ink.

Under epidural anesthesia, for the majority of cases, we infiltrate with a solution composed of 500 ml saline solution 0.9% and epinephrine (adrenaline) concentration of 1/500 000 using 3.0 or 3.5 mm cannulas in the upper abdomen, flanks, and waist.

In the submammary region the cannula runs downward using a small incision in the mammary sulcus; sometimes this area does not require fat removal but must be undermined in tunnels using a 3.0 mm cannula, with no suction. This is to allow easier sliding of the flap.

Following this, the skin and fat will be cut inferiorly and in the superior line below the umbilical scar, forming a flap that will be removed as a block, preserving the safety area (Fig. 22.7).

FIG. 22.7 The flap removed as a block.

In the suprapubic region we use a slant incision, leaving a small portion of level fat remaining in order to have a better fitting for the upper flap coming downward. The periumbilical area always has less thickness of fat.

The umbilical scar is incised in its border. The undermining of the central portion of superior abdomen reaches the xiphoid, making a tunnel (Fig. 22.8).

FIG. 22.8 The undermined tunnel in the upper abdomen.

The width of this tunnel is variable, but always detaches only about 2 cm laterally to the medial border of rectus abdominis muscle

This “economic” undermining preserves the perforating vessels coming from the deep superior and inferior epigastric arteries. The plication will be made using absorbable sutures in two planes; the first one, simple stitches with 2–0 nylon and the other a running suture with 3–0 nylon.

The umbilical flap will be fixed in the aponeurosis in a triangular superior base shape (Fig. 22.9).

FIG. 22.9 The umbilical triangular superior base shape.

At this point, with the patient in a semi Fowler position, the flap is gently moved to the pubis, checking the flap tension. If there is some tension, the division with cannulas will be repeated without suction.

The flap will be sutured to the inferior border with temporary stitches and the incision for a new umbilical placement will be pointed using Pitanguy’s demarcator (Fig. 22.10).

FIG. 22.10 Pitanguy’s demarcator.

Baroudi’s quilting sutures are performed with absorbable sutures, fixing the entire flap to the aponeurosis (Fig. 22.11).

FIG. 22.11 Quilting sutures fix the flap to the aponeurosis.

Finally the umbilical skin, already fixed to the aponeurosis, is sutured to the abdominal skin.

Baroudi’s quilting sutures are finished, the remaining skin will be resected or not, depending on the level of tension (Fig. 22.12).

FIG. 22.12 Resecting the remaining skin and fat after the final position of the flap.

The flap will be sutured in three anatomical levels, finishing with a nonabsorbable intracutaneous tread, which stays in place for 20 or 30 days (Fig. 22.13). The use of a vacuum drain is routine although the liquid volume has been negligible. The sutures are covered with adhesive strips, the umbilical scar is filled with gauze and special foam is applied under a close fitting compression garment (Fig. 22.14).

FIG. 22.13 The intracutaneous suture and the final view of the surgery.

FIG. 22.14 Postoperative garment, special foam and compression stockings.

Postoperative Care

The patient stays in hospital about 24 hours and is mobilized the next morning; the wearing of compression stockings is recommended.

The semicurved position is recommended until the 8th day, and a light diet is used during this period.

A lymphatic drainage massage associated with ultrasound therapy in the manipulated area reduces the recovery time.

The outcomes have been extremely satisfactory, achieving harmonious body contours affording patients self-esteem and comfort.

Complications and Their Management

Epitheliolysis of the scar, granulomas in the late postoperative period, scar hypertrophy, hematomas, necrosis, infections, and unsatisfactory results are possible complications. These are rare in our practice. Two seromas were observed in our cases in spite of the quilting sutures used.

Comments and Conclusion

The resection of the flap as a block permits a fast, more precise and comfortable surgery, and nowadays is routine in our practice. A previous precise diagnosis, based on classification suggested by distinguished authors, offers surgeons the best surgical option to be selected.

Liposuction enhances the body contour and is a safe procedure, to be used in the vast majority of cases. The reduced incidence of reported complications is a consequence of the drastic reduction of the undermined area, preserving the majority of perforating vessels coming from the deep abdominal wall. Fixing the flap to the aponeurosis contributes to the avoidance of seroma formation.

The use of adequate postoperative garments, special foam, and compression stockings, together with lymphatic drainage and ultrasound therapy, makes the recovery time fast and comfortable. See Figs 22.15–22.20 for outcomes.

FIG. 22.15 Preoperative frontal view.

FIG. 22.16 Preoperative lateral view.

FIG. 22.17 Preoperative oblique view.

FIG. 22.18 Postoperative frontal view (28th day after the surgery).

FIG. 22.19 Postoperative lateral view (28th day after the surgery).

FIG. 22.20 Postoperative oblique view (28th day after the surgery).