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19 Abdominoplasty Principles
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a
d
g
h
b
e
c
f
i
Fig. 19.12 The single midline suture is left in position to facilitate
umbilical location (a). It must be precisely placed in the midline. One
umbilical site is identied, and a number 10 scalpel is used to push to
The nal three-layer closure is performed, using interrupted 1-0 Vicryl suture is used for the Scarpa’s fascia closure, 3-0 Vicryl is used for subcutaneous closure, and nally
3-0 Monocryl is used for subdermal skin closure. This
decreases the tension over the skin closure, which helps the
skin to create a ne-line scar (Fig.19.12).
19.6 Tulua’s Technique
With the patient in a standing position, the midline point is
marked 5–6cm from the anterior cleft of the vulva or the
base of the penis. The mark is then extended laterally to the
excise a vertical ellipse corresponding to the shape of the umbilicus.
The skin is removed with a cone of underlying subcutaneous fat (e–g).
Positioning the single drain and three-layer closure follow (b–d, h–i)
sides, 3cm above the groin fold. This line can reach as far
as the posterior axillary line, to avoid “dog ears” and correct
lateral laxity. The end of that transverse line is joined by
another semi-elliptical line that comes from above the umbilicus, which determines the amount of tissue to be removed.
The size of this resection varies from patient to patient.
Inltration with modied Klein’s solution with 3mL of
epinephrine is performed until tumescence and vasoconstriction are achieved.
We usually perform liposuction in the anks and posterior
wall, with some restricted liposuction in the upper abdomen,
above the umbilicus, to leave a symmetrical and at
abdomen.
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A. Perez
Next, dissection of the ap undergoes with the electrocautery, reaching the Scarpa’s fascia and advancing to the umbilicus. The base of the umbilicus is dissected at its base,
continuing upward to the xiphoid respecting the costal
margins.
Then, we continue with the plication of the medial borders of the rectus abdominis, advancing from the xiphoid to
the pubis, going through only one side of the umbilicus. A
single suture of the Scarpa’s fascia is done with 2-0 Vicryl.
Excision of the tissue ap is done, and we continue to place
suction drains.
Multilayered closure continues with 2-0 Vicryl for subcutaneous tissue, Monocryl 3-0 for the dermis, and nal skin
closure with subdermal technique to avoid tension.
Finally, neoumbilicoplasty is performed the same way as
in Saldanha’s technique.
19.7 Postoperative Care
The patient is then moved to the recovery room, covered in
warm blankets, and constant vital signs being monitored.
Abdominal soft-tissue perfusion time must be evaluated
perioperatively to verify that the abdominal binder is not too
tight. Full abdominoplasty patients are kept in for 24h with
nurse care.
We prescribe oral antibiotics, NSAIDs, enoxaparin 40mg
subcutaneous, and pain medication on discharge. A slightly
exed position is instructed, and heavy lifting is prohibited.
Wandering in the rst 24h is indicated and TED stackings
are placed to prevent DVT/PE.
The abdominal binder is always worn in the immediate
postoperative period, except for showering.
19.8 Complications
19.8.1 Seroma
Seroma is a complication dened as the collection of inammatory uid, usually requiring repeated percutaneous drainage, to avoid infection or a less aesthetic result.
It is the most common complication nowadays, which can
be prevented by modifying the level of dissection, placing
progressive tension sutures, or drains.
Minimizing soft-tissue trauma is an important component
of seroma prevention. It is important to remove residual
tumescent uid constantly to avoid brosis and promote
soft-tissue adherence to the abdominal wall. Placement of
high-vacuum drains is important.
If a seroma is detected after drain removal, percutaneous
aspiration must be done weakly until the accumulation
ceases.
19.8.2 Hematoma
Poor hemostasis and large undermining of tissue in abdominoplasty are the principal factors for the formation of a
hematoma.
This results in discomfort and aesthetic irregularities. It is
best to evacuate the hematoma.
19.8.3 Umbilical Complications
Stenosis, ischemia, mispositioning, and necrosis with umbilical loss are the most common umbilical complications.
19.8.4 DVT/PE
In the rst hours after the surgery, ambulation is extremely
recommended to reduce venous stasis and combined with
TED stackings, the risk of thromboembolism is reduced.
The American Society of Plastic Surgeons mentions
infections as the most common adverse event (3.5%).
DVT/PE are potentially life-threatening complications
that require hospitalization and treatment by physicians other
than the plastic surgeon.
It is imperative that surgeons do everything possible to
prevent DVT/PE.Such measures include proper patient positioning, sequential compression devices, perioperative
anticoagulation, adequate hydration, efcient use of intraoperative time, and early postoperative ambulation.
19.9 Pre-and Postoperative Photos
See Fig.19.13.
