|Year : 2015 | Volume
| Issue : 4 | Page : 845-851
Current trends of abdominoplasty
Tarek F Kishk1, Ahmed M Al-Barah1, YM El-Sheikh1, WB El-Khouly2, Abdulmoneim F Omran MSc 1
1 Department of Plastic Surgery, Faculty of Medicine, Menofia University, Menofia, Egypt
2 Department of Anatomy, Faculty of Medicine, Menofia University, Menofia, Egypt
|Date of Submission||20-Dec-2014|
|Date of Acceptance||23-Jan-2015|
|Date of Web Publication||12-Jan-2016|
Abdulmoneim F Omran
Plastic Surgery Department, Faculty of Medicine, Menofia University, Yassin Abd El-Ghaffar Street, Shepin El-Kom, Menofia 32511
Source of Support: None, Conflict of Interest: None
The aim of this study was to compare between traditional abdominoplasty and current techniques of abdominoplasty, follow complications associated with the new techniques of abdominoplasty, etiology and management, and minimize the amount of invasive surgery while maximizing the esthetic surgical results and patient benefits.
Patients and methods
A total of 49 patients (26 women and 23 men) between 20 and 60 years of age were studied in the period from October 2010 to October 2014 at the Plastic Surgery Department, Menofia University Hospitals. The patients were divided into three groups to compare between traditional abdominoplasty, lipoabdominoplasty with limited dissection superior to the umbilicus and lipoabdominoplasty with limited dissection superior to the umbilicus, preservation of scarpas fascia, and lowering incision line.
A total of 49 patients (26 women and 23 men) between 20 and 60 years of age were included in this study. The study was carried out on the basis of inclusion and exclusion criteria, and the choice of participants for each group was carried out randomly. There was a statistically significant difference between different groups in age, blood transfusion, and occurrence of complications (P < 0.05).
We recommend following the new technique of abdominoplasty, which includes lipoabdominoplasty, limited dissection superior to the umbilicus with preservation of scarp's fascia; it was found that fewer complications developed with the use of our new technique for lipoabdominoplasty compared with the use of the traditional technique, and there were greater patient benefits than observed previously.
Keywords: abdominoplasty, lipoabdominoplasty, scarpa′s fascia
|How to cite this article:|
Kishk TF, Al-Barah AM, El-Sheikh Y M, El-Khouly W B, Omran AF. Current trends of abdominoplasty. Menoufia Med J 2015;28:845-51
| Introduction|| |
Abdominoplasty is one of the most common esthetic surgical procedures. Patients request their doctors for abdominoplasty to eliminate abdominal wall laxity, excess skin, excess fat, striae, and diastasis of the rectus muscle  . The ideal abdominal esthetics include tight trunk, inguinal tissues with deep waist concavity, central tissues not as tight, with mild convexity of hypogastrium, mild concavity of epigastrium, midline epigastrium valley between rectus muscle bulges, and vertically oriented umbilicus  . According to the American Society for Aesthetic Plastic Surgery (ASAP)'s 2008 Cosmetic Surgery National Data Bank, the number of abdominoplasty procedures performed has increased by ~333% since 1997  .
The anterior abdominal wall is a hexagonal area defined superiorly by the costal margin and the xiphoid process; laterally by the mid axillary line; and inferiorly by the symphysis pubis, pubic tubercle, inguinal ligament, anterior superior iliac spine, and iliac crest  . The skin of the abdomen has areas of increased adherence to the underlying fascia (zones of adherence), such as the anterior superior iliac crest and the linea alba. The abdominal subcutaneous tissue is divided by two layers of fascia, the superficial Camper's fascia and the deep scarpa's fascia, a strong fibrous layer of connective tissue, which is continuous with the fascia lata of the thigh  . Layers of the anterior abdominal wall include skin, subcutaneous tissue, superficial fascia, deep fascia, muscle, extraperitoneal fascia, and peritoneum  .
In the history of abdominoplasty, flap undermining and techniques were developed that influenced the development of lipoabdominoplasty  .
Advancements were made in undermining of the abdominal flap from 1899 to 1957. Extensive undermining was standardized by Vernon  , Kelly  , and Callia  , facilitating transposition of the umbilicus. Pitanguy  supported the horizontal incision, just above the pubis, curving laterally downwards with intense undermining and transposition of the umbilicus. His major contribution was plication of the straight abdominal muscle without opening the aponeurosis  .
When combining abdominoplasty and suction-assisted liposuction (SAL) techniques, it is important to have an understanding of the blood supply to the abdomen. Huger  evaluated changes in the abdominal wall blood supply after full abdominoplasty and described three vascular zones: zone I consists of the mid abdomen and is mainly supplied by the deep epigastric arcade; zone II consists of branches from the external iliac artery providing supply for the lower abdomen; and zone III, which consists of the flanks and lateral abdomen, is supplied by the intercostal, subcostal, and lumbar arteries  .
