Lipoabdominoplasty: liposuction with reduced undermining and traditional abdominal skin flap resection

Microsurgical Breast Reconstruction can be Performed Safely in Patients with Obesity

BACKGROUND

 Numerous studies have shown that obesity is a risk factor for postoperative complications following breast reconstruction. Hence, obesity has traditionally been considered a relative contraindication to microsurgical breast reconstruction. In this study, we investigated the impact of obesity on outcomes following microsurgical breast reconstruction.

METHODS

 A retrospective analysis of 200 consecutive patients who underwent microsurgical breast reconstruction with free abdominal flaps was performed. Subjects were divided into Nonobese (body mass index [BMI] < 30 kg/m2) and Obese (BMI ≥ 30 kg/m2) cohorts. Univariate and multivariate analyses were performed to evaluate differences in patient characteristics, complication rates, and efficiency metrics between the two groups.

RESULTS

 Of the 200 subjects included in the study, 128 were Nonobese, 72 were Obese. The prevalence of diabetes (3.9 vs. 16.9%, p = 0.002) and hypertension (14.7 vs. 39.4%, p < 0.001) were significantly greater in the Obese cohort. Among unilateral reconstructions, postoperative length of stay (LOS) was longer among Obese patients (3.1 vs. 3.6 days, p = 0.016). Seroma occurred more frequently in Obese patients following bilateral reconstruction (5.7 vs. 0.0%, p = 0.047). Otherwise, there were no significant differences in complication rates between the groups. On multivariate analysis, BMI was not independently associated with complications, LOS, or operative time.

CONCLUSION

 The improvements in clinical and patient-reported outcomes that have been associated with postmastectomy breast reconstruction do not exclude obese women. This study indicates that microsurgical breast reconstruction can be performed safely and efficiently in patients with obesity.

Exploring the use, outcomes, barriers, and facilitators of prehabilitation and rehabilitation in abdominoplasty surgeries: A scoping review

OBJECTIVE

This review aimed to map the literature on prehabilitation and rehabilitation in adults undergoing abdominoplasty, identifying gaps and areas for future research.

METHODS

The review followed the PRISMA guidelines for Scoping Reviews and was registered on the Open Science Framework platform (https://osf.io/m4k5s). The search for studies was conducted in the following electronic databases: PubMed, Scopus, EMBASE, Web of Science, PEDro, LILACS, The Cochrane Library, and CINAHL. The search strategy used the PCC approach: P: abdominoplasty surgery; C: prehabilitation or rehabilitation interventions; C: patient-related outcomes, hospital outcomes, safety outcomes, mortality, intervention description, feasibility of intervention selection and delivery, reported barriers and facilitators, and various study designs.

RESULTS

Among the 2444 references examined, 12 studies met the inclusion criteria, predominantly consisting of small clinical trials. The most frequent surgical approach was combined abdominoplasty, present in 58.3% of the studies. Physiotherapists integrated with the prehabilitation and/or rehabilitation team in 33.3% of cases. Notably, 75% of the studies focused on postoperative rehabilitation, with lymphatic drainage techniques being the most common intervention, appearing in 41.7% of the studies. 33.3% of the studies mentioned respiratory complications such as atelectasis, pneumonia, and respiratory failure as postoperative occurrences. Some gaps were identified, including insufficiently detailed reports of interventions and diversity in the type and timing of outcome measurements.

CONCLUSIONS

This review highlights the lack of data on the effects of prehabilitation and rehabilitation in patients undergoing abdominoplasty, due to the diversity of measures and variable assessment times, emphasizing the need for standardization and multicenter studies to determine optimal interventions and their impacts.

Postabdominoplasty Scar Improvement after a Single Session with an Automated 1210-nm Laser

Abdominoplasty, one of the most commonly performed aesthetic procedures, aims at correcting excess abdominal skin and fat, but generates a long abdominal scar. The efficacy of an automated portative 1210-nm laser in improving the appearance of surgical scars has been previously demonstrated in a double-blind randomized controlled trial. The purpose of this work was to document the use of this laser in real-life practice.

Methods

Eighteen patients undergoing abdominoplasty and treated with the evaluated laser (UrgoTouch, Laboratoires Urgo; one single session immediately after the surgery) were included in this prospective, mono-center, observational study. Change in scar characteristics was assessed using the validated Observer Scar Assessment Scale, and the patients' and surgeon's satisfaction was rated using a four-point scale.

Results

The aesthetic outcome of the scars was very positive with a mean Observer Scar Assessment Scale score of 17.0 (SD 4.6) and 14.4 (SD 3.8) on the 6-60 point scale (60: the worst possible outcome) at 6 and 12 months, respectively. A high degree of satisfaction was also expressed by both surgeon and patients at 6 weeks, 6 months, and 12 months. No laser-related incident was reported during the study, including in patients with darker phototypes.

Conclusions

These findings seem to be consistent with previous clinical evidence on the use of this laser on fresh incisions. The high degree of satisfaction reported by both surgeon and patients seems to comfort the benefits of this procedure at short- and long-term and support the use of this laser in daily practice of plastic surgery.

