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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 35  |  Issue : 1  |  Page : 97-103

Assisted liposuction with abdominoplasty versatility and results


1 Department of General Surgery, Faculty of Medicine, Benha University Hospital, Benha University, Benha, Egypt
2 Department of General Surgery, Benha University Hospital, Benha University, Benha, Egypt

Date of Submission15-Feb-2017
Date of Acceptance16-Mar-2017
Date of Web Publication28-Feb-2018

Correspondence Address:
Ahmed M Kamel Tohamy
Ahmed Orabi Street, Kafr Shoukr, Kalioubya, 13718
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bmfj.bmfj_28_17

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  Abstract 


Background Abdominoplasty is an important and common procedure in plastic surgery; the final results may not always be esthetically pleasing. To overcome these problems, abdominoplasty has been paired with liposuction, which amazingly led to a lower complication rate. The procedure has been updated to prove, in its current form, to be trouble-free.
Aim The aim of this study was to evaluate the safety and surgical outcome of assisted abdominoplasty with liposuction for abdominal contouring.
Patients and methods A total of 30 female patients underwent assisted liposuction with abdominoplasty in the Banha University Hospital. All patients indicated for traditional abdominoplasty were selected from the plastic surgery outpatient clinic for this procedure; all had generalized abdominal lipodystrophy, skin laxity, and musculoaponeurotic flaccidity.
Results In 11 (36.7%) cases, we observed the presence of seroma, and it was solved with aspiration with a syringe. There were five (6.7%) cases of umbilical complications and two cases of wound dehiscence, and secondary suturing was done. The superior and inferior borders were effectively accommodated, because of the uniform thickness of the fatty tissue as a result of liposuction. Consequently, we observed that there was a low incidence of ‘dog-ear’ deformity, which was managed by liposuction and the final scar was shorter. We also observed an improvement in the body shape and in the body contour with marked improvement in subcostal, umbilical, and suprapubic girths, resulting in a more youthful abdomen.
Conclusion Combining abdominoplasty and abdominal liposuction is a safe procedure that achieves gratifying results. It promotes a more youthful abdominal silhouette, better matching between the abdominal flap and the pubis, and a shorter scar. We believe that it is a safer way to treat the abdominal region than classical abdominoplasty and has a fewer complications.

Keywords: abdominoplasty, liposuction, low morbidity, short scar


How to cite this article:
Farid AY, Elhabbaa GI, Abdelmofeed AM, Kamel Tohamy AM. Assisted liposuction with abdominoplasty versatility and results. Benha Med J 2018;35:97-103

How to cite this URL:
Farid AY, Elhabbaa GI, Abdelmofeed AM, Kamel Tohamy AM. Assisted liposuction with abdominoplasty versatility and results. Benha Med J [serial online] 2018 [cited 2018 Jul 22];35:97-103. Available from: http://www.bmfj.eg.net/text.asp?2018/35/1/97/226417




  Introduction Top


Abdominoplasty has been one of the most popular plastic surgery procedures performed, as it deals with one of the areas of the body liable to change, stretch and store fat, as well as being the one area to affect most the entire appearance of the body and trunk. It has no longer become a mere amputation of the flesh but a whole resculpture of the trunk [1].

Every abdominoplasty should have the following objectives, and every technique should be measured against these objective: (a) placing the incision within the bikini line; (b) tightening of the abdomen; (c) decreasing the size of the waistline; (d) decreasing the thickness of the subcutaneous fat throughout the abdomen, flanks, and iliac areas; (e) rejuvenating the pubis from a triangular senescent to an oval youthful form; (f) creating a well-defined xiphoumbilical depression; (g) giving an illusion of an athletic abdomen; (h) reducing or eliminating striae; (i) correcting any hernias; and (j) relieving back pain if this is related to muscle laxity of the abdomen [2].

Abdominal surgery has evolved from one operation applied to all patients requesting contouring to a group of procedures based on individual variations in anatomy [3].

Esthetic surgery of the thoracoabdominal area combining abdominoplasty and circumferential lipoplasty during the same surgical procedure is not a very common surgical procedure, but its use has increased during recent years [4].

