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Keywords Abdominoplasty · Liposuction · Lipoabdominoplasty · Combined approach · Without undermining

The rst abdominoplasty was performed by Kelly (1899), which was the begin­ning of a long and rich history of such surgeries over the past century, followed by many other authors’ improving the aesthetic outcomes of surgeries on the abdomi­nal wall. Horizontal incisions were described by Malbec (1948), Callia (1965), Pontes (1965, 1982), Pitanguy (1967, 1977, 1982), Avelar (1976a, b, 1983a, b,

When performing any surgery on this area, remodeling the body’s contouring was a constant challenge.

2. Remaining adiposities leave behind an inelegant silhouette of the body, but this

developed for abdominoplasty that became well understood by and earned the acceptance of plastic surgeons (Avelar 1985a, b, 1986b). A new eld was thus introduced: aesthetic surgery on the abdominal wall as a complementary proce­dure to solve the excess of panniculus after liposuction. However, liposuction on the submentonian and submandibular regions in patients without cutaneous ac­cidity, even in association with rhytidoplasty, did not present redundant skin after liposuction, or those complications arose after abdominoplasty (Avelar

1983b, 1985c).

The combined procedure of liposuction with resecting excess skin during abdominoplasty didn’t bring new kinds of complications, but the high incidence of seroma, the slough and necrosis of the panniculus, local infection, and hyperpig­mentation of the skin remained. In light of these frequent complications, after a short period of time, I made the radical decision to no longer perform such com­bined procedures (Avelar 1988). Over a period of 10years, I no longer combined both procedures during abdominoplasty, but rather, I returned to my previous ana­tomical research on the abdominal wall (Avelar 1986a, b, c, 1987, 1989), looking for a way to solve the problems stemming from this combination of liposuction with resecting the redundant skin of the abdominal wall. In my previous anatomical study, I described and recommended that liposuction should be performed primar­ily on lamellar layer (the deeper one) in order to preserve the perforator vessels during surgery (Figs.5.5d and 5.6d, e, f). This technical principle has been recom­mended ever since I described the anatomy of the abdominal wall. After 10years of reviewing my previous anatomic study and reecting on the aforementioned complications, I nally concluded that I could combine those two procedures simultaneously (liposuction and the resection of redundant skin of the abdomen wall) as long as the perforator vessels (arteries, veins, and lymphatics) did not sus­tain damage during surgery, thus avoiding dead space (Avelar 1999a, b, c, 2000a, b,

According to clinical evaluations and patient selections, the surgical planning for lipoabdominoplasty with reduced panniculus undermining may be classied in four types of operations: lower lipoabdominoplasty, upper lipoabdominoplasty, upper and lower lipoabdominoplasty, and full lipoabdominoplasty (which is described in Chap. X). Also, Erfon created a classication system that is an excellent guideline for reaching an adequate orientation before surgery (Erfon 2000). The subject of this chapter is restricted to full lipoabdominoplasty, through which all skin above the suprapubic region and below the umbilicus must be resected. In fact, the whole abdomen wall is treated, but the perforator vessels are not cut, because in my origi­nal descriptions (Avelar 1999a, b, c, 2000a, b), the remaining panniculus is not to be undermined. That is the main difference between my technique and the conven­tional abdominoplasty, where wide undermining is performed and all the perforator vessels are cut.

All my operations are performed at the hospital under epidural or general anesthe­sia, where patients stay for at least 24h. I prefer to demarcate the patient’s body the day before the operation. Because I have a useful set of mirrors, my patient can see and follow my demarcations (Fig.5.4). Patient should see their deformities once more, and surgeons must explain the relevant surgical details to them. The patient must stay in a standing position in front of the mirrors in order to follow my drawing on their body (Avelar 1986c). After a careful analysis, all the deformities are drawn. Two areas must be well demarcated: (1) the area for full-thickness skin resection where liposuction will be performed on the panniculus and the location of the nal scars and (2) the areas for deep liposuction (below the fascia supercialis) on the upper abdomen wall, the lateral sides, and the posterior regions (Fig. 5.4). Premedication is a matter of a routine and is prescribed by an anesthesiologist after a clinical evaluation has been completed before surgery.

Full lipoabdominoplasty is the most frequently performed procedure in abdomino­plasty; it is combined with liposuction and skin resection on the entire suprapubic region to repair abnormalities in the abdominal wall. In this modality of lipoab­dominoplasty, the umbilicus is transposed and a new umbilical area is created. Once again, the selection of patients before surgery is a fundamental step for the surgeon to evaluate whether to remove all the skin of the suprapubic region, and the cutane­ous area above the umbilicus may be pulled downward to be sutured to the inferior border of the surgical incision.

1. In all the regions where liposuction is performed, the inltration is deep (in the

After inltration, the surgeon should wait at least 15min before starting the lipo­suction procedure, which is performed at two levels in those two previously demar­cated areas: