Full lipoabdominoplasty

Abstract

Introduction Traditional abdominoplasty has been performed by panniculus resection of the inferior segment of the abdomen after wide undermining since all perforator vessels are cut. Transposition with reimplantation of the umbilicus is a matter of routine procedure. So far liposuction is a useful technique for aesthetic treatment of the abdomen to reshape the body removing only localized adiposities. For these reasons, the indication of isolated fat suction is restricting to patients presenting only excess of adipose tissue on the anterior abdominal wall. When patients present associated deformities, the adequate treatment requires combined procedure which may be performed simultaneously. But very high incidence of local and systemic complications used to occur, such as seroma formation, hematoma, hemorrhage during and after surgery, skin slough, panniculus necrosis and also thromboembolism. No longer had myself become so disappointed with all complications in 1988, I took a radical decision to not perform anymore such combined operation. For 10 years, I devoted much time of perseverance research to my previous anatomic studies on cadaver. Afterward I concluded that it would be possible to combine liposuction with traditional abdominoplasty since the perforator vessels are not cut during surgery. So, in 1998, I concluded my anatomical research and started to perform some abdominoplasty operations as well as medial thigh lifting following the same surgical principles. Therefore I presented and published my combined approach of fat suction with conventional abdominoplasty, without cutting the perforator vessels in order to preserve and maintain adequate blood supply to the remaining abdominal panniculus. The combined procedure minimizes the high incidence of local and systemic complications during and after operation. My method may be employed with smooth and harmonious results on the abdomen and further applications. Although the abdomen is a region that patients concern, but the entire body should be well evaluated. Several abnormalities on the abdominal wall such as unaesthetic and retracted scars, cutaneous stria, skin flaccidity, weakness and diastasis of the musculoaponeurosis, and herniations require adequate aesthetic and reconstructive treatment. Therefore abdominoplasty is a combined procedure since the disorder of the external appearance of the abdomen in association with anatomical structures should be treated properly to achieve the harmony of the body contour. Patient with overweight should not undergo abdominoplasty. Even psychologically unstable persons, expecting too much about the results and scars, demonstrate unrealistic postoperative results and other situations are not good candidates for operation. Surgical demarcation is a useful step which may be done on the day before the operation with the patient in standing position in front of the mirrors in order to follow the surgeon's drawings. Two areas must be well demarcated for adequate orientation during operation: A. The area for skin resection which is the whole segment that is below the umbilicus on the suprapubic region. B. The area for liposuction on the abdominal wall on the lateral and posterior aspects of the torso as well. C. All areas for liposuction must be well demarcated all around the body with emphasis on some asymmetric regions where more volume of fat will be aspirated. Abdominoplasty may be performed under epidural or general anesthesia under the care of the anesthetist. Local infiltration is done according to surgical planning on two levels: deep infiltration on the supramuscular plan on all regions for liposuction and superficial and deep infiltration inside the panniculus on the area for skin resection. The solution is 1000 mL of sodium + 2 mg of epinephrine (1/1000), which is 2/1.000.000. Liposuction is performed on two different levels. The first one is done in the full thickness of the panniculus on the area where skin resection will be performed with preservation of perforator vessels and connective tissue. The second level of liposuction is performed on all regions of the remaining abdominal panniculus with its normal cutaneous covering. Therefore, all fat tissue of the lamellar layer, which is below the fascia superficialis, is aspirated. Afterward, cutaneous incisions on the umbilicus are done following the star-shaped drawing inside the umbilical region to create a natural and aesthetic area after abdominoplasty. Full-thickness skin resection is performed on the suprapubic region following previous demarcations. Since the perforator vessels are not damaged, there is no bleeding during or after skin resection. Although the abdominal panniculus is not undermined, it is possible to perform plication of the abdominal aponeurotic structures from the xiphoid process to the pubis. Following the operation, the umbilical site is exteriorized on the abdominal flap which is done by pulling downward the remaining abdominal flap. Closing of the surgical wound is performed with isolated stitches in three layers. The raw areas preserve the connective tissue, the fascia superficialis, and all perforator vessels. It is an important step to suture the fascia superficialis from the border of the upper panniculus flap to the fascia superficialis on the lower border, followed by running intradermal suture done using absorbent material. On top of it, adhesive tapes are used for covering the surgical wound. Bandaging is done using a garment and no drainage is necessary since there is no bleeding during or after operation. According to the descriptions above, no vessels are damaged during the operation because it is performed as a closed vascular system.