Surgical abdominoplasty alone is also insufficient in the obese patient because the thickness of the abdominal panniculus is not reduced; in addition, secondary to tissue tension with wound closure, some necrosis of skin above the pubis is not unusual [5].

The introduction of liposuction techniques in the 1980s has allowed surgeons to limit scar length in certain candidates, transforming abdominoplasty into a minimally invasive procedure. Furthermore, modifications, such as ‘super-wet’ infusion, cannula design revisions, and ultrasound-assisted liposuction, have improved overall outcomes [6].

The use of liposuction combined with abdominoplasty has been controversial. The combination of techniques has been associated with an increased rate of venous thromboembolism and wound-healing complications. Through improvements in venous thromboembolism prophylaxis, refinements in liposuction techniques, and an understanding of anatomy, this cumulative risk has decreased, although the negative stigmata persist [7].

Suction-assisted lipectomy is an integral component of abdominoplasty for many surgeons [8]; however, liposuction and abdominoplasty provide high levels of patient satisfaction. The combined procedure is similar in discomfort level to abdominoplasty alone and produces the highest level of patient satisfaction [9].


  Patients and methods Top


Between January 2016 and November 2016, 30 female patients underwent assisted abdominoplasty with liposuction of abdomen in Banha University Hospital. This study was carried out in Faculty of Medicine, Benha University Hospitals after obtaining approval from the Ethics Research Committee. All patients were informed about the procedure, type of anesthesia, risks, possible complications, photographing, and inclusion in the study.

All patients are female, with an age range between 21 and 55 years. They presented with abdominal deformities marked by excess abdominal skin and adipose tissue with muscle laxity (Matarasso type III and IV and Toledo type IV and V).

Preoperative routine

The preoperative routine was as follows:
  1. Evaluation of supraumbilical and flanks fullness or any localized pulge.
  2. Complete medical evaluation and optimization by a physician in patients with comorbidities.
  3. A month of regular aerobic exercises in sedentary individuals to build up cardiorespiratory reserves and to unmask latent functional problems.
  4. Preanesthesia evaluation and appropriate corrections where needed.
  5. Attention to diet.
  6. Routine use of low-molecular-weight heparins and anti-embolism stockings.
  7. Measurements for postoperative garment based on hip size.
  8. Markings are done on the same day of operation with the patient upright to mark the midline, xiphoid and pubic symphysis, proposed incision, and estimated dermolipectomy. Any hernia sites are marked and the diastasis is similarly outlined.
  9. Photographing patients in standing and supine positions.


Positioning and anesthesia

The patients were positioned supine, under general anesthesia.

Liposuction

Liposuction was performed as follows:
  1. Stab incisions were made in the infraumbilical skin for tumescent solution injection and subsequent liposuction.
  2. Tumescent solution (1 l of lactated Ringer’s solution, 15 ml of 1% xylocaine, and 2 ml of 1 : 1000 epinephrine solution) was infused to attain adequate skin turgor (super-wet technique).
  3. Liposuction was performed in all areas of the abdomen and flanks ‘including the epigastric area’ until adequate contouring is achieved.
  4. A fan technique was used at all times to ensure a better homogeneous result and to prevent irregularities.
  5. The volume of tumescent fluid injected and the volume of the aspirate were recorded for each case.


Abdominoplasty

A scalpel or electrocautery is used to perform infraumbilical dissection. The dissection is beveled through the deep fat (starting superficial and going deeper as the dissection proceeds upward) to reach the rectus sheath at a point midway between the symphysis and the umbilicus. This preserved the deep suprapubic fat and the suprapubic lymphatics, which lessens seroma formation.

The umbilicus was vertically incised as a vertical ellipse and dissected free with scissors. A modest amount of subcutaneous fat is left intact surrounding the umbilical stalk to maintain its vascularity. Supraumbilical flap undermining was performed as a midline tunnel to the level of the xiphoid process superiorly and bounded laterally by the medial borders of the rectus abdominis muscles carried out in a vertical manner using two planes of sutures starting from the level of the xiphoid process down to the suprapubic region. The navel was sutured in two layers: interrupted absorbable monofilament 4/0 in the deep dermis and a running absorbable monofilament 5/0 subcuticular for skin closure. The abdominal wound was closed in three layers approximated from lateral to medial, and any redundancy was compensated toward the midline to decrease dog-ear formation.

