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20 Lipoabdominoplasty Techniques
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Fig. 20.7 Large 5 and 6mm cannulas work best until there is a loss
of resistance. Fat disruption, this form of fat disruption is not
designed for fat grafting because fat packets are quite large as it
pulls fat off its stroma without suction. Use similar size aspiration
cannulas and you will observe a fast resistance free ow of aspirate
with suction and smooth results. (Courtesy of Le Belle Vie Surgery
Centers)
Fig. 20.8 Flow (speed of
volume aspiration) is
intuitively a function of the
cross-sectional diameter of
the cannula. This
demonstrates how small
increases in cannula size can
affect ow. (Courtesy of Le
Belle Vie Surgery Centers)
then aspirate with a 5mm, similarly with a 6mm disruptor.
You will see a free ow of aspirate that will ow 600–
1000mL/min! Apply pressure with your free hand to bring
the fat to the cannula and liposuction in a radial and symmetrical pattern with the cannula opening facing the muscle
fascia from at least two different access points, preferably in
the skin you plan to excise. Once the major bulk of fat is
removed, use a small cannula (3–4mm) to rene and contours. The area between the lines of excision should have
more aggressive liposuction and thinning of the fat layer.
Flow = pr2 x Velocity
Effect of Cannula Diameter on Flow
8mm dia
=
2
50mm
6mm dia
2
= 28mm
321
4mm dia
= 12.5
2
mm
2mm
dia =
2
3mm
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a b
E. A. Mangubat
c
d
e
Fig. 20.9 (a) 5–6 mm cannulas are rst used to debulk the fat from the
pannus to be removed, which is aided by the fat disruption undertaken
in the previous step. (b) The fat can be seen owing out from the surgical site. (c) The nondominant hand is being shown to feel the tip of the
cannula and guide it to areas of fat deposits. (d) The pinch test has to be
carried out during the liposuction process to check for adequate thickness of the skin ap. (e) The thin ap seen over the tip of the cannula
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20.6 The Abdominoplasty (Video)
Once liposuction is complete, remark any faded preoperative
markings, and nally re-prep and drape for a strictly sterile
abdominoplasty.
Begin with the umbilicoplasty incision to completely iso-
late and mobilize the umbilicus (Fig.20.10a–c).
There are many incision types. I prefer an asymmetric
incision with a V notched located at the inferior midline of
the umbilical stalk to better hide the incision within the
umbilicus and the superior incision is hidden in the hood of
the superior ap (Fig.20.10a–c). Then perform by blunt dissection, a release of all midline attachments from xiphoid to
pubis using blunt dissection to reduce postoperative hematoma (Fig.20.10e–h). You’ll nd that with blunt dissection,
this maneuver is virtually bloodless because of the profound
vasoconstriction induced by the epinephrine.
While most of the blunt dissection release can be accomplished manually using the ngers. Release of the upper
abdominal attachments out of nger reach is facilitated by
the FAST dissector (Fig. 20.11) to release superior attachments at the xiphoid.
Once the complete release is achieved, you will notice
that the upper abdominal skin is very mobile and can be
pulled almost completely down to the pubic hair. With
completed liposuction and skin release, you are ready to tailor tack the skin so that you can precisely measure how much
skin can be excised.
Also important is that you can adjust the visual location
and symmetry of the nal incision by adjusting the clips used
for tailor tacking. If you nd that the tension in the midline is
excessive, you may allow slight upward displacement in the
midline at the point of greatest tension by taking less of the
lower ap skin. When completed, ensure that there is no
excess tension by grasping the towel clips and making sure
they have some movement in the vertical direction
(Fig.20.12a–c). Also, I emphasize that because of the liposuction, the supercial fascial system (SFS) has been disrupted and Scarpa’s fascia is not useful to relieve tension on
wound closure; Scarpa’s remains an intact separate layer with
the lymphatic system running along the deep surface. The
intact lymphatic system allows closure without the need for
drains as it is sufcient to absorb the residual tumescent uid
and serum. Review symmetry, nal incision placement, and
when satised, move on to excise the excess skin and close.
Excision and closure require special consideration. Mark
the clips on both sides of the incision with dots and remove
the Backhaus towel clamps. Then draw the lines by connecting the dots. Don’t be concerned if the dots and proposed
skin excision are not symmetrical as there is often preexisting asymmetry on the skin to be removed. Because liposuction has removed the supercial fat and Scarpa’s fascia is no
longer a supportive structure in wound closure, the wound
closure relies heavily on the dermis for wound strength.
Careful attention must be paid to the amount of dermis available to support skin tension (Fig. 20.13a, b). The lower
abdominal skin is thin and often has an insufcient dermal
thickness to support a tight closure. My special technique to
accommodate a thin dermis is to signicantly bevel the incision toward the excised skin to create extra dermal length for
closure. This is well demonstrated in the video clip.
Umbilicoplasty is completed (Fig.20.13c–k). The second
important distinction is to use an interrupted gure of eight
sutures to reapproximate the skin. Pully mechanics principles show that each leg of a pully, shares and equal load with
the other legs distributing the load more evenly and decreasing the load on each leg of the suture closure. A Figure of 8
stitch has 4 legs to share the load; a 4kg load on the suture is
divided into 4, 1kg loads decreasing wound tension locally
and additive throughout the entire suture line. The wound
should be visually completely reapproximated with minimal
tension on the wound edges to enhance wound healing. The
running subcuticular stitch more nely reapproximates the
wound edges. I use 2-0 Monocryl sutures for the entire skin
closure including the gure of 8 and running subcuticular
sutures because it is strong and does not cause supercial
granulation reactions even in tight closures (Fig.20.13l). If a
diastasis plication is performed, I use a 2-0 PDS suture
because it is long lasting and will dissolve after 3–4months
when it is no longer needed.
