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9 Classication forIndications ofLipoabdominoplasty
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Fig. 9.12 (a) Preoperative view of a 68-year-old woman with two previous pregnancies, seven
scars from previous surgery, excessive skin, and diastasis of the rectoabdominal muscles. (b)
Postoperative view 16months after anchor lipoabdominoplasty
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W. N. Matos Jr et al.
Fig. 9.13 (a, c) Preoperative views of a 42-year-old woman with three previous pregnancies and
60-kg weight loss. (b, d) Postoperative views 1year after lipoabdominoplasty, mastopexy, and
lipoplasty of the waist
9 Classication forIndications ofLipoabdominoplasty
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179
References
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2. Illouz YG.Une nouvelle technique pour lês lipodystrophies localisées. Rev Chir Esth Franc
1980;April:6.
3. Hakme F.Technical details in the liposuction associated with abdominoplasty. Rev Bras Cir
1985;75:331.
4. Wilkinson TS, Swartz BE. Individual modication in body contour surgery: the limited
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5. Bozola AR, Psillakis JM.Abdominoplasty: a new concept and classication for treatment.
Plast Reconstr Surg 1988;82:983–993.
6. Matarasso A.Abdominolipoplasty: A system of classication and treatment for combined
abdominoplasty and suction assisted lipectomy. Aesthetic Plast Surg 1991;15:111–121.
7. Pitanguy I, Salgado F, Murakami R, Radwanski HW, Manad R Jr. Abdominoplasty: classi-
cation and surgical techniques. Rev Bras Cir 1995;85:23–44.
8. Matarasso A. Liposuction as an adjunct to a full abdominoplasty. Plast Reconstr Surg
1995;95:829–836.
9. Matarasso A.Liposuction as an adjunct to a full abdominoplasty revisited. Plast Reconstr
Surg 2000;106:1197–1206.
10. Illouz YG.A new safe and aesthetic approach to suction abdominoplasty. Aesthetic Plast
Surg 1992;16:237–245.
11. Shestak KC. Marriage abdominoplasty expands the miniabdominoplasty concept. Plast
Reconstr Surg 1999;103:120–135.
12. Avelar JM.Uma nova técnica de abdominoplastia—sistema vascular fechado de retalho sub-
dérmico dobrado sobre si memo combinado com lipoaspiração. Ver Brás Cir 1999;13:3–20.
13. Avelar JM.Abdominoplasty: a new technique without undermining and fat layer removal.
Arq Catarinense de Méd 2000;29:147–149.
14. Corrêa MA. Videoendoscopic subcutaneous techniques for aesthetic and recon-
structive plastic surgery. Plast Reconstr Surg. 1995;96(2):446–53. https://doi.org/
10.1097/00006534-199508000-00030. PMID: 7624421.
15. Saldanha OR, De Souza Pinto EB, Matos WN Jr, Lucon RL, Magalhaes FF, Bello
EML.Lipoabdominoplasty without undermining. Aesthetic Surg J 2001;21:518–526.
16. Saldanha OR.Lipoabdominoplasty with selective and safe undermining. Aesthetic Plast Surg
2003;27:322–327.
17. Souza Pinto EB, de Erazo IPJ, Muniz A C, Prado Filho FSA, Salazar GH.Supercial liposuc-
tion. Aesthetic Plast Surg 1996;20:111–122.
18. Taylor GI.The superiorly based rectus abdominis ap: predicting and enhancing its blood
supply based on an anatomic and clinical study. Plast Reconstr Surg 1988;81:721.
19. Uebel CO.Miniabdominoplasty—a new approach for body contouring. Presented at the 9th
Annual Congress of the International Society of Aesthetic Surgery, NewYork, October 1987.
20. Delerm A.Renements in abdominoplasty with emphasis on reimplantation of the umbilicus.
Plast Reconstr Surg 1982;70:632–637.
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fusiform plications. Aesthetic Plast Surg 1996;20:249–251.
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improvement of body contour. Plast Reconstr Surg 1990;86:1008–1013.
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abdominoplasty. Aesthetic Plast Surg 1995;17:307–320.
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plasty. Ann Plast Surg 1987;19:436–447.
26. Rebelo C, Franco T.Abdominoplasty with inframammary scar. Rev Bras Cir 1972;62:249.
27. Carreirão S, Pitanguy I, Correa WE, Caldeira MC. Abdominoplastia vertical. Uma técnica a
ser lembrada. Ver Bras Cir 1983;79:184–194.