19 Abdominoplasty Principles
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Fig. 19.13 Pre and postoperative photographs of patients who have undergone lipoabdominoplasty
References
1. Patronella CK.Redening abdominal anatomy: 10 key elements for
restoring form in abdominoplasty. Aesthet Surg J. 2015;35(8):972–
86. https://pubmed.ncbi.nlm.nih.gov/26508649/.
2. Pollock H, Pollock TA. Progressive tension sutures: a technique
for reducing local complications in abdominoplasty. Plast Reconstr
Surg. 2000;105:2583–6.
3. Matarasso A. Traditional abdominoplasty. Clin Plast Surg.
2010;37:415–37.
4. Matarasso A. Treating all aesthetic units of the abdomen during
abdominal surgery with emphasis on the mons pubis. In: Presented
at the New Frontiers in Aesthetic Surgery Meeting sponsored by
the American Society for Aesthetic Plastic Surgery, Dallas, TX, 18
May 1999.
5. Matarasso A, Matarasso DM, Matarasso EJ. Abdominoplasty:
classic principles and technique. Clin Plast Surg.
2014;41(4):655–72. PMID: 25283453. https://doi.org/10.1016/j.
cps.2014.07.005.
6. Saldanha OR, de Souza Pinto EB, Matos WN Jr, Lucon RL,
Magalhães F, Bello ÉML.Lipoabdominoplasty without undermining. Aesthet Surg J. 2001;21(6):518–26. https://doi.org/10.1067/
maj.2001.121243.
7. Chevrel JP.Hernias and surgery of the abdominal wall. 2nd ed.
Berlin: Springer; 1998. p.4–27.
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8. Rosen MJ.Atlas of abdominal wall reconstruction. Amsterdam:
Elsevier-Saunders; 2012. p.3–20.
9. Rouvière H, Demas A.Human anatomy. Descriptive, topographic
and functional. In: Trunk, vol. 2. 10th ed. Paris: Editorial Masson;
1999. p.72–106.
10. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich
RJ.The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124:1529–44. http://www.
ncbi.nlm.nih.gov/pubmed/20009839. https://doi.org/10.1097/
PRS.0b013e3181b98a6c.
11. Skandalakis JE, Gray SW, Skandalakis LJ, Colborn GL, Pemberton
LB. Surgical anatomy of the inguinal area. World J Surg.
1989;13:490–8. http://www.ncbi.nlm.nih.gov/pubmed/2815794.
12. Varacallo M. Anatomy, anterolateral abdominal wall muscle.
Treasure Island, FL: StatPearls; 2020. www.ncbi.nlm.nih.gov.
https://www.ncbi.nlm.nih.gov/books/NBK470334/.
13. Taylor GI.The superiorly based rectus abdominis ap: predicting
and enhancing blood supply on an anatomic and clinical study.
Plast Reconstr Surg. 1988;81:713–24.
Lipoabdominoplasty Techniques
Lipo-Abdominoplasty: Critical Elements
Excellent Safety Profile
Dissection with liposuction
Vascular supply preserved
Pre-excision skin measurement
Incredible SPEED
1000 ml/min aspiration
Large cannulas
Bloodless
Postop analgesia
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E.AntonioMangubat
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The three critical elements of the procedures can be summarized in Fig.20.1. Each element must be implemented and
respected to achieve the excellent safety prole:
1. Effective tumescence is mandatory to achieve profound
vasoconstriction to avoid blood loss.
2. Liposuction with fat disruption is critical to achieve speed
without irregularities and minimize anesthesia time.
3. Avelar’s concept is critical to preserve vascular supply to
the skin ap.
Fig. 20.1 Each of these steps
is critical elements in
performing a safe and
successful
lipoabdominoplasty.
(Courtesy of Le Belle Vie
Surgery Centers)
My lipoabdominoplasty technique has seven stages that are
related to (but distinctly different from) the critical elements:
1. Preoperative markings.
2. Positioning.
3. Tumescent infusion.
4. Fat disruption.
5. Liposuction.
6. Anterior tailor tacking, marking, excision, and closure.
7. Postoperative dressing.
Abdominoplasty
Avelar concept
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_20].
