Liposuction as an Adjunct to a Full Abdominoplasty Revisited

Cosmetic Follow-Up Liposuction as an Adjunct to a Full Abdominoplasty Revisited Alan Matarasso, M.D. New York, N.Y. This follow-up describes the observations and refinements I have made in the 5 years since my original article was published in the Journal. The purpose of the initial report was to evaluate the safety of performing a full (type IV) abdominoplasty in conjunction with liposuction of the undermined flap and adjacent areas of the abdomen, which represent those regions that would ultimately provide the predominant blood supply to the abdominoplasty flap. With consideration to the vascular anatomy of the anterior abdominal wall, 1 3 the vascular zones I through III described by Huger, 3 and the blood supply that remains after a full abdominoplasty flap is elevated, the regions to be treated by liposuction were divided into four territories or suction areas 1 4 (Fig. 1). Liposuction was performed over the anterior abdominal wall. The concern for the combined procedures was preliminary due to the potentially increased risk of wound ischemia/ necrosis and seroma formation as a consequence of the combined surgery. In that study we compared the complication rates of patients who had a full abdominoplasty alone with those who had a full abdominoplasty and liposuction, and concluded that liposuction could be used safely and reliably as an adjunct to a full abdominoplasty 5 by following the outline below. It should be emphasized, however, that extensive liposuction should not be performed simultaneously with a full (type IV) abdominoplasty. In the combination, certain points should be emphasized: (1) Technical guidelines: The abdominoplasty flap should be elevated superiorly and laterally only to the extent necessary to achieve wound closure with minimal FIG. 1. The anatomic regions (suction areas) for suction lipectomy in abdominoplasty: SA3 (cautious), SA2 (limited), SA1 (safe), and SA4 (unrestricted). (Figure originally published with the April 1995 article.) tension (i.e., undermining in an inverted V-type fashion), thereby preserving the lateral blood supply (Huger zone III) that predominates in the operated abdomen (Fig. 2, right). There should Received for publication September 27, 1999; revised March 28, 2000. Follow-up to Matarasso, A. Liposuction as an adjunct to a full abdominoplasty. Plast. Reconstr. Surg. 95: 829, 1995. 1197

1198 PLASTIC AND RECONSTRUCTIVE SURGERY, October 2000 FIG. 2.(Left) Pre(operative): the blood supply to the anterior abdominal wall. Note Huger zones I through III. (Right) Post(operative): vascular anatomy in the postabdominoplasty patient and its relationship to potential areas of suction lipectomy. DSEA, deep superior epigastric artery; SSEA, superficial superior epigastric artery; MPA, marginal phrenic artery; DIEA, deep inferior epigastric artery; DCIA, deep circumflex iliac artery; SCIA, superficial circumflex iliac artery; SIEA, superficial inferior epigastric artery; SEPA, superficial external pudendal artery; segmental perforators (zone III), intercostal, subcostal, and lumbar arteries. also be reconciliation between the amount of liposuction and the extent of flap undermining and tension on wound closure. Note: Patients who require an inverted T closure of the flap might not be suitable for concomitant liposuction because this limits the lateral zone III crossover blood supply. 6 (2) Suctioning areas 1 through 4: The location, extent, and number of sites suctioned can lead to vascular compromise. Recommendations for suctioning areas were described in the original article (Table I). 3. Screening patients: Selection should be based on the patients potential for complications according to the three-level (low, moderate, or high) risk factor index. High-risk patients are inappropriate candidates for the combined procedure (Table II). If an abdominoplasty patient with acceptable skin quality requires extensive liposuction to achieve adequate contour, a staged procedure beginning with liposuction is a feasible alternative. This concept of downstaging to a less invasive procedure 7 might satisfy patients enough to avoid a second operation. In those patients who have had previous abdominal liposuction and eventually request an abdominoplasty, I have found that there can be a