TULUA Lipoabdominoplasty: Transversal Aponeurotic Plication, No Undermining, and Unrestricted Liposuction. A Multicenter Study of 845 Cases

BACKGROUND

TULUA (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar) is the acronym for a radically different lipoabdominoplasty, intended to add simplicity, improve vascular safety, and attain good results. Modifications are unrestricted liposuction, no flap detachment, massive transverse infraumbilical plication, umbilicus amputation, neoumbilicoplasty, diminished tension wound closure, and low transverse scar settlement. The objectives of this article are to describe the technique and analyze a multicenter experience.

METHODS

Sixty-eight plastic surgeons from 10 countries provided data for a retrospective review of 845 patients. Aesthetic results were scored by each surgeon using the Salles scale and analyzed in combination with complications to identify associations between patient and surgery characteristics.

RESULTS

Of the patients, 95.5 percent were female, 19.7 percent were obese, 35.6 percent had prior scars, 10.4 percent had undergone previous abdominoplasty, 6.5 percent were postbariatric, and 6.6 percent were smokers. One patient had a kidney transplant, and 16.5 percent had comorbidities. Surgery characteristics varied widely, being on average as follows: lipoaspirate, 2967 ml; resection, 1388 g; and surgical time, 3.9 hours; 46.5 percent were not hospitalized. Averaged results were 8.68 of 10 points, besides adequate positioning and proportion of scar and umbilicus, without epigastric compensatory bulging (4.97 of 6 points). Overall complications were 16.2 percent, mostly seroma (8.8 percent); vascular-related complications (i.e., necrosis, wound dehiscence, and infection) constituted 2.7 percent. There were no fatalities. The logistic regression model demonstrated that smoking and obesity duplicate the risk of complications; if age older than 60 years is added, the risk of complication increases seven to nine times. Reported indications were multiple; however, pathologic diastasis was excluded.

CONCLUSION

TULUA lipoabdominoplasty is a new reproducible procedure with good quantified results and an acceptable complication rate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

TULUA Lipoabdominoplasty: No Supraumbilical Elevation Combined With Transverse Infraumbilical Plication, Video Description, and Experience With 164 Patients

BACKGROUND

TULUA (transverse plication, undermining halted at umbilicus, liposuction [without restrictions], umbilicoplasty with a skin graft, and abdominoplasty with low transverse scar localization) is a fundamentally different lipoabdominoplasty technique intended to reduce the risk of vascular compromise, correct wall laxity through a unique plication, allow freedom in choosing the umbilical position, reduce tension on closure, and keep the final scar low.

OBJECTIVES

The objectives of this article were to describe the TULUA technique and its variations, delineate the indications and contraindications, show the expected results, and determine its safety profile.

METHODS

A series of 164 patients is presented. The technique's basic tenets were (1) infraumbilical wide transverse plication; (2) no undermining above the umbilicus; (3) unrestricted liposuction, including the supraumbilical tissues; (4) umbilical amputation and neoumbilicoplasty in the ideal position with a skin graft; and (5) low transverse scar placement. Complications were recorded and tabulated. Results were evaluated utilizing Salles' and the author's graded scales.

RESULTS

Scores averaged 9.4 out of 10 on the Salles' scale and 5.6 out of 6 on the author's scale, demonstrating adequate correction of the abdominal contour and the wall and skin laxity, with properly placed scars and umbilici, and without compensatory epigastric bulging. Overall, 20% of the patients experienced a complication: 9.7% experienced a delay in either the healing or graft take of the umbilicus, 0.6% developed skin necrosis, 0.6% experienced a wound dehiscence, 2.4% had an infection, and 4.9% developed a seroma.

CONCLUSIONS

The TULUA lipoabdominoplasty technique was found to improve abdominal wall laxity and aesthetics to a degree that is similar to traditional abdominoplasty, based on the evaluated parameters. The complications associated with the procedure are within the range of other abdominoplasty techniques, and the technique potentially has a reasonable safety profile with less risk of vascular compromise.

LEVEL OF EVIDENCE: 4

Partial DIEP flap loss in a patient with history of abdominal liposuction

Classically, history of prior abdominal liposuction has been considered a relative contraindication for breast reconstruction using deep inferior epigastric perforator (DIEP) flap. The rationale for this is based on the fact that liposuction can possibly damage perforating vessels, which could compromise flap survival. However, multiple recently published reports have shown that imaging using CT angiography or colour Duplex ultrasonography could be used to accurately assess the adequacy of the perforating vessels before DIEP flap harvest. This contraindication is currently being reconsidered in the scientific literature. We present a case of partial DIEP flap loss in a patient with history of abdominal liposuction that happened despite preoperative identification of adequate perforators using CT angiography and intraoperative clear evidence of patent anastomoses. This occurrence reopens in our view the question of whether DIEP flaps can be safely performed on patients with a history of abdominal liposuction, even in the presence of adequate perforators on regular CT angiography or Doppler ultrasonography. While abdominal liposuction may not injure perforating vessels, its detrimental effect on linking micro-vessels within the flap cannot be fully evaluated using CT Angiography. Therefore, the use of another imaging modality, such as the indocyanine green laser angiography, to assess perfusion before DIEP flap harvesting is performed and could be considered in patients with history of abdominal liposuction.