Complications following abdominoplasty can occur at any time in patients despite adequate surgical techniques and patient care. These problems may cause patient discomfort, delay in recovery, further surgery, or threaten the patient's survival. The surgeon should be aware of the possible complications, their prevention, timely diagnosis, and treatment. The possible risks and complications must be discussed with the patient before surgery  .
| Patients and methods|| |
A total of 49 patients (26 women and 23 men) between 20 and 60 years of age were studied in the period from October 2010 to October 2014 at the Plastic Surgery Department, Menofia University Hospitals. The patients were divided into three groups:
- Group I: A total of 15 patients were included and traditional abdominoplasty with extensive dissection was carried out.
- Group II: A total of 15 patients were included and lipoabdominoplasty with limited dissection superior to the umbilicus was carried out.
- Group III: A total of 19 patients were included and lipoabdominoplasty with limited dissection superior to the umbilicus, preservation of scarpas fascia, and lowering incision line was carried out.
In our study, we chose patients fulfilling the following criteria:
- Infraumbilical striae.
- Moderate excess adiposity.
- Skin and soft tissue laxity.
- Rectus diastasis or myofascial laxity.
In our study, we dealt in careful manner with patients fulfilling the following criteria:
- Patients with BMI more than 35.
- Patients with chronic illnesses or comorbidities.
- Patients with previous abdominal scars.
In all our female patients, possible future pregnancy was discussed with the patient; we advised them to undergo abdominoplasty after the last pregnancy. Preoperative ultrasound study of the abdomen is important to exclude the presence of hernia, ascitis on splenomegaly, a hepatomegaly, or any large intra-abdominal mass.
For the three groups, with the patient standing, the midline and a low abdominal curved line ~8 cm above the upper end of the vulvar cleft were delineated. The amount of skin to be resected was estimated and the inguinal groove extremities were identified. The supraumbilicus incision connecting both extremities was outlined. For groups II and III, the areas that were to receive liposuction were outlined in the supraumbilical and infraumbilical regions and in the flanks.
All participants were administered general anesthesia. Patients were placed in the supine position and intravenous antibiotic was routinely administered. In our cases, all incision lines were injected with a solution of lidocaine 2% and epinephrine (we used an infiltration solution of 1 l Ringer's lactate+20 ml xylocaine 2%+2 ml adrenaline+2 ml dexamethasone). The low transverse incision, marked previously, was performed with a number 10 blade into the dermis of the skin, and then we used electrocautery to complete the incision, sealing the blood vessels within the subdermal plexus. Electrocautery was also used to deepen the incision through the superficial fascia to reach the deep subcutaneous tissue ([Figure 1], [Figure 2], [Figure 3]).
|Figure 1 Preoperative male patient with a lax abdominal wall for traditional abdominoplasty.|
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All participants were administered general anesthesia. Patients were placed in the supine position and intravenous antibiotics were administered routinely. In our cases, all incision lines were injected with a solution of lidocaine 2% and epinephrine (we used an infiltration solution of 1 l Ringer's lactate+20 ml xylocaine 2%+2 ml adrenalin+2 ml dexamethasone). The regions to be liposuctioned were then infiltrated with a tumescent solution. The central abdomen, upper abdomen, lateral abdomen, flanks, hip rolls, and mons were infiltrated. The loose areolar plane between the abdominal wall and the subcutaneous tissue was also infiltrated to facilitate rapid dissection during tissue elevation. Three small incisions by blade 11 were performed in the infraumbilical region to facilitate liposuction in the infraumbilical and supraumbilical regions and liposuction from the flank; liposuction was performed using a size 4 cannula ([Figure 4], [Figure 5], [Figure 6], [Figure 7]).
All participants were administered general anesthesia. Patients were placed in the supine position and intravenous antibiotics were administered routinely. In our cases, all incision lines were injected with a solution of lidocaine 2% and epinephrine (we used an infiltration solution of 1 l Ringer's lactate+20 ml xylocaine 2%+2 ml adrenalin+2 ml dexamethasone). We performed small incisions for infiltration and liposuction in the lower abdominal area for resection during abdominoplasty; the central abdomen, upper abdomen, lateral abdomen, flanks, hip rolls, and mons were infiltrated. In our study, we infiltrated between 1 and 3 l of tumescent fluid for lipoabdominoplasty. The low transverse incision, marked previously, was performed with a number 10 blade into, but not throughout the dermis. Then, we used electrocautery to complete the incision, sealing the blood vessels within the subdermal plexus. Electrocautery was also used to deepen the incision through the superficial fascia to reach the deep subcutaneous tissue ([Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]).
