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J. Erfon et al.
ab c
Fig. 8.2 G2. (a) Planning for mini-lipoabdominoplasty. (b) Type of deformity with indication for
mini-lipoabdominoplasty. (c) Type of deformity with indication for mini-lipoabdominoplasty
(oblique view)
ab c
Fig. 8.3 G3. (a) Planning for mid-lipoabdominoplasty.. (b) Type of deformity with indication for
mini-lipoabdominoplasty. (c) Type of deformity with indication for mid-lipoabdominoplasty
(oblique view)
muscles, and navel in position that allows traction of the upper abdominal skin ap
to the pubis, preserving an adequate extension of it (around 6cm), and without vertical supra-pubic scar (Fig.8.4a–c) (Saldanha etal. 2001; Erfon 2002, 2009, 2011;
Erfon and Mauricio 2016). The surgery indicated for each group was as follows: G1,
liposuction in 1066 patients; G2, mini-lipoabdominoplasty in 112 cases; G3, midlipoabdominoplasty in 97 patients; and G4, full lipoabdominoplasty in 801 cases.
Regarding this, the inclusion criteria were patients with indication to abdominoplasty surgery and liposuction from 19 to 70years of age, BMI less than 30, lipodystrophy in the abdomen and anks, skin accidity or not, and abdominal muscle
diastasis in most of the cases. Smokers were advised to stop for at least 1week prior
and 1week postoperatively. All patients underwent preoperative necessary routine
exams, including ultrasound of the abdominal wall.
This study was carried out in accordance with the 1964 Helsinki Declaration for
research in human subjects and subsequent amendments. All patients provided written informed consent for surgery and the use of photographs.
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ab c
Fig. 8.4 G4. (a) Planning of full lipoabdominoplasty. (b) Type of deformity with indication for
full lipoabdominoplasty. (c) Type of deformity with indication for full lipoabdominoplasty
Technique
Group 1: Liposuction– with the patient standing up in the hospital room, preoperative photos and areas where liposuction will be performed are marked in the anks
and abdomen. With the patient under dorsal position and general anesthesia on the
operating table, marking continues. The subcutaneous space is inltrated with a
saline solution (adrenaline saline 1:1000 mL) in the whole abdomen and anks
(areas where liposuction is to be performed) up to 1.5 or 2.0L.The surgery begins
with small incisions in the pubis and iliac regions (1cm in length), and deep liposuctions are performed in the whole abdomen and anks (Fig.8.1a). The incisions
are sutured with mono-nylon 4-0.
Group 2: Mini-lipoabdominoplasty– markings are drawn only inside the pubic
region. In the center of the pubis and 6 to 7cm from the vaginal cleft, the central
point is marked, and from this point laterally, two segments of lines are drawn up to
the lateral borders of this region on each side. One semicircle is marked uniting the
lateral extreme points of the pubic line, with convexity upward, according to the
amount of skin to be resected in each case. Two oblique lines are drawn from semicircle downward to 2cm laterally to the central point of the pubis dividing the
marked area into three segments (Fig. 8.4a) and without navel incisions (Fig.8.2a).
The subcutaneous space is inltrated with a saline solution (adrenaline saline
1:1000mL) in the whole abdomen and anks (areas where liposuction is to be performed) up to 1.5 or 2.0L.The surgery begins with small incisions in the pubis and
iliac regions (1cm in length), and deep and supercial liposuctions are performed
in the whole abdomen and anks. After liposuction, a total skin resection is carried
out in these lower lateral abdominal regions preserving the whole supercial fascia
as well as the vascularization and lymphatic system (Fig.8.5). Now the skin resection in the central area of the lower abdomen up to the muscle fascia is carried out.
A narrow tunnel from the upper border of the superior skin incision up to the xiphoid
appendix is dissected preserving the abdominal myocutaneous perforating vessels.
The navel is freed from the muscle wall. Plication is carried out using a double zero
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superficial circunfle
iliac ar
superficial epigastr
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Fig. 8.5 Secondary
vascularization for
lipoabdominoplasty
technique (supercial
epigastric artery and
supercial iliac circumex
artery)
J. Erfon et al.
Inferior epigastric artery
x
tery
mono-nylon in “X” separated stitches from the xiphoid appendix to the pubis. The
umbilicus is xed using two stitches in its upper and lower extremity. The supercial fascia is sutured in the middle line of the lower abdomen using 3-0 colorless
mono-nylon. Now the table is set to 45°. The superior abdominal ap is pulled down
to be sutured in the pubic region using ve stitches with zero mono-nylon and continued with subcutaneous points using 3-0 colorless mono-nylon. At this time, a
complementary liposuction is performed when necessary.