E. A. Mangubat (*)
Director- La Belle Vie Cosmetic Surgery Center, Tukwila, Seattle,
WA, USA
e-mail: tony@mangubat.com
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_20
Liposuction w/ Fat Disruption
Tumescent fluid infusion
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E. A. Mangubat
20.1 Introduction
Abdominoplasty has had a long history of development and
with the exception of the incision design, the essential concept of undermining full thickness skin and excising it has
not changed radically until Dr. Juarez Avelar introduced the
concept of lipoabdominoplasty in 1999. His new concept
stimulated the next evolution of abdominoplasty. Our experience with lipoabdominoplasty technique was published in
2008 [1] where we described the essential elements to
accomplish successful results safely. While my original publication was over a decade ago, the essential elements of the
operation are essentially unchanged. The purpose of this
publication is to dive into the video details of the procedure
and help surgeons inexperienced with the procedure to begin
the process of achieving prociency. Acquiring procedure
prociency is a journey and requires more than this book; it
requires a mentor to guide hands-on learning and proper
execution. Please do not consider this publication as the sole
source of education, but rather as the initial source to begin
understanding the operations.
I elected to share the videos describing my lipoabdominoplasty technique created from our procedure prociency program (P3, offered through World Academy of
Cosmetic Surgery) because it highlights the essential
skills of the procedure and demonstrates hands-on teaching to surgeons wishing to master the technique. Thus,
four of the surgical hands seen in the video are our participants (their initials are on the back of the glove) and not
just mine.
The video contains chapter markers so you can immediately nd segments of interest. This is especially useful for a
detailed review. The chapters are supported by many (but all)
video players (e.g., QuickTime, VLC Media Player, iTunes
are among the many platforms that support chapters).
20.2 Preoperative Marking
All surgical planning marks are performed with the patient in
a standing position (Fig.20.2). Most surgeons have personal
preferences to marking areas of liposuction. The lipoabdominoplasty technique should not change your personal liposuction markings.
Approximate the ideal “nal” incision line location; the
level and position that is ideal to achieve postop. It is worth
emphasizing that your approximate incision line is only an
estimated. Once liposuction is complete and the tissue
releases have been performed (more on this topic in the
abdominoplasty section), the tailor-tacking technique will
allow you to precisely measure the amount of skin to be
removed, predict the location of nal incision, and adjust the
incision for any asymmetries that commonly exist due to
variable skin elasticity. It is important to emphasize that the
abdominoplasty incision markings are only preoperative
estimates; the nal incision will be determined during tailor
tacking (Fig. 20.3a–g). If your patient is a candidate for
greater denition, proceed to mark the linea alba, linea semilunaris, superior iliac crest, and anterior iliac spine to help
guide your liposuction renement.
Fig. 20.2 (a, b) Photograph
of a patient who came for
lipoabdominoplasty taken
from the front and side
a b
c
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a
d
b
e
f
g
Fig. 20.3 (a) Marking the inferior incision usually below the caesar-
ean section scar so that it can be excised in Toto. (b) Marking the estimated superior excision. (c–e) Marking the midline (c), lateral extent
20.3 Positioning (No Video)
Positioning is critical and should be supervised by the surgeon to prevent DVT and allow proper estimation of skin
excision. Place the patient in a supine any neutral and at
position. Keep the knees slightly bent with small pillows and
always place SCD’s (sequential compression devices) before
anesthesia induction to prevent DVT and secure the arms on
an arm board at 90°. The patient should remain in this neutral
position throughout the entire liposuction and abdominoplasty procedure. Only after the skin is excised, should the
bed be exed to release tension on the abdominal wound.
Flexing the bed during closure, eases wound tension, and
allows a more secure closure (Fig.20.4).
(d), and intermediate vertical line (e) for skin alignment. (f) The extent
of liposuction is now marked (g) the lower border of the rib cage as well
as xiphisternum is marked
Fig. 20.4 Typical set-up and team required for a lipoabdominoplasty
procedure
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E. A. Mangubat
20.4 Tumescent Infusion
Critical elements summary [1]:
• With general anesthesia, lidocaine concentration is cut
50%, doubling the total safe tumescent volume.
• Tumescent infusion begins supercially allowing uid to
dissect deep saturating entire thickness.
I prefer to perform my abdominoplasties under gen-
eral anesthesia. Many surgeons prefer pure tumescent
local anesthesia (TLA), which is perfectly feasible; however, it requires a more concentrated solution of lidocaine
(0.05%) in the tumescent solution to achieve adequate
anesthesia and limits the total volume of tumescent solution that can be infiltrated which will limit cases to
smaller patients or staged procedures to avoid lidocaine
toxicity.
Lipoabdominoplasty performed under general anesthesia
has the advantage of being able to reduce the tumescent lidocaine concentration to 0.025% lidocaine (50% the required
concentration for TLA) and expand the total volume of
tumescent uid needed to deliver the epinephrine necessary
to achieve hemostasis (epinephrine concentration remains at
1:1,000,000). In addition, the total procedure time is
decreased by as much as 50%.
The incisions for tumescent infusion are made within the
estimated skin excision boundaries (Fig.20.5a). Because our
patients are under general anesthesia, our infusion rates are
brisk. Our fastest pump delivers approximately 1 L/min.