Sub-Scarpa's Lipectomy in Abdominoplasty: An Analysis of Risks and Rewards in 723 Consecutive Patients

BACKGROUND

During the course of performing abdominoplasties, a plastic surgeon will encounter a certain body habitus characterized by a thick, tethered, and excessively redundant upper skin flap. Often these patients also demonstrate diffuse and substantial fascial laxity. One approach to this problem involves direct thinning and release of the flap by resection of the sub-Scarpa's fat pad. In theory, this resection should be safe from a flap perfusion standpoint. However, the safety of the sub-Scarpa's resection has not been completely documented.

OBJECTIVES

The author sought to assess the safety and efficacy of sub-Scarpa's lipectomy in abdominoplasty.

METHODS

A total 723 patients were retrospectively examined and divided into 2 groups: those with (Group B) and those without (Group A) a sub-Scarpa's lipectomy component to the abdominoplasty. Because of differences in the baseline characteristics between the 2 groups, data analysis was performed with a logistic regression model and with propensity score matching.

RESULTS

The sub-Scarpa's lipectomy technique allowed for substantial thinning of the flap: the average weight of the resected fat pad was 411 g. Wide undermining allowed for substantial fascial correction, and excellent results were obtainable even in challenging cases. The sub-Scarpa's lipectomy group did not demonstrate an increase in either minor (<5 cm2) or major (>5 cm2) flap necrosis. However, there was a statistically significant increase in fat necrosis and seroma formation in Group B compared with Group A. In both groups, an increasing body mass index was a risk factor for fat necrosis and major flap necrosis.

CONCLUSIONS

The implementation of a sub-Scarpa's lipectomy during abdominoplasty is a useful technique to consider for selected abdominoplasty candidates. The risks of minor and major flap loss do not seem to be increased compared to the standard abdominoplasty, but the risks of fat necrosis and seroma formation may be greater.

LEVEL OF EVIDENCE: 4

Medial Thigh Contouring in Massive Weight Loss: A Liposuction-Assisted Medial Thigh Lift

BACKGROUND

Thigh’s lifting can be associated with significant complications, if the medial thigh excess is removed en bloc. In this study, the liposuction-assisted medial thigh’s lift (LAMeT) procedure, outcomes and complications were assessed.

METHODS

Twenty four females between 25 and 61 years with grade 2 or 3 on Pittsburgh Rating Scale (PRS) treated with medial thigh’s reduction were enrolled. Medial thigh’s reduction was performed in three different procedures of vertical, horizontal and LAMeT. Vertical thigh’s lift with fascia suspension was conducted in 13 patients with grade 3 of ptosis on PRS; horizontal thigh’s lift with fascia suspension was undertaken in 3 patients with grade 2 on PRS; vertical and horizontal thigh’s lift considered as control group was described as excision-only group; and LAMeT was performed in 8 patients with grade 2 and 3 on PRS.

RESULTS

Complications were observed in 62.5% of patients who underwent vertical or horizontal thigh’s lift with fascia suspension and in 16.7% who experienced the LAMeT without fascia suspension. The most frequent complication was seroma. Hospital stay was significantly lower in the LAMeT.

CONCLUSION

Medial thigh’s lift is a safe and satisfying procedure because it provides aesthetic improvement in massive weight loss patients. The complication rate is higher when skin excess and laxity are removed en bloc, as the resection of excess tissue is poorly selective. The LAMeT preserves lymphatic and blood vessels and allows a more anatomical resection of the excess skin. Thus postoperative complications incidence is lower and the patient heals faster.

Revision Abdominoplasty with Truncal Liposculpting: A 10-Year Experience

INTRODUCTION

Abdominoplasty is one of the most popular body-contouring procedures. Despite its popularity, classic abdominoplasty is still associated with a significant rate of complaints from patients such as: fullness of flanks and epigastric areas, lack of a posterior lumbar curve, hanging skin over the incision line, and visible scars over the flanks and beyond underwear or swimming suit coverage. This study reviews the authors' experience in redo abdominoplasty when the patient is not or partially satisfied with the primary procedure.

PATIENTS AND METHODS

A total of 115 female and 32 male patients underwent revision abdominoplasty with truncal liposculpting between 2007 and 2016. The age distribution of patients ranged from 33 to 73 years, with a mean of 43.1 years. All the patients included in the study had undergone classic abdominoplasty in a different institution. Overall satisfaction with the body appearance after the combined procedure was rated on a scale of 1-5, where 1 is 'poor,' 2 is 'fair,' 3 is 'good,' 4 is 'very good,' and 5 is 'excellent.' The evaluation was made 12 months after the composite body-contouring procedure.

RESULTS

Four hundred to 1500 ml of fat were obtained with liposuction (mean 840 ml). The amount of clean, adipose tissue transplanted to the buttocks varied from 95 to 425 (mean 286 ml) and to the lower limbs from 75 to 270 ml (mean 195 ml). The stromal-enriched lipograft technique was used in all the cases to enrich the fat transplantation. There was no hematoma, infection or deep vein thrombosis. Seventy-five percent reported that their appearance after composite body contouring was 'very good' to 'excellent' (30% 'excellent' and 45% 'very good') and 20% responded that their appearance was 'good.' Only 5% of patients thought their appearance was less than good ('fair'). The average follow-up time for this group of patients has been 6.3 years (range 1-10 years).

CONCLUSION

Truncal liposculpting with modified abdominoplasty accomplishes very good aesthetic results in a single surgical procedure with a low rate of complications and high patient satisfaction in cases of revision abdominoplasties.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Abdominoplasty with Circumferential Liposuction: A Review of 1000 Consecutive Cases

BACKGROUND

The authors present the technique called "abdominoplasty with concurrent circumferential liposuction," where the whole trunk is addressed as a single aesthetic unit.