mini-lipoabdominoplasty, but the superior central line is drawn with inverted convexity downward, improving the umbilicus-pubic distance and the lateral markings going beyond the pubis according to the amount of skin to be resected in
each patient, permitting more skin resection than in mini-lipoabdominoplasty,
without umbilicus incisions (Fig. 8.3a). Surgery is carried out as described in
mini-lipoabdominoplasty.
room, preoperative photos and areas where liposuction will be performed are
marked in the anks and abdomen. With the patient under dorsal position and general anesthesia on the operating table, marking continues: the table is set to horizontal position. In the center of the pubis and 6 to 7cm from the vaginal cleft, the
central point is marked, and from this point laterally, two segments of lines are
drawn up to the lateral borders of this region on each side, and they are extended
laterally into the lower abdominal sulcus according to the amount of skin to be
resected. The umbilical marks are drawn in a diamond shape, and from the top of it,
two segments of lines the same size as the pubic lines are marked laterally in oblique
tery
ic
femoral artery
Group 3: Mid-lipoabdominoplasty– markings seem to be the same as used in
Group 4: Full lipoabdominoplasty– with the patient standing up in the hospital
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position according to the skin accidity. From the lateral points of these two segments, two markings are drawn on each side: one to conclude demarcation uniting
with the markings in the lower abdominal groove and another downward in oblique
direction to the center of the pubis, approximately 1 or 2cm laterally to this central
point, ending up with three marked areas in the lower abdomen (Fig.8.4a).
The subcutaneous space is inltrated with a saline solution (adrenaline saline
1:1000 mL) in the whole abdomen and anks (areas where liposuction is to be
performed) up to 1.5 or 2.0L.The surgery begins with small incisions in the pubis
and iliac regions (1cm in length), and deep liposuctions are performed in the whole
abdomen. Deep and supercial liposuction continues in the anks and in the lower
lateral abdominal areas previously marked. After liposuction, a total skin resection
is carried out in these lower lateral abdominal regions preserving the whole supercial fascia as well as the vascularization and lymphatic system. Now the skin
resection in the central area of the lower abdomen and a transverse strip of the
pubis reducing its length is performed up to the muscle fascia. A tunnel from the
upper border of the superior skin incision up to the xiphoid appendix is dissected
preserving the abdominal myocutaneous perforating vessels. The umbilicus is separated from the abdominal wall. The width of the tunnel varies according to the
diastasis of the rectus abdominis muscle up to 2cm laterally over its medial borders. Plication is carried out using a double zero mono-nylon in “X” separated
stitches from the xiphoid appendix to the pubis. The umbilicus is xed using two
stitches in its upper and lower extremity, leaving 1cm freed from the abdominal
wall. The supercial fascia is sutured in the middle line of the lower abdomen using
3-0 colorless mono-nylon. Now the table is set to 45°. The superior abdominal ap
is pulled down to be sutured starting with ve stitches in the pubic region using
zero mono-nylon. A “V” incision is performed on the navel new position, and it is
sutured on its new position at this time using internal stitches with 4-0 colorless
mono-nylon or Monocryl. Suture is concluded using subcutaneous separated
stitches with 3-0 colorless mono-nylon or Monocryl in the whole inferior abdominal incision. At this time, a complementary liposuction is carried out where necessary. Drains are not used. Dresser with dry gauze and elastic belt is used for
2months.
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Results
From July 2001 to January 2021, a retrospective study was carried out. A total of
2076 lipoabdominoplasty or only liposuction cases were performed by the senior
author using this described technique, in which 1066 were of liposuction only
(Fig.8.6), 112 of mini-lipoabdominoplasty (Fig.8.7), 97 of mid- lipoabdominoplasty
(Fig.8.8), and 801 of full lipoabdominoplasty (Fig.8.9). Patients’ ages ranged from
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J. Erfon et al.
Fig. 8.6 (a) Patient with lipodystrophy (pre-op for liposuction). (b) 6months post-op. (c) Pre-op
for liposuction. (d) 6months post-op
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Fig. 8.7 Patient submitted to mini-lipoabdominoplasty: (a, c) pre-op view. (b, d) 6months post-op
19 to 70years (the average age was 36.4years). The weight of skin resection varies
from 105 to 850g (the mean weight of skin resection was 465.48 g): full lipoabdominoplasty 704.40 g, mid-lipoabdominoplasty 498.10 g, and minilipoabdominoplasty 156.55 g, respectively. The liposuction volume ranged from
550 to 3850 mL (the mean volume was 2765.43 mL): full lipoabdominoplasty
3255 mL, mid-lipoabdominoplasty 3065 mL, and mini-lipoabdominoplasty
1845mL.The time of surgery varies from 1:30 to 3:00h (mean of 2:00h). Drains
are not used (Fig.8.3g). The time of follow-up was 6months or more when post-op
photography was taken (Figs.8.4, 8.5, 8.6, and 8.7).