Assessment of the esthetic results

Esthetic results were assessed by plastic surgeons not involved in the study; assessment was based upon evaluation of the abdominal contour, the umbilicus, and the scar. A scoring system compiled by the candidate was developed for assessment of the abdominal contour and the umbilicus based upon the description of an esthetically pleasing abdominal contour and umbilicus and the modified Vancouver scar scale was used for scar assessment [10].
  1. Supraumbilical and flanks contour satisfaction level of patients can be done by scoring as follows:
    1. Excellent.
    2. Very good.
    3. Good.
    4. Unsatisfied.


Statistical analysis

Data management and statistical analysis were performed using the statistical package for the social sciences version 23 (SPSS; SPSS Inc., Chicago, Illinois, USA).

Numerical data were summarized using mean, SD, and range; categorical data were summarized as numbers and percentages. Comparisons between multiple groups were made using repeated measure analysis of variance (ANOVA) test, post-hoc comparisons were made, and adjustment for multiple comparisons was performed using Bonferroni correction.

All P values are two-sided. P values less than 0.05 were considered significant, whereas P values greater than 0.05 were statistically insignificant. P value less than 0.01 was considered highly significant (**) in all analyses.


  Results Top


A regards statistical analysis of preoperative measurements of abdominal girths, we found that the mean subcostal girth was 108 cm, whereas mean umbilical girth was 130 cm and mean suprapubic girth was 110 cm ([Table 1] and [Table 2]).
Table 1 Statistical analysis of preoperative abdominal girth measurements (subcostal, umbilical, suprapubic)

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Table 2 Statistical analysis of 1-week postoperative abdominal girth measurements (subcostal, umbilical, suprapubic)

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As regards statistical analysis of 1-week postoperative measurements of abdominal girths, we found that the mean subcostal girth was 100 cm, whereas the mean umbilical girth was 117 cm and the mean suprapubic girth was 106 cm ([Table 3]).
Table 3 Statistical analysis of 1-month postoperative abdominal girth measurements (subcostal, umbilical, suprapubic)

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As regards the statistical analysis of 1-month postoperative measurements of abdominal girths, we found that the mean subcostal girth was 96 cm, whereas mean umbilical girth was 112 cm and mean suprapubic girth was 104 cm ([Table 4]).
Table 4 Statistical analysis of 3-month postoperative abdominal girth measurements (subcostal, umbilical, suprapubic)

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As regards statistical analysis of 3-month postoperative measurements of abdominal girths, we found that the mean subcostal girth was 93 cm, whereas the mean umbilical girth was 108 cm and mean suprapubic girth was 101 cm ([Table 5]).
Table 5 Preoperative and follow-up subcostal girth measurement

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Statistical analysis of preoperative and postoperative measurements of subcostal abdominal girths by ANOVA and post-hoc comparisons showed highly significant results (P<0.001) ([Table 6]).
Table 6 Preoperative and follow-up umbilical girth measurement

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Statistical analysis of preoperative and postoperative measurements of umbilical abdominal girths by ANOVA and post-hoc comparisons showed highly significant results (P<0.001) ([Table 7]).
Table 7 Preoperative and follow-up suprapubic girth measurement

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Statistical analysis of preoperative and postoperative measurements of suprapubic abdominal girths by ANOVA and post-hoc comparisons showed highly significant results (P<0.001) ([Table 8]).
Table 8 Statistical analysis of postoperative follow-up of possible complications

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As regards statistical analysis of follow-up of possible complications, we found that the most frequent complication is seroma (36.7%), whereas the least frequent complications are wound dehiscence and flap necrosis (6.7%) ([Figure 1] and [Table 9]).
Figure 1 Chart demonstrates percentage of complications.

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Table 9 Statistical analysis of postoperative follow-up of grade of satisfaction of patients

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As regards grade of patient satisfaction, we found that about 43.3% considered results of operation to be excellent, 30% considered results of operation to be very good, 20% considered results of operation to be good, and 6.7% considered that results of operation were not satisfying ([Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6]).
Figure 2 Chart demonstrates percentage of patient satisfaction.

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Figure 3 Preoperative photo.

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Figure 4 Early postoperative photo.

