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J. M. Avelar
a
d
Fig. 5.7 Perioperative photos demonstrating full lipoabdominoplasty. Liposuction is done on full
thickness of the panniculus of the supra pubic region. Photo (a) from bottom one can see the cannula below the skin; (b) on lateral view after liposuction showing that the skin is free of adipose
tissue; (d) resection of the skin after liposuction; (c) the skin is being resected; (d) one can see the
raw area without panniculus
evaluate and compare the thickness of both sides (Avelar 1985b, 1986b,
1999a, b, c).
After deep liposuction, the abdominal subcutaneous panniculus easily slides
over the musculoaponeurotic wall, keeping all the perforator vessels as multiple
pedicles (Figs.5.6 and 5.7). This situation is similar to that on a child’s panniculus
because they don’t have adiposity in the lamellar layer on any of the regions of the
abdominal panniculus (Avelar 1986a, b, c, 1989). The areolar layer must be preserved to achieve the regular thickness of the remaining panniculus, yielding a harmonious result and a good balance in the body contouring (Fig.5.6). However, in
some cases, a surgeon may perform supercial liposuction on the upper panniculus
ap to reduce its thickness.
Full-Thickness Skin Resection
After performing liposuction, the rst step is to incise the umbilicus according to
my procedure (Avelar 1976a, b, 1978, 1979), in which a star-shaped incision is
made inside the umbilical region. In order to facilitate the umbilical incisions and to
avoid the accidental perforation of the deep structures of the abdominal cavity, I
created a double half-circular instrument (Fig.5.8). It is introduced into one part on
each side of the umbilicus, which joins around the umbilical pedicle and is pulled
upward (Avelar 1983a). Cutaneous incisions are carried out on the umbilical cavity
with a number 11 knife, followed by the anatomical dissection of the umbilical
pedicle. Afterward, a cutaneous resection is performed with this knife on the entire
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Fig. 5.8 Photos during surgery demonstrating that creation of the new umbilical region starts with
triangular incisions around the umbilicus. Photo (a) using my surgical instrument with two half
circles which are articulated around the umbilicus and cutaneous incisions are done with bladder.
11; (b) all incisions are already done; (c) the umbilicus is in the center of my double half circle
instrument
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Fig. 5.9 Tunnelization of the midline on superior abdomen for reinforcement of the muscular
abdominal wall during full lipoabdominoplasty. Photo (a) after liposuction of full thickness of the
panniculus on infraumbilical region one can see preservation of the perforator vessels and the
umbilicus was isolated with triangular incisions; (b) using special surgical instruments to create a
subcutaneous tunnel on midline without undermining; (c) my surgical instruments developed to
avoid panniculus undermining
area around the suprapubic region by retracing the demarcations (Fig.5.7c, d). The
subdermal structures and the perforator vessels underneath are preserved during this
liposuction procedure. After full-thickness skin resection has been performed, the
vessels of the previous panniculus are left undamaged, showing no bleeding during
or after the skin resection (Fig.5.6d, e, f).
Finally, a fundamental aspect of my method is that after liposuction on the full
thickness of the panniculus has been carried out, the only anatomical structures that
remain are the connective tissues, all the perforator vessels (arterial, venous, and
lymphatic), and the nerves (Figs.5.5d and 5.6f).
Afterward, the surgeon’s assistant pulls the remaining panniculus upward with
strong hooks to show the perforator vessels and connective tissues coming from
the muscular level to the panniculus, which is now possible because the lamellar
layer was previously aspirated (Fig.5.9). I created special dissectors to be introduced from the midline above the umbilicus to the xyphoid process (where there
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J. M. Avelar
a
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d
Fig. 5.10 Plication of the muscular abdominal wall during full lipoabdominoplasty. Photo (a)
internal image after tunnelization on midline on upper abdomen one can see preservation of the
perforator vessels on each side; (b) after plication the rectus abdominalis the perforator vessels are
preserved; (c) sequential diagrams showing plication: (c1) before plication; (c2) after reinforcement; (c3) details of plication on midline; (d) scheme demonstrating plication of the rectus abdominalis on upper abdomen
are no perforator vessels), according to my previous descriptions (Fig. 5.9c)
(Avelar 1986a, b, c, 1987, 1989). Therefore, only the connective tissues are dissected when the instruments are introduced into the fourth and backward movements, without any lateral ones (Fig.5.9b). The perforator vessels can be seen on
each side of the tunnel that was created by the dissectors on the superior segments
of the muscles of the rectus abdominalis. In fact, they indicate the location of the
muscles for reinforcement sutures (Fig. 5.10). When conventional abdominoplasty is performed, a wide undermined area is formed that cut all perforator
vessels.
Reinforcing theRectus Abdominalis andAponeurotic Wall
According to my previous publications (Avelar 1983a, 1987), the treatment represented by reinforcing the musculoaponeurotic abdominal wall isn’t a routine procedure in conventional abdominoplasty. It is a useful surgical step when the patient
presents with moderate or severe muscular accidity, diastasis in the rectus abdominalis, or herniation in the abdominal wall, as mentioned by Pontes (1965) and
emphasized and popularized by Pitanguy (1967, 1977, 1982)
Although the abdominal panniculus isn’t undermined during full lipoabdominoplasty, the plication of the abdominal aponeurotic structures can be performed on
the midline and laterally to reinforce the muscular wall and to treat the diastasis of
the rectus abdominalis (Figs.5.10 and 5.11) (Avelar 2000a, b). This surgical step
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d
Fig. 5.11 Perioperative photos showing plication of the infra umbilical segment following Erfon’s
approach. Photo (a) demarcation two vertical line with blue ink; (b) resection of the fascia supercialis on midline; (c) after resection the midline is demarcated with blue ink; (d) the infra umbilical segment after plication on midline
wasn’t described in my original publication (Avelar 1999a, b, c), because my rst
22 patients did not show any indications for this. However, Leão presented plication
on the midline of the abdominal wall via the tunnel approach without panniculus
undermining (Leão 2000a, b). Afterward, I found a good indication for plication in
some of my patients who underwent lipoabdominoplasty without panniculus undermining because they presented the diastasis of the rectus abdominalis, from the
xyphoid process to the suprapubic region. Although I can identify the diastasis and
an umbilical hernia, I always ask patients to undergo a CT scan in order to demonstrate the abnormality to them, which is useful for patients to gain support from their
private health insurance (Fig.5.3). I ask to measure the distance between the rectus
abdominalis from the xyphoid process to the pubis bone and to evaluate the presence of herniation on the umbilicus and on the area of diastasis. Also, I measure, via
a CT scan, the thickness of the abdominal panniculus and the muscles.
Therefore, when there is such an indication, reinforcement via the plication of
the musculoaponeurotic abdominal wall is simultaneously performed with my new
lipoabdominoplasty procedure. Because there is a wide distance between the rectus
abdominalis from the diastasis, there is also a wide distance from the perforator vessels on one side to those on the other (Figs. 5.3 and 5.10). I don’t perform any
undermining on the midline, because by using my special dissector, I can identify
the inner border of the muscles on each side. The shorter width of the diastasis of
the rectus abdominalis, the less chance that the perforator vessels will be damaged.
Therefore, the plication is 5 to 6cm and is performed from the xyphoid process to
the umbilical region by using isolated stitches. The pedicle of the umbilicus isn’t
routinely shortened, except in patients who have undergone massive weight lost and
who have very long segments of pedicle.
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J. M. Avelar
a
de
Fig. 5.12 Perioperative photos for demarcation of the new umbilical region on abdominal ap
after its downward traction. Photos (a, b) the lower segment of my surgical instrument is placed on
umbilicus; (b) the other segment lies on the abdominal ap and the new umbilicus is drawn; (c)
lateral view of my surgical instrument with two segments; (d) oblique view with one segment on
the other, the superior one is 1cm shorter than the inferior one; (e) a new umbilicus 1week after
surgery with natural depression on the umbilical region
The creation of the new umbilical region during full lipoabdominoplasty is
described in Chap. X (Figs.5.8 and 5.12).
Traction fortheRemaining Panniculus andtheDemarcation
oftheNew Umbilical Area
After reinforcing the musculoaponeurotic wall, the operating table needs to be bent.
The upper abdominal ap is pulled downward over the infraumbilical area until it
has reached the lower incision (Fig.5.12). A temporary stitch is applied on the midline, and another one is applied on each side of the previous one. Afterward, the
table needs to be returned to the straight position so that the abdominal ap is in its
normal position, at which point the future umbilical area can be demarcated. I created a new surgical instrument to establish a new umbilical area (Avelar 1983a). My
instrument has two segments like a pair of forceps. One segment is introduced
through the inferior border of the abdominal ap and placed on the umbilicus close
to the muscles on the midline. The other segment of the instrument lies on the
abdominal ap so that the natural projection of the umbilicus can be determined.
The upper segment is made 1cm shorter than the inferior one so that the new umbilical area can be marked 1cm lower than the projection of the umbilicus on the
middle of the abdominal ap (Figs.5.5e and 5.12d).
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After the demarcation of the new umbilical area, a 2cm diameter circle is drawn,
which is divided into three equal skin aps (Fig.5.12b) (Avelar 1976a, b, 1978,
1983a, b). One of them is superior and the other two are inferior on the left and the
right, and they are alternately stitched with the other three of the umbilicus.
