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J. M. Avelar and R. C. Ribeiro
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Fig. 7.5 The main surgical principles of abdominoplasty without panniculus undermining are
preservation of the perforator vessels which work as multiplex pedicles for the remaining panniculus providing adequate blood supply (arterial, venous, and lymphatics). Photo (a) perioperative
showing several perforator vessels preserved during abdominoplasty; (b) diagram showing the
composition of the anatomic unit of a perforator vessel: A artery, V vein, L lymphatic, N nerve; (c)
diagram showing location of the perforator vessels coming from rectus abdominalis muscle; (d)
the abdominal wall is divided into nine regions: three odds (epigastric, umbilical, hypogastric) and
three even hipochondriac, lumbar, and inguinal
Surgical Principles
Until my publications, the surgical principles of my method had not been described
in the medical literature. For this reason, I present to the reader the following new
concepts as surgical principles that improve abdominoplasty. My technique is recommended for patients presenting with excess skin, localized adiposities, a redundant panniculus, muscular accidity, and diastasis in the rectus abdominalis
(Fig.7.6). Knowing the anatomy of the abdominal panniculus, particularly of the
vascularization described in my previous publications (Avelar 1986a, b, c, 1989), is
7 Surgical Principles andClassication ofLipoabdominoplasty
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Fig. 7.6 Lower lipoabdominoplasty in a 32-year-old patient combined with plication of the muscular abdominal wall. Photos (a, c, e) before surgery; (b, d, f) post-operative photos showing
reinforcement of the rectus abdominalis and its aponeurosis
fundamental to performing this procedure. Key elements of the technique are
described below:
1. The operation is performed as a closed vascular system, which represents a new
technique that is based on new concepts for improving body contouring (Avelar
1999a, b, c, 2000a, b). Because in this method the vascular network is not dam-
aged, the perforator vessels supply the abdominal panniculus as multiple pedicles (Figs.7.5 and 7.7).
2. The cutaneous excess is treated via the full-thickness skin resection of the
suprapubic (Figs. 7.1, 7.2, and 7.8), infraumbilical, and/or submammary
regions.
3. Deep liposuction is performed before skin resection on all the abdominal
regions that present with localized adiposities. Very often, other regions of the
posterior and lateral aspects of the torso must be simultaneously treated to
achieve a good aesthetic balance in body contouring.
4. In the area of skin resection (suprapubic, submammary, or infraumbilical), lipo-
suction is performed before the full-thickness skin resection (Figs.7.1, 7.2, 7.8,
7.9, and 7.10).
5. The connective tissue and all vessels of the resected skin area are also pre-
served. This prevents the destruction of the perforator vessels and prevents
small vessels from coursing perpendicularly to the communicating vessel
network in the fascia supercial (Figs.7.5 and 7.7b) provided by the subdermal
vascularization.
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J. M. Avelar and R. C. Ribeiro
a
Fig. 7.7 Anatomic study of the abdominal panniculus demonstrating the basic principles of
lipoabdominoplasty. Photo (a) abdominal panniculus of a cadaver after liposuction one can see:
skin (S), with preservation of the areolar layer (AL), lamellar layer (LL), communicating vessels
(CV), perforator vessels (P), rectus abdominalis (RA); (b) diagram showing all anatomical structures; (c) diagram of the anatomic unit of a perforator vessel: A artery, V vein, L lymphatics, N nerve
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AV
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Fig. 7.8 Schemas demonstrating lower lipoabdominoplasty technique. Drawing (a) surgical
demarcations of the operation delimitating the area of full-thickness of liposuction; (b) liposuction
procedure is rstly done on area for skin resection, afterwards on lamellar layer, below the fascia
supercialis on the remaining panniculus; (c) nally the wound is sutured by layers leaving a scar
on supra pubic region; (d) diagram showing all regions of the abdominal wall
6. All the perforator vessels work as multiple pedicles to supply normal vascular-
ization (through the arterial, venous, and lymphatic vessels) to the remaining
abdominal panniculus (Figs.7.5, 7.7, and 7.9).
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a
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Fig. 7.9 Liposuction procedure of the abdominal panniculus is performed on two layers.
Perioperative photos demonstrating: (a) full-thickness where skin resection is done; (b) deep liposuction, below fascia supercialis, all over the remaining panniculus; (c) diagram shows liposuction on full thickness of the panniculus where skin resection is done and deep liposuction under the
remaining panniculus
7. The lymphatic vessels, which surround the arteries and veins, are preserved
because the perforator vessels are not cut. Therefore, the lymph coming from
the abdominal panniculus maintains its normal circulation after surgery, avoiding seroma formation (Figs.7.5, 7.7, and 7.9).
8. Cauterization during surgery is not necessary, because this method doesn’t
damage the blood vessels.