METHODS

Between January of 2008 and June of 2016, abdominoplasty with circumferential liposuction was performed in 1000 patients (984 women and 16 men) by the senior author. Patients had a mean body mass index of 27.5 kg/m (range, 18.1 to 34.5 5 kg/m). Liposuction was performed circumferentially and the abdominal flap was detached up to the costal margins. Simultaneous fat grafting was also performed if required. Outcomes and complications were documented.

RESULTS

Traditional abdominoplasty incisions were used in 359 patients, whereas extended incisions were used in 641 patients. The mean duration of follow-up was 27 months (range, 12 days to 61 months), and the mean duration of surgery was 154 minutes (range, 109 to 260 minutes). The mean amount of simultaneously aspired supernatant lipoaspirate was 1940 cc (range, 1700 to 4580 cc). Simultaneous gluteal fat grafting was performed in 34 percent. None of the patients had any skin necrosis. The most common complication was seroma (19 percent).

CONCLUSIONS

In abdominoplasty, the entire central body should be considered as a single unit. Circumferential widespread liposuction with standard undermining of the abdominal flap up to the costal margins is safe and yields superior aesthetic outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Arm Contouring After Massive Weight Loss: Liposuction-Assisted Brachioplasty Versus Standard Technique

Massive weight loss (MWL) brachioplasty is frequently requested for the improvement of the appearance and function of arms. Despite its diffusion, this procedure can be associated with significant complications. Liposuction-assisted brachioplasty (LAB) preserves the vascular, nervous, and lymphatic network and reduces the incidence of postoperative complications. This retrospective cohort study is aimed at analyzing two different modalities of arm contouring after MWL by evaluating the outcomes and complications. Of 31 patients (all females, average age 43.5 years), 20 were managed with standard brachioplasty represented by a swallowtail scar and monobloc resection and 11 with brachioplasty combined with aggressive liposuction. Evaluated parameters included age, body mass index, method of weight loss, and complications rate. No statistical analysis was used. Major postoperative complications (reoperation, bleeding, or thromboembolism) were not reported in both groups. The incidence of minor complications (wound separation, wound infection, and seroma) was globally 42%; the incidence of complications was significantly lower in the LAB group (9% vs. 60%). The incidence of hypertrophic scarring or keloid was higher in the control group (55% vs. 18%). Most patients were satisfied after surgery: in the LAB group, 81.8% of the patients expressed a high degree of satisfaction and 18.2% a good degree of satisfaction after 4 months of follow-up. In our experience, the LAB should be preferred in MWL patients because it has a lower rate of complications and a faster recovery than the standard technique. Proper execution requires considerable technical skill and experience.

Drainless Abdominoplasty Using Barbed Progressive Tension Sutures

We describe our current technique of drainless abdominoplasty using barbed progressive tension sutures. The perioperative management and detailed steps of procedure are outlined, including indications for concomitantly performing liposuction and repair of diastasis of the rectus abdominis muscles. This approach reliably improves abdominal contour, minimizes complications, and is straightforward to learn and perform.

Efficacy of Liposuction as a Delay Method for Improving Flap Survival

BACKGROUND

Flaps are often used in repairing tissue defects and partial or full flap loss is still an important morbidity cause. Several techniques have been tried to increase flap circulation but none of these could replace the delay technique. Our goal in this study is to show the efficacy of liposuction in delay of dorsal rat cutaneous flaps and improvement in flap survival.

METHODS

Twenty-four Wistar rats were used. The rats in group 1 received 9 × 3-sized caudally-based random pattern skin flaps. In group 2, liposuction was done under the tissue island spotted as the flap and after 14 days, standard flap surgery was done. In group 3, surgical delay was done and after 14 days, standard flap surgery was done. In group 4, liposuction was done under the tissue island spotted as the flap and standard flap surgery was done right after the liposuction.

RESULTS

The rate of necrotic tissue in group 3 (surgical delay; mean % 13.7) was less than the rate in group 2 (liposuction delay; mean % 15.1), although the difference was not statistically significant. The necrosis rates in group 3 (surgical delay) and group 2 (liposuction delay) were less than the rates in both group 1 (only flap; mean % 41.5) and group 4 (liposuction flap; mean % 40.0) and this difference was statistically significant (p < 0.0001).

CONCLUSION

Liposuction can be an alternative to surgical delay as a less invasive method in the clinic.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Liposuction Preserves the Morphological Integrity of the Microvascular Network: Flow Cytometry and Confocal Microscopy Evidence in a Controlled Study

BACKGROUND

Liposuction is a very popular technique in plastic surgery that allows for the taking adipose tissue (AT) on large surfaces with little risk of morbidity. Although liposuction was previously shown to preserve large perforator vessels, little is known about the effects of liposuction on the microvasculature network.

OBJECTIVES

The aim of this study was to analyze the effect of liposuction on the preservation of microvessels at tissue and cellular levels by flow cytometry and confocal microscopy following abdominoplasty procedure.

METHODS

Percentage of endothelial cells in AT from liposuction and en bloc AT was determined by multicolor flow cytometry. Moreover, vessel density and adipocyte content were analyzed in situ in 3 different types of AT (en bloc, from liposuction, and residual AT after liposuction) by confocal microscopy.