After suturing the triangular aps, a dry gauze is placed inside the umbilicus,
which is kept for 1week—that is, until the patient returns to the ofce for their rst
instance of postoperative care. Afterward, a new gauze is placed inside the umbilicus, which is changed every 10 to 15days during the rst 2months after surgery.
The nal aspect of the new umbilicus is a natural depression with the triangular skin
aps on the side of the cavity.
The nal step of the operation is the suture of the wound is performed with
absorbent material and with isolated stitches in three or four layers. According to
the above description, the raw area preserves the connective tissues, the fascia
supercialis, and all the perforator vessels. It is important to suture the fascia supercialis from the border of the upper panniculus ap to the lower border of the fascia
supercialis, where liposuction is not performed.
Afterward, the subdermal layers are also sutured with separate stitches, and
nally a running intradermal suture is applied by using absorbent material. On top
of it, adhesive tapes are used to cover the surgical wound.
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Bandaging
I don’t use any kind of drainage after lipoabdominoplasty, because no preoperative
damage is caused to the perforator vessels and because there is no bleeding during or
after the operation. A thick layer of cotton is placed on the patient’s abdomen, and a
comfortable garment is dressed as a nal bandaging. The patient may leave the hospital the next day provided that they keep the bandaging for 1week, at which time they
return to the ofce for their rst instance of postoperative care. The nal result after
full lipoabdominoplasty takes about 6months to 1year (Figs.5.13, 5.14, and 5.15).
Discussion
Kelly (1899) has been credited with performing the rst operation whose treatment
reinstated the aesthetics of the abdomen wall. Since then, so much attention has
been paid to nding a procedure that can achieve better results. The transposition of
the umbilicus proposed by Vernon (1957) was an important step for abdominoplasty. Afterward, the wide undermining of the abdominal panniculus was introduced by Callia (1965), and Pitanguy (1967) and improved the approach by
reinforcing the muscular abdominal wall (Figs.5.3, 5.10, 5.11, and 5.13). However,
the very high rates of complications have been severe impediments to performing
abdominoplasty because the perforator vessels are cut to achieve wide undermining.
Local and systemic complications have been reported by Grazer and Goldwyn
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J. M. Avelar
Fig. 5.13 A 59-year-old patient underwent full lipoabdominoplasty according to the described
technique. Photos (a, c, e) before operation; photos (b, d, f) after full lipoabdominoplasty with
creation of the new umbilical region
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Fig. 5.14 A 63-year-old patient underwent full lipoabdominoplasty according to the technique
described. Photos (a, c) frontal and oblique view before operation; (b, d) after full lipoabdominoplasty with creation of the new umbilical region
(1977), Lodovici (1982), Guerrerosantos (1982a, b), Guerrerosantos etal. (1980),
Mélega (1982), and D’Assumpção (1982), among other authors.
Since the beginning of my career, I have identied several challenges to abdominoplasty: (1) the creation of a new umbilical region, (2) complications during and
after the operation, and (3) adiposities remaining after surgery.
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Fig. 5.15 A 66-year-old patient underwent full lipoabdominoplasty according to the described
technique. Photos (a, c, e) before surgery; photos (b, d, f) after full lipoabdominoplasty with creation of the new umbilical region
First, I presented a new technique that makes triangular cutaneous incisions
around the umbilicus (Avelar 1976a, b, 1978 1979, 1983a, b) to avoid leaving a
circular scar after surgery; such scars have been reported by Grazer and Goldwyn
(1977), Lodovici (1982), and others.
Second, complications during and after abdominoplasty were even more difcult
to solve, which motivated me to organize the Brazilian Symposium of
Abdominoplasty featuring renowned foreign and Brazilian plastic surgeons to serve
as a remarkable panel for discussion (Fig.5.16). My purpose at that time was to try
to nd a solution, but those severe complications were challenges for all plastic
surgeons, according to a discussion among 19 panelists. At that time, I concluded
once more that abdominoplasty was a eld that still required technical improvements to minimize complications. It was quite often performed as a combination of
procedures (Avelar and Padovez 1982) and as an approach for breast augmentation
(Hinderer 1982).