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Figure 5 1-month postoperative photo.

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Figure 6 Postoperative photo of midline necrosis case.

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  Discussion Top


Abdominoplasty is among the most popular procedures in esthetic surgery generating high levels of patient satisfaction. It is, nevertheless, associated with a significant incidence of complications. These, however, do not seem to negatively affect patient satisfaction [11].

Despite the good results obtained with a full abdominoplasty, significant complications and secondary surgical revision rates are still reported. Multiple surgical strategies have been described to lower the complication rate, such as lipoabdominoplasty, selective undermining, internal fixation techniques, avoidance of electrocautery, use of pressure dressings, and use of fibrin glue. The fact is that overall complication rates as high as 30% have been reported [12]. Poor esthetic result is avoidable by combining liposuction with abdominoplasty to get rid of excess subcutaneous fat in the entire abdomen and in the adjoining regions such as the hips and trochanteric regions to harmonize the overall results [13]. Some advantages of using liposuction as an adjunct to abdominoplasty, including easier upper flap advancement, have been described [14].

The limited undermining of the dermofat flap in lipoabdominoplasty reduces distal flap ischemia and necrosis by preserving most of the periumbilical and supraumbilical perforator vessels to the abdominal skin. The reduction in the incidence and volume of seromas was also attributed to the same factor [15].

Literature review revealed similar results reported by many authors. In 2005, LázaroCárdenas–Camarena presented a series of 310 female patients who underwent abdominoplasty combined with circumferential liposuction. The abdominoplasty was performed with minimal superior undermining, performing only that necessary to permit muscle plication, preserving maximal blood supply to the distal flap. The author reported that 63 (20.3%) patients had minor complications such as seroma in the lumbar region, palpable or visible irregularities, hyperpigmentation, and asymmetry or hypertrophy of scars, and three (1.3%) patients had major complications including cutaneous necrosis, infection on the liposuctioned area, and fat embolism. Lázaro concluded that the combination of abdominoplasty and circumferential liposuction permits excellent body contouring in a single surgical procedure with minimal complications. In 2007, Lázaro updated his experience with lipoabdominoplasty by another series of 122 female patients who underwent combination abdominoplasty and circumferential lipoplasty. As mentioned in the previous series, undermining was performed only to the internal edge of the rectus abdominis muscles, the extent necessary to perform plication of their medial edges. Postoperative complications were minor. There was no flap necrosis, hematoma, or postsurgical infection [16].

Compared with the present study, Lázaro reported the good esthetic result and high patient satisfaction that we had with lipoabdominoplasty, and a nearly comparable rate of minor complications. The very low incidence of major complications reported by Lázaro, which we did not have in our series, may be explained by the more extensive circumferential liposuction Lázaro was performing, in addition to the large sample studied, which would permit for rare events to reveal.

Attributing the absence of any major complications in our study to the small sample studied is supported by the results of other two small series of lipoabdominoplasty published in 2002, one by David L. Abramson who reported no complications in a series of 24 patients who underwent combined abdominoplasty and ultrasound-assisted lipoplasty. There were no seromas, flap loss, wound breakdown, or infection, and all patients were satisfied with their results. In particular, they noted improvement in the supraumbilical area and in the lateral flank and waist areas [17].In 2005, Grant Stevens et al. [18] published a retrospective study that evaluated two groups of abdominoplasty patients. Group 1 had abdominoplasty only and group 2 had abdominoplasty combined with suction-assisted lipoplasty. Grant Stevens et al. [18] concluded that there were no statistically significant differences in complication rates when comparing abdominoplasty with suction-assisted lipoplasty to abdominoplasty alone.

Compared with the present study and the aforementioned studies published on the topic, which reported that the combined procedure had a lower complication rate compared with the traditional full abdominoplasty, the higher complication rate in lipoabdominoplasty group reported by Grant Stevens et al. [18], which equals the complication rate of the traditional abdominoplasty, is attributed to perform the same extent of undermining in both groups.


