Modifications in Lipoabdominoplasty: An Update

MODIFICATIONS IN LIPOABDOMINOPLASTY:  AN UPDATE

 

Goals/Purpose:

Lipoabdominoplasty published in 2001 and 2006 demonstrated a safe approach combining abdominoplasty and liposuction, based on lipoundermining, selective undermining and Scarpa's fascia preservation. 

We have been using this technique since 2000 and, during this period, we could observe important key points that allowed us to overcome difficulties, as well as evolve and improve the technique.

Isolated selective undermining can restrain flap movement to the pubic area, resulting in scar tension, higher scar positioning and mons pubis unaesthetic expansion.

Complete Scarpa's fascia preservation in the lower abdomen can result in  prolonged edema and permanent bulging due to the  “sandwich” effect caused by the double Scarpa's fascia (flap Scarpa's fascia that moves over the preserved lower abdomen Scarpa's fascia).

The purpose of this paper is to present the technique's modifications and evolution, solutions to the difficulties, as well as the approach and methods to improve the results that started in 2007 and has been systematized since 2008. Always maintaining the philosophy of safety and anatomic structures preservation proposed at the beginning.

 

Methods/Technique:

We studied 605 patients from 2007 to 2011, aged from 24 to 69 years old, 80% being female. Flanks liposuction was performed in all patients and combined body contouring liposuction was performed in 40%.

 

Preoperative Evaluation

The whole abdomen was evaluated: skin, musculature, presence of scars and hernias, including fat distribution in the upper abdomen, hypochondrium and lateral region.

Technique

We mark the adipose tissue disposition to be liposuctioned from the hypochondrium to the pubis, flanks and the infraumbilical skin resection fuse.

After the pinch test, we perform a dynamic marking of the skin excess with the patient standing. And adjust it with the patient sitting and in dorsal decubitus, in order to correct the skin excess in all positions.

Saline solution and epinephrine (1:500.000 UI) are infiltrated. Power-assisted liposuction (PAL) is performed with 3.5, 4, 5 cannulas at the upper abdomen and hypochondrium, reaching the medial and superficial portions of the deep layer and the deep and medial portions of the subcutaneous superficial layer. Liposuction is intensified at the transition of the rectus and oblique abdominis muscles. With the patient positioned in lateral decubitus, flanks liposuction is performed.

In the lower abdomen, the resection is performed to remove the Scarpa's fascia, preserving part of the deep fat, where the lymphatic system is located.

The selective undermining of the diastasis region along the medial margins of the recto abdominal muscles preserves the perforating vessels. We have mildly amplified the undermining at the umbilical region to facilitate the flap movement when necessary. Medial line infraumbilical lipectomy is performed for the aponeurosis exposure, connecting it to the upper undermining for the complete muscular diastasis plication.

Mons lipolifting with fixation is performed in a way that the scar is positioned 6 to 7 cm from the vaginal introitus, preventing its expansion and providing a good transition from the abdomen to the pubis.

The excess skin resection is performed and the navel is transposed using omphaloplasty (flap technique).

 

Results/Complications:

 

The mild selective undermining amplification at the umbilical level does not affect flap viability, because the superior epigastric artery is not ligated, and most of the perforating arteries are preserved based on the anatomic study of the mapping of the vascular territories of the abdomen published by J. Brian Boyd (1984). This amplification has the advantage of reducing the tension and maintaining a lower scar in the pubic region. It also prevents upper abdomen bulging in patients who present major diastasis, problem found in these patients when only the selective undermining was performed.

In the lipoabdominoplasty technique published in 2001, the Scarpa's fascia preservation in the lower abdomen was preconized. After the flap movement, containing deep fat, Scarpa's fascia and superficial fat, its accommodation over the preserved Scarpa's fascia generated a double fascia (“sandwich” effect) , causing prolonged edema and permanent bulging.

The Scarpa's fascia has no function; therefore there is no reason for it to be preserved in the lower abdomen. The lymphatic vessels are located over the recto abdominis aponeurosis, overlaid by the deep fat; therefore we have changed the resection preserving the deep fat partially. Through this approach, we could maintain the same low incidence of seroma.

The modifications mentioned above have not altered the complication rate observed in our previously published works: epitheliosis (1.5%), seroma (1.5%), hematoma (0.3%), and epidermolise (0.1%) and necrosis (0%).

 

 

 

Conclusion:

After seven years performing lipoabdominoplasty (published in 2001), from 2000 to 2006, we have made some modifications based on anatomic studies of the lower abdomen lymphatic system and mapping of the abdominal perforators.  These modifications have made it easy to perform the technique and improved the results. However, we have maintained the philosophy of an approach that proposes a safe combination of liposuction and traditional abdominoplasty.

Cases