|Figure 10 Elevation of the umbilicus by a hook at 12 and 6 o'clock positions for incision and isolation.|
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|Figure 12 Midline lower incision extending from the umblicus to the lower incision line.|
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|Figure 13 Drawing of the midline before reapplying the new umbilicus; the superior and inferior midline stitches were used to identify the exact location of the midline.|
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|Figure 14 Fourth day postoperatively, in the supine position, the upper trunk was bent 45° to allow wound healing.|
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| Results|| |
A total of 49 patients (26 women and 23 men) between 20 and 60 years of age were included in this study. This study was carried out on the basis of inclusion and exclusion criteria, and the selection of patients in each group was carried out randomly.
There was a nonstatistically significant difference between different groups in age, BMI, HB, panus weight, hospital stay, and follow-up period (P > 0.05). There was a statistically significant difference between different groups in age blood transfusion (P < 0.05) ([Table 1]).
In group I, 46.7% of the patients developed complications, and this was high in relation to groups II and III. This might be because of cutting and affection of blood supply, with a high incidence of complications ([Table 2]).
It was found that the incidence of seroma in group II was similar to that in group I, 33.3%, which was higher than that in group III; it was observed that seroma occurred in only two cases, 10.5%. The preservation of scarpas fascia in group III reduced the incidence of seroma in comparison with groups I and II ([Table 2]).
Among the patients in group III, 16 (84.2%) were satisfied with the results of the operation and surgeon satisfaction was about 14 (73.3%). This result was considered better than the results of groups I and II ([Table 2]).
There was a nonstatistically significant difference between different groups in the occurrence of hematoma, seroma, wound infection, and loss of sensation (P > 0.05). There was a statistically significant difference between different groups in the occurrence of edge necrosis (P < 0.05) ([Table 3]).
| Discussion|| |
Despite the popularity of these procedures, there are limited published prospective studies evaluating liposuction and abdominoplasty. Lipoabdominoplasty has been receiving attention recently. Several investigators have recommended alternative techniques that preserve the scarpa fascia in an effort to reduce complications, particularly the risk of seromas  .
Although abdominoplasty is a procedure that has been evolving over the past century, there have been significant improvements as recently as in the last 5 years. Consequently, today, abdominoplasty and other body-contouring procedures have become among the most commonly requested operations in cosmetic surgery.
There are two major groups of patients who benefit from abdominoplasty: recently pregnant women and those achieving massive weight losses. The weight loss group has expanded significantly in the past 10 years because of the evolution of various weight loss operations such as laparoscopic banding and gastric stapling  .
Combining liposuction with abdominoplasty was not allowed or was advocated cautiously in the 1990s  , but now, lipoabdominoplasty is considered the superior alternative  .
In terms of local complications of abdominoplasty, seroma following abdominoplasty is one of the most common complications and has been reported to occur in up to 60% of abdominoplasties. Some studies show that there is an increase in seroma rates when liposuction is used in abdominoplasty  and other studies indicate a reduced rate of seroma formation. Many of these studies included small numbers of participants and the technique for abdominoplasty was not standardized, because of several surgeons performing the operation. Many different techniques have been used in an attempt to reduce seromas, including drains, quilting sutures, compression garments, and minimal handling of the skin flap  .
In group I, 33.3% of patients presented with seroma, which is higher than that in group II (20%). The incidences of seroma in both groups I and II were higher than that in group III, in which only one (5.3%) patient developed postoperative seroma. This may have been because lipoabdominoplasty with limited selective undermining reduced seroma formation and preservation of scarpas fascia, which preserve lymphatic and reduce seroma. Many authors agree that seroma formation is a common complication after abdominoplasty, with an incidence that varies from 1 to 38%. Although the rate of seroma in our study was significantly high in group I (33.3%) and in group II (20%), our results are similar to those of Rangaswamy  , who reported no seromas in his study.
Our results are not in agreement with those of Castus et al.  , who found that lipoabdominoplasty with limited dissection reduced the incidence of seroma to 0% and they recommended avoiding insertion of a drain postoperatively. We consider drains important and lipoabdominoplasty should not interfere with insertion of drains even with limited dissection; three patients in group II and one patient in group III developed seroma. We believe that lipoabdominoplasty with limited dissection and with preservation of scarpas fascia does not prevent the occurrence of seroma and hematoma, but reduces their incidence.
Our results were in agreement with those of Willkinson and Swartz  for cases of lipoabdominoplasty; they reported the following incidences: epidermolysis, 1.5%, seroma, 1%, hematoma, 1%, and necrosis, 0.1%. Found 0% incidence of partial wound necrosis in group III  .
| Conclusion|| |
The advantages of new techniques of abdominoplasty over traditional abdominoplasty are as follows:
- We can perform abdominoplasty in patients who are considered unsuitable for the traditional operation.