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E. A. Mangubat
cd
Fig. 20.10 (a) Umbilicoplasty incision being marked with a V notch at
the inferior midline. (b) Incision to release the umbilicus is completed.
(c) Blunt dissection to release the umbilical stalk. (d, e) Midline zone of
fe
adherence is disrupted using ngers and (f) using fast dissector as seen
in Fig.20.11(g, h). Central peri-umbilical and inferior midline zones of
adherence are broken
20 Lipoabdominoplasty Techniques
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gh
Fig. 20.10 (continued)
Fig. 20.11 The FAST dissector is a special design that allows dissec-
tion, irrigation, and aspiration. In the abdominoplasty procedure, the
FAST dissector allows blunt release of myocutaneous ligaments that
are unreachable with the ngers allowing greater movement of the
abdominal ap
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E. A. Mangubat
c
Fig. 20.12 (a) Tailor tacking of the upper abdominal skin is done to
the pubic area, which helps in adequate skin excision. Care is taken to
eliminate the dog ear by pulling the ap skin inwards. (b) Points are
marked on the inner aspect of the towel clips. (c) These points are now
marked to complete the ap excision line
gh
b
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a
327
c
d
fe
Fig. 20.13 (a, b) Upper and Lower oblique incisions to retain more
dermis in the ap edges to be sutured. (c, d) Avulsion of the abdominal
pannus by blunt dissection from the Scarpa’s fascia which is dissected
lateral to medial. (e) Umbilicus is held with a long Ellis forceps and the
superior and inferior incision edges are brought closer to each other (f).
The mobility of the umbilical stalk is assessed, superior extent (g) and
inferior extent (h). An inverted “V” shaped incision with a curved upper
extent is marked (i), incised (j), and umbilicus delivered and sutured
with the wedge inset into the notch in the umbilicus stalk (k). Finally,
the abdominoplasty incision is closed with deeper gure of 8 suture and
supercial subcuticular suture (l)
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E. A. Mangubat
i
j
kl
Fig. 20.13 (continued)
20.7 Dressings
The neoumbilicus is dressed using a parafn gauze
(Fig.20.14a) and the lipoabdominoplasty is dressed sterilely
with Steri-Strips and then supported with Hypax tape
(Fig. 20.14b). After complete sterile coverage, the lipoabdominoplasty is treated much like a standard liposuction procedure by applying a liposuction compression garment (we
use the garments manufactured by Design Veronique but
there are many different brands). We ensure that the garment
is smooth to minimize skin creases. Lastly, we add to the
skin support by placing a 1″ thick foam pad over the abdomen and waist and then apply a four-panel binder over the
foam the keep the abdominal skin at and immobilized.
There will be signicant drainage, so we place the patient
into adult diapers (depends) that catch the drainage. The
patient and caregivers are instructed on care and the patient
is discharged to home. Postsurgery visits are 1–2days after
the procedure so that the skin can be assessed and any creases
can be treated and adjusted. The foam and binder stay in
place for approximately 7days to ensure skin stability and
smoothness (Fig.20.15).
a
bc
20 Lipoabdominoplasty Techniques
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b
Fig. 20.14 (a) The neoumbilicus is dressed using a parafn gauze (b) and the lipoabdominoplasty is dressed sterilely with Steri-Strips
a
329
def
Fig. 20.15 (a–c) Preoperative photographs of a 40-year-old lady who has undergone two pregnancies. (d–f) Postliposuction and abdominoplasty
photographs taken 4weeks after surgery
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E. A. Mangubat
20.8 Pearls
1. Tumescent infusion should start at the surface. All uid
will hydrodissect deeply. Deep infusion rarely hydrodissects all the way to the surface. Be generous with tumescent volume and wait until a complete blanche is present
before beginning. This is the key to bloodless surgery.
2. Fat disruption is the key to SPEED without irregularities.
Begin deep next to muscle fascia and work supercially.
Loss of resistance in all planes marks the end point of
mechanical disruption.
3. After complete umbilicoplasty release, the abdominal
ap will become very mobile. Bluntly releasing all midline attachments will give you signicant amounts of
abdominal skin ap mobility.
4. Tailor-tack the abdominal ap so you can precisely determine the amount of skin to be removed and the exact
location of the nal lower abdominal incision.
5. When making your ap excision incisions, take into
account the thinness of the lower abdominal ap. Steeply
bevel your incision to create a de-epithelialized plane of
tissue dermis to strengthen the closure. Then use interrupted gure-of-eight sutures of 2-0 Monocryl to give the
incision closure strength. I also close with 2-0 Monocryl.
6. No drains are necessary.
20.9 Summary
The details of my technique for lipoabdominoplasty are best
understood by studying the video. Words fall short of a complete description and understanding of the ne details. I
advise you to view the videos immediately after reading the
paragraph so you can fully experience the details described.
If you are an experienced liposuction surgeon, consider that
there are a few more skills you need to master in order to
perform lipoabdominoplasty competently and safely. Once
mastered, you can have a brand new service to offer in your
practice safely!
References
1. Lonergan I, Mangubat EA.The Avelar Lipoabdominoplasty: initial
operative experience and results in 67 consecutive patients. Am J
Cosmet Surg. 2008;25(4):251–60.
2. Mangubat EA.Eliminating lidocaine from large-volume tumescent
liposuction. Am J Cosmet Surg. 1999;16(4):293–8.
3. Mangubat EA. Presentation: “Fat disruption using the Blugerman
liposhifting instrument”. American Academy of Cosmetic Surgery,
2003 fall symposium, Philadelphia, PA; 2003.
4. Avelar JM.Abdominoplasty: a new technique without undermining
and fat layer removal. Arq Catarinense Med. 2000;291:147–9.
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