  Conclusion Top


The slight difference in the complication rate of lipoabdominoplasty reported by various authors will not challenge the conclusion that lipoabdominoplasty with limited undermining assisted with liposuction of abdomen is a safe procedure that gives better esthetic results with a lower complication rate compared with traditional abdominoplasty.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Matarasso A. Abdominoplasty. Aesthetic Plast Surg 1989; 16:289–303.  Back to cited text no. 1
    
2.
Ramirez OM. Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach. Plast Reconstr Surg 2000; 105:425–435.  Back to cited text no. 2
    
3.
Matarasso A, Matarasso SL. When does your liposuction patient require an abdominoplasty? Dermatol Surg 1997; 23:1151–1160.  Back to cited text no. 3
    
4.
Cárdenas-Camarena L. Aesthetic surgery of the thoraco-abdominal area combining abdominoplasty and circumferential lipoplasty: 7 years’ experience. Plast Reconstr Surg 2005; 116:881–890; discussion 891–892.  Back to cited text no. 4
    
5.
Ousterhout DK. Combined suction-assisted lipectomy, surgical lipectomy, and surgical abdominoplasty. Ann Plast Surg 1990; 24:126–132; discussion 132–133.  Back to cited text no. 5
    
6.
Richard WD, Wesley WH, Michael B, Amer AS. Circumferential suction lipectomy of the trunk with anterior rectus fascia plication through a periumbilical incision: an alternative to conventional abdominoplasty. Plast Reconstr Surg 2004; 113:727–732.  Back to cited text no. 6
    
7.
Trussler AP, Kurkjian TJ, Hatef DA, Farkas JP, Rohrich RJ. Refinements in abdominoplasty: a critical outcomes analysis over a 20-year period. Plast Reconstr Surg 2010; 126:1063–1074.  Back to cited text no. 7
    
8.
Brink RR, Beck JB, Anderson CM, Lewis AC. Abdominoplasty with direct resection of deep fat. Plast Reconstr Surg 2009; 123:1597–1603.  Back to cited text no. 8
    
9.
Swanson E. Prospective outcome study of 360 patients treated with liposuction, lipoabdominoplasty, and abdominoplasty. Plast Reconstr Surg 2009; 33:1597–1651.  Back to cited text no. 9
    
10.
Oliveira G, Chinkes D, Mitchell C, Oliveras G, Hawkins HK, Herndon DN. Objective assessment of burn scar vascularity, erythema, pliability, thickness, and plainmetry. Dermatol Surg 2005; 31:48–58.  Back to cited text no. 10
    
11.
Momeni A, Heier M, Torio-Padron N, Penna V, Bannasch H, Stark BG. Correlation between complication rate and patient satisfaction in abdominoplasty. Ann Plast Surg 2009; 62:5–6.  Back to cited text no. 11
    
12.
Costa-Ferreira A, Rebelo M, Vásconez LO, Amarante J. Scarpa’s fascia preservation during abdominoplasty: a prospective study. Plast Reconstr Surg 2010; 30:322–327.  Back to cited text no. 12
    
13.
Illouz YG. A new safe and aesthetic approach to suction abdominoplasty. Aesthetic Plast Surg 1992; 16:237–245.  Back to cited text no. 13
    
14.
Ohana J, Illouz YG, Elbaz JS, Flageul G. New approach to abdominoplasties: technical classification and surgical indications: progress allowed by liposuction, neo-umbilicoplasty and use of biological glue. Ann Chir Plast Esthet 1987; 32:344–353.  Back to cited text no. 14
    
15.
Saldanha OR, De Souza Pinto EB, Mattos WN, Pazetti CE, Lopes Bello EM, Rojas Y et al. Lipoabdominoplasty with selective and safe undermining. Aesthetic Plast Surg 2003; 27:322–327.  Back to cited text no. 15
    
16.
Lázaro C-C, Victor L-B. Full abdominoplasty with circumferential lipoplasty. Aesthet Surg J 2007; 27:493–500.  Back to cited text no. 16
    
17.
Abramson DL. Ultrasound-assisted abdominoplasty: combining modalities in a safe and effective technique. Plast Reconstr Surg 2003; 112:898–902.  Back to cited text no. 17
    
18.
Grant Stevens W, Cohen R, Vath SD, Stoker DA, Hirsch EM. Does lipoplasty really add morbidity to abdominoplasty? Revisiting the controversy with a series of 406 cases. Aesthet Surg J 2005; 25:353–358.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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