Outline

Suction-assisted lipectomy (SAL) in association with abdominoplasty has been regarded with trepidation, with ischemia of the apron flap, skin loss, and open wounds among the potential dire consequences. Leaving midabdominal and epigastric fatty excess, however, confers suboptimal contour and often a mediocre cosmetic result. In this study, a theoretical and technical approach that improves esthetics and safety in anterior and circumferential abdominoplasty with contouring using SAL is described and evaluated. Forty-two patients were treated with follow-up ranging from 5 to 40 months (mean follow-up 19 months). Through a low-transverse incision, the upper flap is elevated widely to the umbilical horizontal. The umbilicus is circumcised. The dissection then proceeds in a narrow column above the rectus sheaths to the xiphoid. Judicious subcostal undermining is performed, maintaining an intact bilateral subcostal “perforator zone” of 4 to 6 cm. Diastasis repair and anterior sheath plication are performed, and the umbilicus is anchored to the fascia. Excess skin and fat are excised from the inferior aspect of the flap, and the flap is inset. Wetting solution is instilled, and SAL of the entire flap, particularly in the midline and in the region of the neoumbilicus, is performed. Data were reviewed retrospectively. Twenty-seven anterior and 15 circumferential procedures were performed. There were 36 females and 6 males. There was one hematoma (3%) requiring re-exploration (male, circumferential), and 3 seromas (7%) treated with percutaneous aspiration. There was no infection, skin loss, or wound dehiscence. Contrary to classic abdominoplasty undermining to the costal margins, the maintenance of a broad subcostal blood supply allows for liberal flap contouring with suction. With this technique, liposuction can be safely used in abdominoplasty to maximize esthetic outcomes.

Abdominal and flank contouring with suction-assisted lipectomy (SAL) in conjunction with abdominoplasty has long been regarded with trepidation. Contemporaneous performance of SAL in, and in the proximity of, an undermined abdominoplasty flap has raised concerns of flap ischemia, with skin loss and open wounds as potential dire consequences. The dilemma is that although performance of an abdominoplasty without flap fat reduction and contouring, by either direct excision or by suction, is safe, it has very clear esthetic limitations. Residual midabdominal, epigastric and lateral fatty excess and peri-incisional step-transitions confer suboptimal contour, and often a mediocre cosmetic result.

Despite historical admonitions against extensive use of SAL in abdominoplasty flaps,1,2 reports on their safe combination have steadily emerged.3–6 Huger 7 described 3 anterior abdominal wall vascular zones based on the superior epigastric vessels (zone I), inferior epigastric and circumflex iliac vessels (zone II), and intercostal, subcostal, and lumbar perforators (zone III). In a classic abdominoplasty, wherein the remaining lateral (zone III) blood supply is dominant, the central flap is rendered “least safe” for treatment with suction lipectomy 1,8; ironically, this is often the region that, from an esthetic standpoint, requires the most contouring. Consequently, there has been a paradigmatic shift from the classic wide abdominoplasty flap undermining to a more selective approach to the extent of dissection, and to maintenance of an increasingly rich blood supply.9–11 With increasing respect for, and preservation of, blood supply, more liberal contouring by liposuction and ultimately enhanced esthetics can be achieved. In this study, a theoretical and technical approach that improves esthetics and safety in anterior and circumferential abdominoplasty with contouring using SAL is described and evaluated.

Forty-two patients were treated from May 2004 through April 2007, with follow-up ranging from 5 to 40 months (mean follow-up 19 months). Patients were selected to include only ASA class I (no medical problems) and ASA class II 12 (well-controlled thyroid disease or hypertension, with no pulmonary or cardiac disease). All were nonsmokers, at a sustained weight loss “plateau.” All patients were type 3, 4, or 5 according to Bozola and Psillakis 13 classification, ranging from mild skin excess and infraumbilical musculoaponeurotic laxity (type 3), to large skin excess, musculoaponeurotic laxity, and excessive fat (type 5). The data were reviewed retrospectively.

The skin is marked preoperatively in the standing position. Inferior and superior incision lines are oriented to maintain the final suture line location as low to the pubis as possible, and at or below the anterior superior iliac spines. A grid pattern is marked to facilitate closure. The superior incision line marking is an estimate, confirmed at the end of the procedure. Suction areas are marked over the midline-anterior abdomen, epigastrium, and flanks.

Surgery is performed with the patient under general anesthesia in all cases. Through a low-transverse incision, the upper flap is elevated widely to the umbilical horizontal, and the umbilicus is then circumcised. From the level of the umbilicus, cephalad dissection then proceeds in a narrowing column in the midline to the xiphoid. The width of this “tunnel” is maintained only as wide as is required to effectively plicate the anterior rectus sheathes to the midline, while maintaining maximal blood supply from zone I and III perforators. The medial border of the rectus muscle is identified, and undermining is carried between 1 and 2 cm laterally over each anterior rectus sheath. The width of the rectus diastasis then determines the total width of the “tunnel”, ie, a 3-cm diastasis requires an undermining width of approximately 6 to 7 cm. A lighted retractor is necessary for this dissection, and for later rectus plication in the undermined region (Fig. 1A, B).