Vol. 106, No. 5 / FULL ABDOMINOPLASTY REVISITED 1199 TABLE I Recommendations for Avoiding Complications in Combined Abdominoplasty and Liposuction Type of Complication Local Recommendation 1. Consider vascular territories, location (SA1 through SA4) 2. Limit the number of liposuction sites beyond the arc formed from the inframammary crease to the groin crease 3. Limit the extent of liposuction in the arc, which contains the axial blood supply 4. Maintain flap thickness by not suctioning between the skin and Scarpa s fascia 5. Limit suction-assisted lipectomy on skin that will be undermined a. SA2 is safer than SA3 b. Below the umbilicus is safer than the terrible abdominoplasty triangle (SA3), where the flap is most in danger of devascularization 6. Avoid a T closure 7. Don t crisscross liposuction sites 8. Screen patients according to their risk factors (see below Table II) 9. Incorporate seroma precautions Systemic 1. Patients must be suitable candidates for an abdominoplasty alone 2. Screen patients according to their risk factor index (see below Table II) 3. Observe measures to avoid local complications (above) 4. Perform the majority of liposuction before the abdominoplasty 5. Avoid liquid fat pooling in the wound 6. Hydrate patients 7. Observe pulmonary precautions 8. Observe venous thromboembolism precautions 9. Use systemic corticosteroids SA1, safe suction area; SA2, limited suction area; SA3, cautious suction area; SA4, unrestricted suction area. slightly more difficult degree of flap dissection and a greater possibility of postoperative seroma formation. EFFECT OF RECENT ADVANCES IN PLASTIC SURGERY: SUPERFICIAL SUCTION LIPECTOMY, ULTRASOUND- ASSISTED LIPOSUCTION, AND LARGER-VOLUME WETTING SOLUTION I do not recommend that fat removal extend to the layer between the skin and Scarpa s fascia. Consequently, I do not perform superficial suction lipectomy (or scissor removal) in any open flap procedure. Furthermore, I have TABLE II Risk Factor Index in Combined Abdominoplasty and Liposuction Class I (low risk)* II (moderate risk) III (high risk) Risk Factor Age Volume of suction-assisted lipectomy Concomitant procedures Intraabdominal surgery** Suction-assisted lipectomy location, extent, and sites Obesity T-closure scars Deep vein thrombosis Smoking exposure Comorbid medical conditions Multiple risk factors The risk factor index system is used to establish a patient profile and to determine the feasibility of combined surgery. * These factors lengthen the procedure, increasing the possibility of deep vein thrombosis. ** This risk factor is the subject of conflicting reports. not used ultrasound-assisted liposuction or power-assisted liposuction in open abdominoplasty procedures. In a combined abdominoplasty/liposuction procedure, I rarely infuse more than 1 liter of superwet solution (1 liter of Ringer s lactate, 20 cc of 1% lidocaine, and 1 cc of 1:1000 epinephrine). I have found that larger volumes make electrocoagulation of the operative field during dissection cumbersome and prolong wound drainage. Furthermore, by using smaller volumes, I create sufficient reserves of solution for other potential sites of treatment without exceeding safe lidocaine levels. 8 Intraoperatively, I inject the rectus fascia with 10 cc of 0.25% Marcaine and epinephrine solution to reduce postoperative discomfort. The operating table is reverse flexed when the wetting solution is infused so that the injection needle can be introduced in a tangential plane. This reduces the possibility of inadvertent intraabdominal penetration by this needle, which could be a more likely source of injury than the suction cannula itself. Abdominal cavity penetration can be avoided by paying particularly close attention when suctioning around scars and in the epigastric area. RECENT OBSERVATIONS AND MODIFICATIONS (1) I recommend extensive education of patients so they understand that although there

1200 PLASTIC AND RECONSTRUCTIVE SURGERY, October 2000 are many abdominal contour operations available, they are not interchangeable; liposuction, limited abdominoplasty, and full abdominoplasty, with or without liposuction, are distinctly different procedures for distinctly different conditions. Although patients will often accept scars if they achieve the contour they desire, most patients are tuned in to liposuction as the procedure of choice, because that is the procedure with which they are familiar. It is imperative that patients recognize that loose skin that may masquerade as fat (and can be distinguished with the lifting test) cannot be treated effectively through liposuction. Patients should be advised as well of the adverse effect fat removal can have on skin with marginal tone. Currently, liposuction of the abdomen has become a more frequently performed procedure than an open flap procedure. (2) When performing an abdominoplasty, my preference is to make the upper incision first in a vest-over-pants technique for flap elevation as described by Planas. 9 When designing the upper flap, the lateral segments are arched like a reverse handlebar moustache, which helps reduce the upper and lower wound edge discrepancy (a defect often encountered when closing), thereby diminishing the incidence of dog-ear formation. For the lower flap, a modified bicycle-handle incision developed by Baroudi and Moraes 10 is used. (3) I no longer routinely tack all quadrants of the umbilicus to the fascia, because I find that it has little impact on the final aesthetic FIG. 3. The seven aesthetic units of the female abdomen.

Vol. 106, No. 5 / FULL ABDOMINOPLASTY REVISITED 1201 outcome, and if a tacking suture pulls out from the fascia it can create a distorted umbilicus. (4) Operating on related abdominal aesthetic units, such as the mons pubis, at the time of abdominal contour surgery will further ensure a harmonious appearance. 11 There are six units to consider in men (epigastrium, lower abdomen, flanks, mons pubis, umbilicus, and sacrum) and seven aesthetic units in the female abdomen (those six plus dorsal back rolls) (Fig. 3). (5) A continued source of frustration in treating abdominal contour patients is the inability to extract the intraabdominal (visceral) fat routinely seen in males and perimenopausal females that could contribute significantly to the full appearance of the abdomen. This deformity is further exacerbated by the difference in the metabolic rates of subcutaneous fat and visceral fat. These patients might experience disappointment in the modest change that any abdominal contour operation achieves in narrowing the waistline, which indeed is often reflected in the narrow disparity in hip-to-waist ratio. Moreover, abdominoplasty patients with excessive intraabdominal fat may seem to have a wider waistline because the procedure postoperatively pushes in the abdominoperineal diameter and therefore enlarges the width or waistline (Fig. 4). (6) I continue to observe patients weekly for 6 weeks postoperatively to monitor the development of any fluid collection and percutaneously drain (tap) the fluid. If there is a persistent seroma, I will intervene sooner by introducing a seroma catheter (Greer Medical, Santa Barbara, Calif.) or instituting the seroma protocol. 12 (7) Patients are advised to use any postoperative garment that provides a snug but not tight fit and are instructed on its intermittent use to avoid potential occlusive complications. 13 Furthermore, both surgeon and patient should be aware that a long travel period (e.g., by plane or automobile) 14 increases the risk of developing venous thromboembolism. (8) Extreme vigilance is necessary to avoid the possible risks involved in abdominal surgery, particularly systemic ones such as pulmonary thromboembolism. 15 All patients are appropriately screened for surgery; occasionally I screen for hereditary thrombophilias such as protein C deficiency, protein S deficiency factor V Leiden mutation, or prothrombin 20210 A mutation. It is important that patients are sufficiently hydrated, are placed in sequential pneumatic compression devices prior to the induction of anesthesia, undergo pulmonary care, and discontinue the use of all female hormones. 16 I recommend systemic steroids for prophylaxis against pulmonary fat embolism syndrome. 17,18 (9) Smoking is often considered a relative contraindication to abdominoplasty. Although FIG. 4. In those patients with significant intraabdominal adiposity, abdominoplasty narrows the anteroposterior diameter and can seem to enlarge the width.

1202 PLASTIC AND RECONSTRUCTIVE SURGERY, October 2000 there are no controlled studies examining the influence of smoking or smoke exposure to the combined operation, it is my belief because of the known effect on flap vasculature that liposuction in conjunction with an abdominoplasty should be avoided in patients who smoke. (10) By incorporating during the past 5 years the modification discussed, the most common local complications seroma, skin necrosis, and abnormal scarring have been reduced, and no new complications encountered. OTHER CONCEPTS Combining the advantages of abdominoplasty pancreas removal, skin tightening, and muscle reinforcement, or liposuction subcutaneous fat removal is enticing. Numerous other innovative approaches have been designed to avoid the wide flap undermining of abdominoplasty and partial dissection of liposuction (that seem to be the culprits in wound ischemia and seroma formation) and still allow concomitant unrestricted liposuction in the course of a full abdominoplasty. This includes limited dissection of the upper flap to the xyphoid in an inverted V type fashion, thereby leaving flap perfusion intact with the lateral intercostal blood supply (Huger zone III), 5 quilting sutures, 19,20 neoumbilicyzation, 21 and lower abdominal flap full-thickness skin resection. 22 CONCLUSIONS A limited degree of liposuction can be combined safely with abdominoplasty when performed according to the aforementioned guidelines. However, abdominoplasty, and body contouring in general, carry a greater degree of morbidity and mortality and greater potential for unsatisfactory scarring and complications than facial aesthetic procedures. If patients and surgeons weigh and accept the risks and benefits of body contour surgery, the advances made during the last two decades can provide gratifying results. Alan Matarasso, M.D. 1009 Park Avenue New York, N.Y. 10028 matarasso@aol.com REFERENCES 1. Nahai, F., Brown, R. G., and Vasconez, L. O. Blood supply to the abdominal wall as related to planning abdominal incisions. Am. Surg. 42: 691, 1976. 2. Hester, T. R., Jr., Nahai, F., Beegle, P. E., and Bostwick, J., III. Blood supply of the abdomen revisited, with emphasis on the superficial inferior epigastric artery. Plast. Reconstr. Surg. 74: 657, 1984. 3. Huger, W. E., Jr. The anatomic rationale for abdominal lipectomy. Am. Surg. 45: 612, 1979. 4. Taylor, I. G., Watterson, P. A., and Zelt, R. G. The vascular anatomy of the anterior abdominal wall: The basis for flap design. Perspect. Plast. Surg. 5: 1, 1991. 5. Matarasso, A. Abdominoplasty. In B. Guyuron, B. M. Achauer, E. Eriksson, et al. (Eds.), Plastic Surgery: Indications, Operations, Outcomes, Vol. IV.: Aesthetic Surgery. Philadelphia: Mosby-Year Book (in press). 6. Dillerud, E. Abdominoplasty combined with liposuction (Letter). Ann. Plast. Surg. 27: 182, 1991. 7. Matarasso, A. Minimal-access variations in abdominoplasty. Ann. Plast. Surg. 34: 255, 1995. 8. Matarasso, A. Lidocaine in ultrasonic-assisted lipoplasty. Clin. Plast. Surg. 26: 431, 1999. 9. Planas, J. The vest over pants abdominoplasty. Plast. Reconstr. Surg. 61: 694, 1978. 10. Baroudi, R., and Moraes, M. A bicycle-handlebar type of incision for primary and secondary abdominoplasty. Aesthetic Plast. Surg. 19: 307, 1995. 11. Matarasso, A. Treating All Aesthetic Units of the Abdomen during Abdominal Surgery with Emphasis on the Mons Pubis. Presented at the New Frontiers in Aesthetic Surgery Meeting sponsored by the American Society for Aesthetic Plastic Surgery, Dallas, Texas, May 18, 1999. 12. Matarasso, A. 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