- Decreased duration of surgery.
- Small incision.
- Better wound healing.
- Stronger abdominal wall.
- Decreased possibility of postoperative wound infection.
- The arteries supplying the dissected skin can be preserved.
- Direct simple liposuction during surgery.
- Scarp's fascia can be preserved.
- Decreased blood loss during the operation.
- Better wound healing.
- The wound is smaller, and skin dissection is more superficial.
- Preservation of anterior abdominal wall sensations.
We recommend use of the new technique of abdominoplasty, which includes lipoabdominoplasty and limited dissection superior to the umbilicus with preservation of scarp's fascia. We encountered fewer complications with our new technique for lipoabdominoplasty compared with the traditional technique, and greater patient benefits.
| Acknowledgements|| |
Conflicts of interest
| References|| |
Charles TH, Robert BW, Sherrell AJ, Scott BP, Geoffrey GC, Scott SL. In: Charles H Thorne, Robert W Beasley, editors: Abdominoplasty and lower truncal circumferential body contouring. Chapter 53 Grabb and Smith′s plastic surgery
. 6th ed. Philadelphia, PA: Lippincott-Raven Publishers; 2007; 141-162.
Wilkinson TS, Swartz BE. Individual modifications in body contour surgery: the ′limited′ abdominoplasty. Plast Reconstr Surg 1986; 77
American Society for Aesthetic Plastic Surgery (ASAPS). Cosmetic Surgery National Data Bank (2008). Available at: http://www.surgery.org
[Last Accessed on 2014 Jun 20].
Chim H, Evans EK, Salgado CJ, Mardini S. In: Rosen M, editor. Atlas of abdominal wall reconstruction. Philadelphia, PA: Elsevier; 2012.
Mitz V, Elbaz JS, Vilde F. Study of dermal elastic fibers during plastic surgery of the trunk. Ann Chir Plast 1975; 20
Chowdhry S, Hazani R, Collis P, Wilhelmi BJ. Anatomical landmarks for safe elevation of the deep inferior epigastric perforator flap: a cadaveric study, Eplasty 2010; 10
Saldanha OR, Azevedo SF, Delboni PS, Saldanha Filho OR, Saldanha CB, Uribe LH. Lipoabdominoplasty: the Saldanha technique. Clin Plast Surg 2010; 37
Vernon S. Umbilical transplantation upward and abdominal contouring in lipectomy. Am J Surg 1957; 94
Kelly H. A report of gynecologic diseases (excessive growth of fat). Johns Hopkins Med J 1899; 10
Callia WEP. Dermolipectomia abdominal (operação de Callia)
. São Paulo: Carlos Erba; 1963.
Pitanguy I. Abdominoplasty: classification and surgical techniques. Rev Bras Cir 1995; 85
Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am Surg 1979; 45
Brauman D. Liposuction abdominoplasty: an evolving concept. Plast Reconstr Surg 2003; 112
:288-298 discussion 299-301.
Shiffman MA. The complicated abdominoplasty: upper abdominal scars. Am J Cosmet Surg 1994; 11
Song AY, Jean RD, Hurwitz DJ, Fernstrom MH, Scott JA, Rubin JP. A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast Reconstr Surg 2005; 116
:1535-1544 discussion 1545-1546.
Blanchard PD. Diastasis recti abdominis in HIV-infected men with lipodystrophy. HIV Med 2005; 6
Matarasso A. Abdominolipoplasty: a system of classification and treatment for combined abdominoplasty and suction-assisted lipectomy. Aesthetic Plast Surg 1991; 15
Le Louarn C, Pascal JF. The high-superior-tension technique: evolution of lipoabdominoplasty. Aesthetic Plast Surg 2010; 34
Munhoz AM, Ishida LH, Sturtz GP, Cunha MS, Montag E, Saito FL, et al
. Importance of lateral row perforator vessels in deep inferior epigastric perforator flap harvesting. Plast Reconstr Surg 2004; 113
Rangaswamy M. Lipoabdominoplasty: a versatile and safe technique for abdominal contouring. Indian J Plast Surg 2008; 41
Castus P, Grandjean FX, Tourbach S, Heymans O. Sensibility of the abdomen after high superior tension abdominoplasty. Ann Chir Plast Esthet 2009; 54
Khan UD. Risk of seroma with simultaneous liposuction and abdominoplasty and the role of progressive tension sutures. Aesthetic Plast Surg 2008; 32
:93-99 discussion 100.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
[Table 1], [Table 2], [Table 3]