To allow for the inferior transposition of the flap, judicious lateral undermining is performed, maintaining an intact bilateral subcostal “perforator zone” of 4 to 6 cm. The remainder of the flap mobility is conferred by discontinuous undermining provided by suction lipectomy.

Anterior sheath plication is then performed with interrupted monofilament suture from the xiphoid to the pubis (0-polydioxanone alternating with 0-polypropylene). The umbilicus is tacked to the fascia, maintaining a short umbilical stalk, with interrupted 2–0 polydioxanone at 6 and 12 o'clock. These sutures are left untied until final apposition to the dermis of the flap.

The upper flap is then placed on traction inferiorly, and the limits of skin and caudal flap resection are marked and excised. The location of the neoumbilicus is then marked and incised. Sharp excision of sub-Scarpa's fat is then carried out immediately beneath and surrounding the neoumbilical site, promoting a gentle concavity in this region.

On-Q catheters (I-Flow Corp., Lake Forrest, CA) are inserted into the dissection plane, instituting continuous administration of 0.25% bupivicaine. Temporary inset of the flap is then carried out at the superficial fascial system level with interrupted 0 and 2–0 polydioxanone suture, and at key points at the dermal level with 2–0 polydioxanone. Wetting solution consisting of 1 mL of epinephrine (1:1000) per liter of lactated ringers is infiltrated. No local anesthetic is added to the solution, removing the potential for lidocaine toxicity in these cases that are all performed under general anesthesia. Liberal SAL is then performed both below and above Scarpa's fascia using 3- and 4-mm cannulae over the entire flap and flanks, providing both discontinuous undermining and esthetic refinements.

The neoumbilicus is then “anchored” to the dermis under mild tension with the tying of the preplaced sutures. Two closed suction drains are inserted, and final tailoring and inset of the flap are carried out in the superficial fascial system and dermal planes. Compressive binders are never used.

Forty-two procedures were performed in 42 patients, 36 women and 6 men. Twenty-seven cases were ventral abdominoplasties, and 15 were circumferential dermolipectomy-abdominoplasties. Of the circumferential cases, 8 achieved massive weight loss (MWL) by nonsurgical means only, and 7 underwent bariatric surgery (bypass or band). Of these, 4 were performed laparascopically, and 3 were open incisional procedures. Total aspirate volumes by SAL ranged from 350 to 3,100 mL (mean 1,260); estimated flap suction volumes ranged from 350 mL to approximately 1,200 mL.

Minor complications included 3 seromas (7%), successfully treated with serial percutaneous aspiration, and 3 scar irregularities (7%, 2 dog-ear deformities and 1 wide scar) that required revision under local anesthesia. There were no infections, and no cases of flap ischemia, skin loss, or open wound. There was one hematoma (3%) that required a return to the operating room (a circumferential case, with the bleeding site in the superior gluteal region). There were no deep vein thromboses or other major complications.

In the pursuit of elevating our craft to an art form, we are charged with achieving excellence in esthetic results for our patients while maintaining, and increasing, the level of safety. A classic abdominoplasty, particularly in cases where fatty excess is substantial above the line of proposed direct excision, has considerable cosmetic limitations; residual localized epigastric adiposity, peri-incisional step-transitions at the transverse suture line, suboptimal periumbilical contour, often with a “pasted-on” appearance of the neoumbilicus, and flank and other regional excess are commonly seen in the absence of additional contouring, either by direct fat excision or by suction lipectomy.

The keys to advances in both abdominoplasty esthetics and safety when combined with liposuction have been careful patient selection and careful and selective undermining of the abdominoplasty flap.3–6,9–11 As Heppe elegantly stated, liposuction combined with abdominoplasty maintaining lateral vascular perforators can be a winning combination “in the battle between beauty and blood supply.”14

The theoretical and technical advantages described in this series of cases are based first on patient selection; all patients were healthy nonsmokers, who had reached and sustained weight loss. It is my current practice to have patients diet and exercise preoperatively, and that postbariatric surgery and nonsurgical MWL patients be at a sustained “plateau” for a minimum of 6 months.

Selective direct undermining, and discontinuous lateral undermining, preserves abundant zone III (lateral) perforators and a number of zone I (superior epigastric) perforators. With liberal liposuction of the abdominoplasty flap, the “turgor” of the flap is decompressed, allowing for more flap mobility and inferior transposition. The resulting increased laxity in the flap, in conjunction with umbilical “anchoring” the flap (where blood supply is rich) ultimately results in the ability to position the final transverse suture line further inferiorly under minimal or no tension in the suprapubic region. I find that when asked about the choice of a scar that can be covered by a “French Bikini,” ie, arching laterally above the anterior superior iliac spines, or one that can be covered with a lower-cut bikini or underwear, or hidden below the waist of low-rise jeans, most opt for the latter. Additionally, direct sharp defatting of the flap at the neo-umbilical position in the sub-Scarpa's plane, combined with additional suction lipectomy in the region result in a more pleasing periumbilical concavity.