RESULTS

Flow cytometric analysis showed that en bloc AT contained 30.6% ± 12.9% and AT from liposuction 21.6% ± 9.9% of endothelial cells (CD31(pos)/CD45(neg)/CD235a(neg)/CD11b(neg)) (P = .009). Moreover, analysis of paired AT from the same patients (n = 5) confirmed a lower percentage of endothelial cells in AT from liposuction compared to en bloc AT (17.7% ± 4.5% vs 21.9% ± 3.3%, P = .031). Likewise, confocal microscopy showed that en bloc AT contained 8.2% ± 6.3%, AT from liposuction only 1.6% ± 1.0% (P < .0001), and AT after liposuction 8.9% ± 4.1% (P = .111) of CD31(pos) vessels. Conversely, adipocyte content was 39.5% ± 14.5% in the en bloc AT, 45% ± 18.4% in AT from liposuction (P = .390), and 18.8 ± 14.8% in AT after liposuction (P = .011).

CONCLUSIONS

For the first time, we demonstrate that liposuction preserves the microvascular network. Indeed, a low percentage of endothelial cells was found in AT from liposuction and we confirm the persistence of microvessels in the tissue after liposuction.

The no-drain, no-quilt abdominoplasty: a single-surgeon series of 271 patients

BACKGROUND

Recent innovations in abdominoplasty include progressive tension "quilting" sutures or Scarpa fascia preservation to limit the risk of seromas and hematomas. No-drain abdominoplasty with progressive tension sutures has been well documented. The authors describe outcomes in patients undergoing abdominoplasty with a modified surgical technique (including sub-Scarpa fascia fat preservation) and no use of drains or progressive tension sutures-the "no-drain, no-quilt" abdominoplasty.

METHODS

A retrospective, single-surgeon (A.A.Q.), single-site analysis of all abdominoplasty patients from 2003 to 2012 was performed. Data were extracted from paper case notes. All patients underwent surgery carried out under general anesthesia. The operative technique and postoperative regimen are described.

RESULTS

Two hundred seventy-one patients were identified over the 10-year period. Patients had a mean age of 45 years and mean body mass index of 27, and 98 percent were women. Concomitant abdominal liposuction was undertaken in 61 percent of all patients (165 of 271). Twenty-one patients (7.7 percent) had a seroma and five patients (1.8 percent) had a hematoma. Seven patients (2.6 percent) required a return to the operating room to manage complications, and 24 (8.9 percent) required elective revision. Patients were admitted for an average of 1.7 days, and mean follow-up was 6.2 months.

CONCLUSIONS

Abdominoplasty can be performed safely without drains or quilting sutures/progressive tension sutures. Benefits are discussed in terms of the potential for reduced intraoperative time (compared with progressive tension sutures), and reduced patient discomfort and inpatient stay (compared with drain use). The authors demonstrate low complication and elective revision rates in their series.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Evaluation of abdominal cutaneous sensibility following abdominoplasty

BACKGROUND

Cutaneous hypesthesia is an undesirable postoperative outcome following abdominoplasty. The purpose of this study was to evaluate postabdominoplasty cutaneous sensibility using clinical, quantitative, and reproducible methods.

METHODS

Thirty patients who underwent abdominoplasty were divided into three groups: 0 to 12 months (short-term follow-up), 12 to 24 months (intermediate-term follow-up), and greater than 24 months (long-term follow-up) following abdominoplasty. Abdominal skin was divided into 12 areas, and superficial tactile sensibility was assessed subjectively using a patient questionnaire and objectively using Semmes-Weinstein monofilaments. Statistical analysis was performed using the t test, with significance defined as p ≤ 0.05.

RESULTS

Seventeen patients (56.7 percent) subjectively reported the presence of any abdominal cutaneous sensibility change postoperatively. Of those, 82.4 percent reported indifference toward this outcome. The greatest degree of objective sensibility loss was noted in area 8 (infraumbilical), followed by areas 5 (supraumbilical) and 11 (midline infraincisional). In these areas, there were statistically significant decreases in the average cutaneous pressure thresholds between the short-term and intermediate-term follow-up groups, the intermediate-term and long-term follow-up groups, and the short-term and long-term follow-up groups.

CONCLUSIONS

Postabdominoplasty cutaneous sensibility losses improve over time. These findings may enable plastic surgeons to better inform their patients regarding the risk of sensibility loss and the longitudinal outcome of such changes postoperatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Defining the lymphatic system of the anterior abdominal wall: an anatomical study

BACKGROUND

Studies describing recent abdominoplasty modifications have reported a decreased incidence of seroma, attributed to preservation of abdominal lymphatics. However, there are limited anatomical data to support this hypothesis. The authors sought to characterize the lymphatic architecture of the abdominal wall and provide a conceptual basis for further refinement of abdominoplasty techniques.

METHODS

Fifteen tissue samples from five patients undergoing abdominoplasty were sectioned and analyzed. Slides were stained with hematoxylin and eosin, CD31, and D2-40 and assessed by a pathologist and a plastic surgeon for the presence and number of lymphatics. Results were reported as mean percentage of lymphatic-specific antibody per analyzed area.