9. Unlike the classical abdominoplasty—in which postoperative drainage is an
important procedure that may need to be applied many times for 3, 5, or 7days
and sometimes for longer than 3weeks—this new surgical technique does not
require drainage, because it doesn’t cause bleeding during or after surgery and
doesn’t allow seroma formation (Figs.7.5, 7.7, and 7.9).
10. Blood transfusion is unnecessary because there is no bleeding during or after
surgery.
Nevertheless, in some patients presenting with localized adiposities associated
with the accidity of the muscular wall of the abdomen, liposuction is performed in
combination with abdominoplasty to treat all the problems of the regions (Fig.7.6).
Concerning liposuction for the treatment of the abdominal wall, several authors
have introduced their contributions to this eld. In fact, Illouz’s (1980) technique
opened up a new era in body-contouring surgery, particularly on the abdominal
wall. I also contributed by presenting and publishing my approach as a combination
of conventional abdominoplasty with liposuction (Avelar 1985a, b, 1986a, b). Even
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Fig. 7.10 Perioperatives photos demonstrating deep liposuction (below fascia supercialis) with
preservation of perforator vessels. (a) Liposuction was done on suprapubic area with arrow indicating downward direction of the traction; (b) after traction and suture; (c) internal photo showing
the perforator vessels after liposuction on perpendicular position; (d) after traction the perforator
vessels are inclined due to traction of the panniculus, working as multiple pedicles to the remaining
panniculus
J. M. Avelar and R. C. Ribeiro
before incorporating liposuction, I introduced my method for the creation of a natural umbilicus during abdominoplasty (Avelar 1976a, b, 1979, 1983a, b). Furthermore,
I carried out careful anatomical research on corpses, which brought signicant
information on the alterations and behavior of the subcutaneous tissue after liposuction (Figs.7.5 and 7.7).
Classication ofLipoabdominoplasty
The abdominal wall can be anatomically divided into nine regions: three odd, and
single namely epigastric, umbilical, and hypogastric, and three even, right and left,
namely hypochondriac, ank, and inguinal (Fig. 7.5d) (Avelar 1989). Aesthetic surgery can be classied into only two segments: superior and inferior (above and
below the umbilical area, respectively). A careful analysis of my patients who have
undergone abdominoplasty without panniculus undermining and resection shows
that abdominoplasty can be classied into four types:
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Fig. 7.11 A 48-year-old patient underwent lower lipoabdominoplasty. Photos (a, c) before surgery
showing localized adiposities on upper and lower abdominal wall with previous surgical scars on
supra pubic region; (b, d) after lower lipoabdominoplasty
abcde
Fig. 7.12 A 39-year-old patient underwent lower lipoabdominoplasty presenting previous scars
on suprapubic region and irregularities caused by previous liposuction performed elsewhere.
Photos (a, d) before surgery; (b) surgical demarcations of the areas of remaining adiposities as
well as the area for skin resection; photos (c, e) after operation of lower lipoabdominoplasty
1. Lower abdominoplasty (Figs.7.6, 7.7, 7.8, 7.9, 7.10, 7.11, 7.12, and 7.13)
2. Upper abdominoplasty (Figs.7.1, 7.2, 7.3, and 7.4)
3. Lower and upper abdominoplasty (combined procedure) (Figs.7.14, 7.15, 7.16,
and 7.17)
4. Full abdominoplasty (Figs.7.18, 7.19, and 7.20)
Lower abdominoplasty must be employed for the correction of unaesthetic
deformities on the inferior segment of the abdomen (Figs.7.6, 7.7, 7.8, 7.9, 7.10,
7.11, 7.12, and 7.13). According to surgical demarcation, the area in the suprapubic
region is adequately demarcated (Fig. 7.8a, b, c) and the operation may be performed under general or epidural anesthesia combined with local inltration. Two
levels of local inltration must be carried out: a deep inltration on the supramuscular parts of all regions for liposuction and supercial inltration on the area for
skin resection. The solution of inltration is determined by the routine of each surgeon. The rst step of the operation is to perform two types of liposuction: one on
the full thickness of the panniculus in the suprapubic region where skin resection
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J. M. Avelar and R. C. Ribeiro
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Fig. 7.13 Lower lipoabdominoplasty in a 36-year-old patient without transposition of the umbilicus. Photos (a, c) before surgery; (b, d) 6months after lower lipoabdominoplasty
ab c
Fig. 7.14 Diagrams demonstrating upper and lower lipoabdominoplasty. (a) Surgical demarca-
tions: on upper abdominal wall a half-moon area is drawing below submammary sulcus; (b) fullthickness liposuction of the panniculus is done on areas where skin resection is performed and
deep liposuction (below the fascia supercialis) is done on remaining panniculus; (c) suture on
submammary sulcus and supra pubic region
will be performed (Figs.7.8a and 7.9a) and one at a deep level over all the areas
presenting with localized adiposities (Figs.7.8b and 7.9b, c).