Because my cosmetic surgery fellow works with me, we use
two pumps to deliver the uid rapidly reducing the infusion
time by at least 50%.
Here is an important pearl for safety and efcacy: I keep
the tip of the tumescent infusion cannula supercial next to
the skin surface (Fig. 20.5b). The infused uid always
hydro- dissects to inltrate the deeper tissue. The converse is
not always true. By beginning tumescent infusion supercially, we are able to bath the entire thickness of the fat layer
in epinephrine signicantly reducing bleeding. It is worth
emphasizing that because we use general anesthesia, we can
reduce the lidocaine concentration to 0.025% permitting a
greater volume infusion avoiding lidocaine toxic levels yet
providing signicant postop pain relief.
Pay attention to maximum lidocaine loads. Post the maximum tumescent volume on the procedure board and only
bring that amount of tumescent uid into the operating room.
This ensures that you will not exceed the maximum recommended lidocaine loads and reduce the possibility of toxicity. The approximate volume infused will vary with patient
size. But keep at least 2 bags of intralipid in your crash cart
at all times tumescent infusion is used in case of onset of
lidocaine toxicity.
Occasionally, we will infuse the maximum lidocaine dose
before completing the tumescent infusion. Our strategy to
continue infusing to achieve critical vasoconstriction is to
mix our tumescent uid without lidocaine and only
1:1,000,000 epinephrine as rst published in 1999 [2].
Unless we feel that uid overload is a risk, we do not
spare volume (Fig.20.5c–e). We wait 15–20min to ensure
complete blanching to minimize bleeding before beginning
fat disruption.
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a
c
d
b
e
Fig. 20.5 (a) The incisions for tumescent infusion are made within the
estimated skin excision boundaries. (b) Keep the tip of the tumescent
infusion cannula supercial next to the skin surface. (c) Tumescent uid
is inltrated in the peri-umbilical area so as to hydro dissect the area.
(d) Inltration has to be extended beyond the inferior incision line. (e)
The abdominal ap is over inltrated and it looks tense
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20.5 Fat Disruption andLiposuction
Critical elements summary:
• Complete tumescent vasoconstriction must occur before
beginning fat disruption and liposuction.
• Begin fat disruption deep next to deep muscle fascia. Use
5–6mm fat disruptors. Going slowly until there is a loss
of resistance.
• Work to become more supercial and disrupt the suprascarpal fat, again until loss of resistance.
• Monitor any bleeding at this juncture. It can only worsen
with time. I recommend having tranexamic acid available
should bleeding become a problem for any reason.
My rst report of mechanical fat disruption was in 2003
[3]. The technique has evolved to include the use of VASER
ultrasound (Fig.20.6a) to create a gentle dermal release and
a much larger mechanical fat disruptor cannulas (Fig.20.6b)
that allows signicantly faster volume aspiration’s without
leaving large irregularities. The contemporary instruments
measure 5 and 6mm in diameter that possess a multitude of
raised surfaces that are designed to push and pull fat away
from its supporting stroma. My fat disruptor cannula was
designed to eliminate fat and is not suitable for fat grafting
because the fat particles are too large. Note the large fat disruption surface (Fig.20.7).
20.5.1 Fat Disruption Instrumentation
andTechnique
See Fig.20.7.
By now VASER ultrasound is a well-known device and is
useful for disruption of dense areas of fat and areas of prior
liposuction that contain signicant subcutaneous scarring.
For the virgin abdominoplasty patient, the device is not usually needed and will not be discussed further.
Without suction, the fat disruptor cannula is inserted deep
next to the muscle and is carried out slowly at rst, deliberately disrupting the deep fat layers until there is a clear loss
of resistance in the deep layer. Once achieved, direct the fat
disruptor cannula to the supercial fat layers. Again, the endpoint is loss of cannula resistance in all directions over the
entire area to be aspirated. Note that even using these larger
cannulas, you are able to disrupt close to the skin surface
without surface defects as long as no suction is applied during disruption. It typically takes 5–6min to achieve loss of
resistance for the entire the abdomen.
Begin lipoaspiration with the same size cannula as the disruptor and begin deep next to muscle. Do not hesitate to use the
larger cannula on larger patients. Flow is a function of the cannula’s cross-sectional surface area and radius [1] (Fig.20.8).
The 5 and 6 mm cannulas are my personal workhorse
instruments (Fig.20.9). I match the aspiration cannula diameter with my disruptor diameter, e.g., use a 5mm disruptor
a
Fig. 20.6 (a) VASER ultrasound technology is being used for a gentle dermal release. (b) Large mechanical fat disruptors being used for fat
disruption and faster evacuation
b
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