RESULTS

Lymphatic vessels were observed in the dermis, superficial fascia, and loose areolar tissue but not in deep or superficial fat. The highest concentration was in the dermis (mean, 82.6 percent; range, 69 to 89.2 percent). The Scarpa fascia contained 9.4 percent of lymphatics (range, 7.0 to 11.4 percent), whereas the loose areolar tissue at the specimen base contained an average of 7.9 percent (range, 2.6 to 19.5 percent). These lymphatics were consistently located in the deepest third, with the Scarpa fascia lying an average of 34 percent of the total tissue thickness above muscle fascia. Lymphatic prevalence did not increase in specimens near the superficial epigastric vessels.

CONCLUSIONS

Abdominoplasty flap lymphatics are most common in the dermis, with a significant proportion (approximately 17 percent) also appearing near fascial layers. This confirms the presence of deep lymphatic channels that could potentially be preserved during abdominoplasty or lipoabdominoplasty.

Comparison of Limited-Undermining Lipoabdominoplasty and Traditional Abdominoplasty Using Laser Fluorescence Imaging

BACKGROUND

Body contouring that involves abdominoplasty and/or liposuction is a common cosmetic surgery procedure. Although single-staged lipoabdominoplasty has gained popularity, safety concerns remain.

OBJECTIVES

The authors compared abdominal flap perfusion and overall complication rates for traditional abdominoplasty and limited-undermining lipoabdominoplasty.

METHODS

Eighteen abdominoplasty patients were evaluated in a prospective study. All patients were nonsmokers and lacked major comorbidities. The control group (n = 9) underwent traditional abdominoplasty with wide undermining. The study group (n = 9) underwent abdominoplasty with limited undermining as well as liposuction of the abdominal flap. The groups were similar with respect to age and body mass index. Patients received follow-up for an average of 97 days. Fluorescence imaging was utilized for perfusion studies. Results and complications were documented, and statistical significance was ascertained via the Student t test.

RESULTS

Neither group had major complications or revisions. Minor complications included an exposed suture, resulting in delayed wound healing, in the control group. A patient in the study group had a small area of fat necrosis and a small seroma, neither of which required further treatment. No significant difference in abdominal flap perfusion was found between the control (57%) and study (50%) groups based on fluorescence levels relative to a designated baseline reference marker.

CONCLUSIONS

Results of the study indicate that no significant differences exist between the 2 operations with respect to the rates of abdominal flap perfusion or complications.

LEVEL OF EVIDENCE

3.

Minimising complications in abdominoplasty: An approach based on the root cause analysis and focused preventive steps

Significant complications still occur after abdominoplasty, the rate varies widely in different series. This variation suggests that there is a lot of scope for improvement. This paper reviews the various complications and also the technical improvements reported in the last 20 years. The root cause of each complication is analysed and preventive steps are suggested based on the literature and the author's own personal series with very low complication rates. Proper case selection, risk stratified prophylaxis of thromboembolism, initial synchronous liposuction, flap elevation at the Scarpa fascia level, discontinuous incremental flap dissection, vascular preservation and obliteration of the sub-flap space by multiple sutures emerge as the strongest preventive factors. It is proposed that most of the complications of abdominoplasty are preventable and that it is possible to greatly enhance the aesthetic and safety profile of this surgery.

Outpatient lipoabdominoplasty: review of the literature and practical considerations for safe practice

BACKGROUND

Lipoabdominoplasty, popularized by Saldanha et al in 2001, is a powerful technique to contour the abdomen and flanks. It has not gained widespread use as concerns exist about increased complications related to wound healing and thromboembolism.

OBJECTIVES

The authors review the existing literature on lipoabdominoplasty and discuss their experiences with the technique in a retrospective case series.

METHODS

A literature search of PubMed/MEDLINE using the search terms lipoabdominoplasty and abdominoplasty was performed by 2 independent investigators. The charts of 85 consecutive patients who underwent lipoabdominoplasty between February 2007 and July 2012 were reviewed.

RESULTS

A combined 1316 lipoabdominoplasty patients had results reported in the literature. Of these patients, 21 of 1316 (1.6%) developed seroma, 5 of 1032 (0.5%) experienced hematoma, 6 of 1032 (0.6%) experienced venous thromboembolism, and 3 of 1032 (0.3%) developed pulmonary embolism. In our case series, all patients were women with an average age of 48 years (range, 27-70 years), average body mass index of 25.2 (17.7-35.5), average follow-up of 8 months (range, 1-54 months), average lipoaspirate of 1605 mL (range, 150-5350 mL), and average weight of resected tissue of 1039 g (range, 128-4838 g). The average operative time was 225 minutes (range, 88-435 minutes), and average time in recovery prior to discharge was 124 minutes (range, 33-270 minutes). Seroma occurred in 20 of 85 patients, 1 patient developed deep venous thrombosis (DVT), 1 patient developed cellulitis, and 1 patient developed an abscess.

CONCLUSION

Lipoabdominoplasty is a safe and effective procedure in appropriately selected patients. Performing the procedure in an outpatient setting requires attention to multiple factors in the perioperative period to ensure safe patient outcomes. Larger prospective studies should be performed to evaluate best practices regarding rare complications such as DVT or pulmonary embolism.