After liposuction has been completed, the connective tissues and all the perforator vessels remain attached to the musculoaponeurotic plane, which creates a
depression on the suprapubic area (Fig.7.10a). Following the liposuction procedure
on the full thickness of the panniculus, a deep liposuction is conducted on the lamellar layer (below the fascia supercialis) on all the regions of the abdominal wall
presenting with localized adiposities for which skin resection will not be performed
(Fig.7.9b, c), as described in my previous publications (Avelar 1999a, b). As long
as the areolar layer is well preserved, the nal aspect of the abdomen wall will show
a harmonious surface. The remaining panniculus easily slides over the musculoaponeurotic plane because the lamellar layer does not present with any adiposities and
because all the perforator vessels are preserved, which work as multiple pedicles
that supply blood to the remaining abdominal panniculus (Figs.7.9c and 7.10c, d).
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Fig. 7.15 A 49-year-old female patient before and after combined upper and lower lipoabdominoplasty. Photos (a, d) before operation; (b, e) demarcations of the areas for skin resection on halfmoon shaped below the breasts and on supra pubic areas, also localized adiposities on umbilical,
supra umbilical and supra iliac. She presented a transversal scar on upper abdominal region which
is adverse condition for full lipoabdominalplsty. Photos (c, f) post-operatory view six months after
operation regions
The plication of the musculoaponeurotic wall may be performed according to surgical planning when the patient presents with diastasis in the rectus abdominalis or
when it shows up on computerized tomography (CT scan), which is a routine preoperative exam.
The next step of the operation is to pull the remaining panniculus downward
(Fig.7.10b), to be sutured to the inferior border of the raw area. The wound must be
sutured on three levels: on the fascia supercialis, on the subdermal layer, and on
the dermis (Fig.7.10b). If necessary, a running suture is performed in the dermis,
and adhesive tapes are applied on the surgical scars without any traction. Surgeons
should use a garment covering over the whole area of the abdominal wall, which is
maintained for the 1week before the patient returns for the removal of their dressing
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Fig. 7.16 A 51-year-old female patient underwent upper and lower lipoabdominoplasty. Photos
(a, c, e) before operation showing unaesthetic shape of the breasts and adiposities on superior and
inferior abdomen; (b, d, f) after operation. One can see the projection of the breasts as well as the
aesthetic improvement on the superior and inferior regions of the abdomen. The nal scars are
located on submammary sulcus and on supra pubic region
ab
Fig. 7.17 A patient underwent upper and lower lipoabdominoplasty for reparation of previous
surgeries on abdomen and breasts. Photos (a, c) before operation showing unaesthetic shape of the
breasts and adiposities on superior and inferior abdomen, on arms, on posterior aspects of the torso
as well; (b, d) after operation. One can see improvement of the breasts, on the superior and inferior
regions of the abdomen, as well as on arms and posterior regions of the torso
and the application of new adhesive tapes, which are changed once every 2weeks
for the next 2months. The nal result may be evaluated 6months to 1 year later
(Figs.7.11, 7.12, and 7.13).
Upper abdominoplasty should be performed when a patient presents with deformities localized specically on the upper segment, above the umbilical region
(Figs.7.1, 7.2, 7.3, and 7.4). Upper lipoabdominoplasty is a less-common modality
for aesthetic surgery on the abdomen wall. As always, this procedure requires adequate surgical planning and careful, correct demarcation before the operation
(Figs.7.1a and 7.2a). Two areas for skin resection are marked on the superior abdomen, where two crescent shapes are drawn bilaterally below the submammary fold.
In addition, other areas for liposuction are marked all over the abdominal wall to
indicate where to remove localized adiposities.
This surgery must be performed in a hospital or a clinic with all the necessary
equipment for an operation. It may be carried out under general anesthesia or
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Fig. 7.18 Technical systematization of full lipoabdominoplasty. (a) Preoperatory demarcation of
the area for skin resection and the triangular incisions on the umbilicus; (b) liposuction on fullthickness of the panniculus; (c) cutaneous incisions around the umbilicus; (d) skin resection was
done following by deep liposuction on supra umbilical region; (e) a special instrument is placed to
demarcate the new umbilicus on the abdominal ap; (f) the upper abdominal ap is pulled downwards and the suture was done
ab cd
Fig. 7.19 A 54-year-old patient presenting localized adiposities and panniculus accidity on all
regions of the abdominal wall underwent full lipoabdominoplasty. Fotos (a, c) before surgery; (b,
d) after full lipoabdominoplasty
epidural associated with local inltration. Following surgical demarcation, two levels of local inltration must be carried out: a deep one on the supramuscular parts of
all the regions for liposuction and a supercial one on the full thickness of the panniculus where liposuction will be performed. The solution of inltration is determined by the routine of each surgeon.
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