Since 2001 when he began this technique, the senior author has observed better
results and less complications using lipoabdominoplasty when compared with the
traditional abdominoplasty technique that he used to perform before, from January
1980 to June 2001.
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J. Erfon et al.
Fig. 8.8 Patient submitted to mid-lipoabdominoplasty: (a, c) pre-op view. (b, d) Results 1year later
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a b
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Fig. 8.9 Patient submitted to full lipoabdominoplasty: (a, c) pre-op view. (b, d) 6months post-op
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c d
J. Erfon et al.
Fig. 8.9 (continued)
Complications
Since 2001, the senior author has been using the lipoabdominoplasty technique and
observed one important reduction in the number of complications when compared
with the traditional abdominal technique. He used to have more than 60% of seroma
using the traditional technique, which reduces to 0.40% using lipoabdominoplasty
technique. Considering the 1010 cases of lipoabdominoplasty (Groups 2, 3, and 4),
localized hematomas occurred in 0.30% of the cases, all of which were treated with
syringe aspiration only in the ofce: two cases in patients submitted to full
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lipoabdominoplasty (0.20%) and one case in mid-lipoabdominoplasty (0.10%); skin
necrosis occurred in the same patient submitted to mid-lipoabdominoplasty that had
hematoma, in 2cm at the distal end of the lower abdominal ap that needed reoperation with sedation and local anesthesia, with good results; one case (0.10%) of skin
allergy to chlorhexidine occurred on the fth day of post-op that needed hospitalization
and intensive treatment with satisfactory results but with spots on the skin in the whole
area where the antisepsis was done that were still being treated and slowly evolving;
hypertrophic scar occurred in 22 (2.21%) cases where most of them were treated with
triamcinolone and 7 (0.70%) of these needed surgical revision and beta therapy (radiation therapy) and trans-operative application of intra- scar triamcinolone; and secondary surgeries were performed in 52 (5.22%) of the cases for complementary liposuction,
and in 3 (0.30%) of these patients, more skin resection was carried out too.
For Group 1: 1066 patients undergoing liposuction alone, the main complication
was the 92 (8.63%) cases that required re-operation to improve aesthetic results.
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Discussion
Since 2001, the senior author has been using the abdominoplasty with liposuction
without undermining as described by Avelar (1999) to the cases of miniabdominoplasty introducing resection of the supercial fascia and subcutaneous
tissue on the central third of the lower abdomen (Erfon 2001). He later used the
same idea to perform full abdominoplasty as recommended by Saldanha that also
introduced the term lipoabdominoplasty (Saldanha et al. 2001). The author suggests, from the beginning, a simple and didactic classication for patients who are
candidates for this surgery, based on skin accidity, lipodystrophy, and diastasis of
the rectus abdominis muscles and the extent of scars necessary for surgical correction, grouping the patients into four groups, with the respective indication of the
type of surgery for each group: Group 1, liposuction; Group 2, minilipoabdominoplasty; Group 3, mid-lipoabdominoplasty; and Group 4, full lipoabdominoplasty. The author started dividing the lower abdomen into three areas: the
two lateral regions where the total skin was resected and the supercial fascia and
important anatomical structures were preserved and the central area that is resected
from the skin up to the muscle fascia including a transverse strip of the pubis reducing its length (Erfon 2002, 2009, 2011). The tunnel for plication is carried out from
the umbilicus up to 1 or 2cm over the xiphoid appendix and the width of this tunnel
up to 2cm lateral to the medial borders of the rectus abdominis muscles, preserving
the abdominal myocutaneous perforating vessels, permitting a good vascularization
of the abdominal ap and a safe plication (Erfon and Mauricio 2016). At the same
time, the term mid-lipoabdominoplasty was introduced to special cases that it’s
impossible to pull down the superior abdominal ap as is usual in full lipoabdominoplasty and needs more skin resection than in mini-lipoabdominoplasty, avoiding
supra-pubic or very high scars (Erfon 2001, 2002).
In the cases of mid-lipoabdominoplasty, the senior author recommends an adequate umbilicus-pubic distance of 6cm or more to improve the aesthetic results
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