Tension Suture Technique Combined with Lidocain-Adrenalin-Saline-Infiltration Decreases Complications in Abdominoplasty

Backgrounds and Aims:

Due to growing interest into body contouring has abdominoplasty become one of the most common aesthetic operations. New techniques have appeared to reduce the relatively high incidence of complications in abdominplasty. One technique is the tension suture technique, which can be combined with lidocain-adrenalin-saline-infiltration. Our aim was to analyse the results of this combined technique.

Material and Methods:

This retrospective study consisted of 95 women operated on in a private hospital by one senior plastic surgeon between years 2004 and 2009. Sixty patients had other operations in addition to abdominoplasty: 49 liposuctions, six breast reductions or mastopexies, three umbilical hernioplasties, one brachioplasty, one partial excision of labias, and one blepharoplasty.

Results and Conclusions:

The operative time was 82 minutes ranging from 45 to 173 minutes. Peroperative bleeding was a mean of 196 ml in abdominoplasty only and 254 ml when combined with additional operation. Patients did not have any major complications and the total incidence of minor — not clinically significant — complications was 12.6%. Obesity, smoking, comorbidities, previous operations on belly area or additional operations did not affect the complication rates. Our study supports the view that the tension suture technique combined with lidocain-adrenalin-saline-infiltration decrease the formation of seroma and wound complications in abdominoplasty. Lidocain-adrenalin-saline-infiltration also fastens and eases the operation without increasing the risk of bleeding in experienced hands.

Lipoabdominoplasty: An exponential advantage for a consistently safe and aesthetic outcome

Background:

Extensive liposuction along with limited dissection of abdominal flaps is slowly emerging as a well proven advantageous method over standard abdominoplasty.

Materials and Methods:

A retrospective study analyzed 146 patients managed for the abdominal contour deformities from March 2004 to February 2010. A simple method to project the post operative outcome by rotation of a supine lateral photograph to upright posture in 46 patients prospectively has succeeded in projecting a predictable result. All patients were encouraged to practice chest physiotherapy in ‘tummy tuck’ position during the preoperative counseling. Aggressive liposuction of entire upper abdomen, a limited dissection in the midline, plication of diastasis of rectus whenever indicated, panniculectomy and neoumblicoplasty were done in all patients.

Results:

The patients had a mean age of 43, youngest being 29 and oldest 72 years. Majority were of normal weight (94%). Twelve were morbidly obese; 57 patients had undergone previous abdominal surgeries; 49 patients had associated hernias. Lipoabdominoplasty yielded a satisfactory result in 110 (94%) patients. The postoperative patient had a definitely less heavy harmonious abdomen with improved waistline. The complications were more with higher BMI, fat thickness of more than 7 cm and prolonged operating time when other procedures were combined.

Conclusions:

Extensive liposuction combined with limited dissection method applied to all abdominoplasty patients yielded consistently safe, reliable and predictable aesthetic results with less complications and faster recovery. The simple photographic manipulation has helped project the postoperative outcome reliably. The preoperative chest physiotherapy in tummytuck position helped prevent chest complications.

Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases

BACKGROUND

Although abdominoplasty and other body-contouring procedures are being performed more frequently, the incidence of seroma and other complications has remained relatively unchanged. In 2000, a small retrospective series introduced progressive tension sutures (PTS) in abdominoplasty to reduce seroma without the use of drains.

OBJECTIVES

The authors review the PTS technique and their experience with the procedure.

METHODS

A retrospective chart review of 597 consecutive abdominoplasty patients treated over 12 years was performed. Collected data included surgical setting, concomitant procedures, and complications.

RESULTS

Of the 597 abdominoplasties, 52.4% were performed in the hospital and 47.6% in an American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)-accredited facility. In 63.7% of cases, abdominoplasty was combined with another procedure(s). Liposuction was performed on the abdominoplasty flap or an adjacent area to the abdominoplasty dissection in 67% of patients. The average amount fat aspirate from these areas was 953 mL. No drains were placed. The rate of local complications was 4.2%; all but one of these complications (seroma; 0.1%) were minor. There were no systemic complications related to PTS and no venous thromboembolisms.

CONCLUSIONS

PTS are an adjunct to abdominoplasty that can minimize seroma and potentially decrease other local complications. They provide secure fixation of the flap to eliminate motion and broadly transfer tension to the superficial fascial system. Drains can safely be eliminated from abdominoplasty, even when liposuction is performed. Systemic complications may be avoided and patient recovery expedited.

Seroma in lipoabdominoplasty and abdominoplasty: a comparative study using ultrasound

BACKGROUND

Abdominoplasty is one of the most frequently performed cosmetic procedures, and its combination with liposuction has become more common. Seroma is one of the most common complications in abdominoplasty. The aim of this study was to compare the rate of seroma formation in patients who underwent either abdominoplasty with or without the use of quilting sutures or lipoabdominoplasty.

METHODS

Fifty-eight female patients were divided into three groups and underwent one of the following procedures: group A (n=21), abdominoplasty without quilting sutures; group B (n=17), abdominoplasty with quilting sutures; and group C (n=20), lipoabdominoplasty. To investigate seroma formation, abdominal ultrasound was performed in five regions of the abdominal wall (epigastrium, umbilical, hypogastrium, right iliac fossa, and left iliac fossa) at two postoperative periods (P1, between postoperative days 11 and 14; and P2, between postoperative days 18 and 21).