Third, the remaining adiposities after abdominoplasty were improved via the
development of liposuction by Illouz (1980, 1983a, b, 1984, 1986a, b). In early 1983,
I went to Paris to learn the liposuction technique by observing Illouz perform his
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Fig. 5.16 Photo of a panel during the symposium with several authors of articles about abdominoplasty. The Panel had also: Souza Pinto (President), Pitanguy and Serson Neto (Moderators),
Carreirão (Secretary). The panelists: from left to right: Hakme, Jorge Psillakis, Juarez Avelar
(Brazil), Jaime Planas (Spain), Mario Gonzalles Ulloa (Mexico), Ulrich Hinderer (Spain), Luiz
C. Martins, Willian Callia, Ramil Sinder, Talita Franco, Ricardo Baroudi and Ronaldo Pontes
(Brazil). Besides the pannelists in the photo, there were also: Claudio Rebello (Brazil),
Guerrerosantos (Mexico), and Raymond Vilain (France)
J. M. Avelar
revolutionary approach. When I started to perform my rst operations, I recognized
that the cannulas worked inside an unknown anatomical compartment of the human
body. I immediately started to study the anatomy of the subcutaneous layers to gain
more anatomical knowledge. I devoted considerable time to anatomic research on
cadavers to nd new information, after which I could identify the lamellar layer,
which is close to the muscles, and the areolar layer, which is more supercial.
Those layers are separated by the fascia supercialis, which features such rich
vascularization that I called the vessels communicating vessels (CVs). They serve
as a “peripheric heart” because the very high blood pressure inside the perforator
vessels is what decreases the communicating vessels’ ability to irrigate the areolar
and subdermal layers (Fig.5.6d, e, f). The perforator vessels are quite thick because
they come from the epigastric artery running inside the rectus abdominalis muscles
that perpendicularly cross the lamellar layer (Fig.5.6d, e, f). I performed dissections
on several cadavers of various ages, sexes, levels of adipose tissue, heights, and
ethnicities. I also performed liposuction on them while looking for new anatomic
information and documenting the behavior of the subcutaneous compartment after
liposuction (Avelar 1986a, b, c, 1987, 1989).
According to my publications, the fascia supercialis is a sophisticated anatomical structure between the areolar and lamellar layers with peculiar characteristics in
the abdominal wall. Each region’s layers is different from the others, and more differences appear between thin people and people with localized adiposities.
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A similar anatomy was found in the upper and lower thirds of the medial thighs
and in some regions of the torso. On the abdominal wall and the posterior regions of
the torso, the fascia supercialis is well identied on CT when the image is well
analyzed on the same level while using the bone structures as anatomic references
(Fig.5.3). Later, Lockwood (1995) described the importance of the fascia supercialis in media thigh lifting. Also, an outstanding anatomic study was performed by
Levy, the details of which appear in Chap. X, concerning the differences in thickness and the histological alterations of the subcutaneous tissue after severe weight
loss. He also described the difference between weight loss from diet and that from
bariatric surgery.
The aesthetic treatment of the abdominal wall introduced by Illouz (1980, 1983a,
b, 1984, 1986a, b) employing the liposuction procedure has been improved, but
there was another problem, namely the excess skin of the abdominal wall after surgery. As soon as I started to perform liposuction on the abdominal wall, I recognized
that the excess skin would need to be resected (Avelar 1985a, b, 1986a, b, c). Thus,
a new aesthetic procedure was introduced for abdominoplasty: an approach combining liposuction with the resection of cutaneous redundance. Therefore, the surgical results on body contouring were greatly improved. Such a combined procedure
has highly increased the incidence of complications (e.g., seroma, the slough and
necrosis of the panniculus, and infection). However, those sorts of complications
didn’t occur on the face and neck when associated procedures of liposuction with
rhytidoplasty were performed (Avelar 1983a, 1985c). So, in 1988, I made an
extreme decision not to perform combined procedures of liposuction with the resection of the excess skin during abdominoplasty (Avelar 1988).
Although I didn’t perform any more combinations of these techniques, I started
to think about and to study my previous anatomical descriptions on the panniculus
of the abdominal wall (Avelar 1986a, b, c, 1987, 1989). Finally, I concluded that I
could perform liposuction with the resection of the redundant skin as long as the
perforator vessels were not cut because they preserve normal blood supply to the
remaining abdominal panniculus, thus avoiding dead space underneath (Fig.5.6d,
e, f). Another technical improvement was described by Matarasso (Matarasso 2000)
after he heard my presentation at the ISAPS course in Montreal (Avelar 2000a),
namely lipoabdominoplasty as a new technique in abdominoplasty (Avelar 1999a,
b, c, 2000a, b). My descriptions in publications and during presentations were clear
enough and the surgical principles well understood enough that they were accepted
by several other surgeons (Ribeiro 2016); as a result, nowadays, lipoabdominoplasty has become a common operation (Erfon 2000; Leão 2000a, b; Saldanha 2002).
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Conclusions
Since 1999, abdominoplasty has undergone signicant technical improvements in
that it can now be performed in combination with a liposuction procedure that preserves the perforator vessels; this is the main surgical principle of lipoabdominoplasty (Fig.5.6d, e, f) (Avelar 1999a, b, 2000a, b). As long as the perforator vessels
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