Wetting solution is instilled and aspirated at approximately 1:1 ratio. No lidocaine is used to remove the potential for early or late-effect lidocaine toxicity. Bupivicaine 0.25% administered continuously through the on-Q catheters provides sufficient local postoperative analgesia. Total aspirate volumes by SAL ranged from 350 to 3,100 mL (mean 1,260), which included both the abdominoplasty flap and additional regional suction including flanks and back; the estimated flap and bilateral subcostal region suction volumes ranged from 350 mL to approximately 1,200 mL. The SAL is performed with 3- and 4-mm Accelerator III cannulas (Byron Medical, Inc., Tucson, AZ), which are used “openings-down” particularly when suctioning in the plane between Scarpa's fascia and dermis.

I never use a compressive binder immediately, although after 10 to 14 days I will use external compression in selected cases. All patients are admitted for observation for at least one night, with an indwelling bladder catheter, antiembolic compression boots, and continuous pulse oximetry. These patients are all mobilized on the evening following surgery. There were no cases of deep vein thrombosis or pulmonary embolism.

This is also a technique that is applicable to all classifications of abdominal skin, fat, and fascial excess,13 including circumferential cases after MWL (Figs. 2–5). Three cases involved patients who had previously undergone open bypass procedures through a vertical midline incision (Fig. 6). In no case was a vertical or fleur-de-lis excision performed; all were treated with circumferential transverse excisions, limited direct central undermining, and liberal liposuction with no wound complications.

Differing from a classic abdominoplasty with wide undermining to the costal margins, abdominoplasty with broad lateral subcostal perforator preservation allows for liberal flap contouring with suction. With this technique, liposuction can be safely used in abdominoplasty to maximize esthetic outcomes.

1. Matarasso A. Liposuction as an adjunct to a full abdominoplasty. Plast Reconstr Surg. 1995;95:829–836. Ovid Full Text Mount Sinai Serials Request Permissions Bibliographic Links [Context Link]

2. Christman KD. Death following suction lipectomy and abdominoplasty. Plast Reconstr Surg. 1986;78:428. Ovid Full Text Mount Sinai Serials Request Permissions Bibliographic Links [Context Link]

3. Avelar JM. Fat suction versus abdominoplasty. Aesth Plast Surg. 1985;9:265–276. [Context Link]

4. Dillerud E. Abdominoplasty combined with suction lipoplasty: a study of complications, revisions, and risk factors in 487 cases. Ann Plast Surg. 1990;25:333–343. Ovid Full Text Mount Sinai Serials Request Permissions Bibliographic Links [Context Link]

5. Ousterhout KD. Combined suction-assisted lipectomy, surgical lipectomy and surgical abdominoplasty. Ann Plast Surg. 1990;24:126–132. Ovid Full Text Mount Sinai Serials Request Permissions Bibliographic Links [Context Link]

6. Illouz YG. A new safe and aesthetic approach to suction abdominoplasty. Aesthetic Plast Surg. 1992;16:237. Mount Sinai Serials Bibliographic Links [Context Link]

7. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am Surg. 1979;45:612. Mount Sinai Serials Bibliographic Links [Context Link]

8. Matarasso A. Liposuction as an adjunct to full abdominoplasty revisited. Plast Reconstr Surg. 2000;106:1197–1206. [Context Link]

9. Lockwood T. High-lateral-tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96:603–615. Ovid Full Text Mount Sinai Serials Request Permissions Bibliographic Links [Context Link]

10. Saldanha OR, De Souza Pinto EB, Mattos WN Jr, et al. Lipoabdominoplasty with selective and safe undermining. Aesthetic Plast Surg. 2003;27:322–327. Mount Sinai Serials Bibliographic Links [Context Link]

11. Graf R, Reis de Araujo LR, Rippel R, et al. Lipoabdominoplasty: liposuction with reduced undermining and traditional abdominal skin flap resection. Aesthetic Plast Surg. 2006;30:1–8. Mount Sinai Serials Bibliographic Links [Context Link]

12. ASA Physical Status Classification System. American Society of Anesthesiologists. Available at: http://www.asahq.org/clinical/physicalstatus.htm. Accessed December 5, 2007. [Context Link]

13. Bozola AR, Psillakis JN. Abdominoplasty: new concept and classification for treatment. Plast Reconstr Surg. 1988;82:983–993. Ovid Full Text Mount Sinai Serials Request Permissions Bibliographic Links [Context Link]

14. Heppe H. Combined liposuction with abdominoplasty. Plast Reconstr Surg. 2001;108:577–578. Ovid Full Text Mount Sinai Serials Request Permissions Bibliographic Links [Context Link]

Key Words: abdominoplasty; liposuction; suction assisted lipectomy; abdominoplasty safety; abdominoplasty aesthetics; limited undermining; perforator preservation