RESULTS

The rate of seroma formation at both P1 and P2 was significantly higher in group A. It was observed that in group A at P1, the regions of right iliac fossa and left iliac fossa developed larger fluid collections. In group B, there were no significant differences with respect to fluid collections among the five study regions at both P1 and P2. In group C, there were significantly larger fluid collections in the hypogastrium region at P1 and in the umbilical and hypogastrium regions at P2.

CONCLUSION

Abdominoplasty with quilting sutures and lipoabdominoplasty are effective techniques for the prevention of seromas compared with abdominoplasty without quilting sutures.

SAFE circumferential liposuction with abdominoplasty

The SAFELipo technique allows for safe, consistent liposuction that does not damage flap blood supply and is easily taught to, and reproducible by, other surgeons. The fat separation used in the SAFELipo technique is performed without suction, which prevents suction avulsion injury to blood vessels by the cannula. Blood vessels then remain intact while free, separated fat is aspirated with small diameter cannulas.

Fibroadenoma in the bilateral accessory axillary breast

The authors treated a case of bilateral accessory axillary breast tissue. Excision with histologic examination confirmed the diagnosis of fibroadenoma. Treatment left the woman with incision scars (3.5 cm) in the axillary pyramid, a location often not seen during a patient's normal movements. Thus, despite a minor aesthetic incision, gives the advantage of complete histologic analysis was gained. Liposuction treatment was used in this case. The scar results were good.

Abdominoplasty: same classification and a new treatment concept 20 years later

Twenty years after my first paper on abdominoplasty, I find that the classification of abdominoplasty remains the same, but new operative techniques allow for accentuated improvement of the results through more liposuction, less undermining in tunnels, and reduction of skin traction. I use the same classification of diagnoses proposed in 1988, dividing the aesthetic alterations into five groups, and describe my experience during a 6-year period with 502 patients. I used vibroliposuction and performed plicature of the muscular aponeurosis through tunnels (where there are no important muscular perforator vessels), without damaging the vascularization. I propose an appropriate ratio of 1/1.5 between infra- and supraumbilical segments for uses in diagnosis and treatment, and the same ratio between the perimeter of the waist and the hips up to 1/1.618, known as the golden or divine proportion. According to this new treatment concept, vibroliposuction is used in GI. Vibroliposuction and suprapubic fusiform skin resection with an indigenous canoe shape are used in GII. Vibroliposuction, fusiform skin resection, and plicature of the external oblique muscle aponeurosis through two lateral tunnels are used in GIII. Vibroliposuction, fusiform skin resection, plicature of the rectus muscles aponeurosis through a medial tunnel, and detachment of the umbilicus aponeurotic implantation and reattachment in a maximum proportion of 1/1.6 between the infra- and supraumbilical skin segment with a bolster stitch are used in GIV. In GV, all the infraumbilical skin and a subcutaneous segment are removed after vibroliposuction, then a median tunnel from the umbilicus to the xiphoid process and a plicature of the rectus muscle aponeurosis from the pubis to the xiphoid process are made, and then the umbilicus is transposed. When necessary, a plicature of the oblique external muscle aponeurosis through two lateral tunnels is made resulting in three tunnels.

Composite body contouring

BACKGROUND

Aesthetic surgery of the thoracoabdominal region is one of the most frequently performed surgical procedures in plastic surgery. The combination of circumferential liposuction, autologous fat grafting of the buttocks and/or lower limbs, and the modified transverse abdominoplasty as an adjuvant procedure all done in a single surgical procedure is not very common. The authors present a prospective study of the surgical technique of composite body contouring, emphasizing the low rate of complications and the high overall patient satisfaction.

METHODS

A total of 64 consecutive female patients were operated on between January 2004 and January 2007. All the patients who were included in the study were candidates for a classical abdominoplasty. Posterior and lateral syringe-assisted liposuction combined with fat insertion into the buttocks and/or lower limbs was performed. Autologous fat grafting was done in the gluteal area for buttocks enhancement and in the lower limbs to correct contour deformities. Anterolateral liposuction with modified transverse abdominoplasty was done as an adjuvant procedure. Overall satisfaction with body appearance after composite body contouring was rated on a scale of 1-5.

RESULTS

From 1,500 to 4,600 ml of fat was obtained with liposuction (mean = 2,478 ml). Forty-five patients had fat grafting only to the buttocks area. Six patients had fat insertion into the lower limbs and 13 had fat injection into the buttocks and lower limbs. The amount of fat transplanted to the buttocks varied from 165 to 625 ml (mean = 346 ml) and to the lower limbs it varied from 75 to 270 ml (mean = 195 ml). Three patients (5%) suffered from early complications, including infection (3%) and hematoma formation (2%). Nine patients (14%) had late complications, including hypertophic scars (7.5%), dog ears (4.5%), and localized fat excess (2%). Nine patients (14%) underwent revision surgery. Sixty-three percent reported that their appearance after composite body contouring was "very good" (42%) or "excellent" (21%) and 27% responded that their appearance was "good." Only 10% thought their appearance was less than good, (7% "fair" and 3% "poor").The average follow-up time has been 3.2 years (range = 2-5 years).

CONCLUSION

Composite body contouring combines circumferential liposuction, fat grafting of the buttocks and lower limbs, and modified transverse abdominoplasty to accomplish very good aesthetic results in a single surgical procedure with a low rate of complications and high patient satisfaction.