Chapter 10
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Medium Denition Lipoabdominoplasty:
ANatural Evolution ofHigh-Denition
Techniques
GiulianoBorille andLuisFernandezde Córdova
Abstract The technique presented is the result of reuniting two surgical tech-
niques, both described by Brazilian authors, the lipoabdominoplasty and mediumdenition liposuction.
The term medium denition was selected in order to differentiate this approach
from high-denition liposculpture techniques associated with the use of external
energy devices.
The four cornerstones of medium-denition liposuction are
1. absence of external energy, which allows a more supercial liposuction,
2. creation of thinner aps to mimic the conditions of an athlete in what we call the
athletic triad,
3. use of continuous compression of key areas of the skin by customized hand-
crafted pads,
4. prevention of umbilicus sagging.
The umbilical scar is a key aesthetic landmark of the anterior abdominal wall.
The aim of this chapter is to share the results of two popular body contouring
techniques combined, Medium denition Liposuction & Abdominoplasty. Taking
into consideration that liposuction may lead to the presence of loose skin, adding to
G. Borille
Division of Plastic, Aesthetic and Reconstructive Surgery, Clinica Borille, Porto Alegre, Brazil
L. F. de Córdova (*)
Division of Plastic, Aesthetic and Reconstructive Surgery, Global Plastic Surgery, Mexico, Mexico
Division of Plastic, Aesthetic and Reconstructive Surgery, Instituto Superior de Ciencias da
Saúde Carlos Chagas, Rio de, Janeiro, Brazil
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_10
181© The Author(s), under exclusive license to Springer Nature
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the equation the removal of excess skin and subcutaneos tissue through an abdominoplasty, allows for a tightening effect to occur, improving the body contour and the
aesthtetic of the abdominal wall.
Keywords Lipoabdominoplasty · Liposuction · Abdominoplasty · Muscular
denition
G. Borille and L. F. de Córdova
Introduction
The technique presented in this chapter is the result of combining two techniques:
medium-denition liposuction (MDLipo) and lipoabdominoplasty. Coincidentally,
both techniques were described by Brazilian authors, abdominoplasty without
undermining and fat layer removal by (Avelar 2000; Juarez and Illouz 1986; Ribeiro
et al. 2016; Saldanha 2003; Avelar 1983) and MDLipo by Borille.
In order to present abdominal denition, there must be three elements at the same
time that the authors refer to as the athletic triad:
1. Muscle hypertrophy
2. Small amount of subcutaneous fat
3. Tight skin
One of the technique specics that differentiate MDLipo technique from other
denition techniques is that it does not sculpt muscle anatomy in the subcutaneous
fat, creating volumes based on adipose tissue.
Medium-denition liposuction can be considered a sequence for obtaining natural
and dened results, from soft to high denition, with four exclusive cornerstones:
1. Absence of external energy from medical devices
2. Creation of thinner aps than those created by the traditional liposuction
approach (Fig.10.1)
3. The use of continuous compression of key areas of the skin by customized hand-
crafted pads, producing well-controlled brosis
4. Prevention of umbilicus sagging after liposuction
Since this procedure is based almost entirely on thinner aps and wider subcutaneous undermining, MD lipoabdominoplasty is not limited to a narrow central tunnel as previously described techniques.
The lack of external energy allows the surgeon to create thinner aps and aspirate
in more supercial planes, minimizing the risks in regard to ap survival due to
burns or necrosis, that are present when using Vaser, laser, or radiofrequency. These
thin aps depend on the vascular subdermal plexus preservation to ensure their
long-term viability. The nuances in pigmentation, ap survival, and aesthetic results
secondary to vascular territories are the reason for the specic cannula design used
(three holes, in line, one side of the tube) sparing the plexus from mechanic and
thermic trauma (Fig.10.2).
10 Medium Denition Lipoabdominoplasty: ANatural Evolution ofHigh-Denition...
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Fig. 10.1 Flap thickness
evaluation by
transluminescence
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Fig. 10.2 Custom-made
three holes, in line, one
side of the tube cannulas to
spare the plexus from
mechanic and thermic
trauma and ensure ap
survival
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Fig. 10.3 Skin retraction
and adhesion for muscular
denition after 12months
PO MD
lipoabdominoplasty
G. Borille and L. F. de Córdova
The instrument used during the procedure is as important as the customized
handcrafted abdominal pads that will allow the skin to adhere to the deeper muscle
anatomy through a process of well-controlled brosis production between the muscle transition and skin. This guided and controlled brosis aids in creating denition
by exposing real muscular anatomy, hills and valleys, lights and shadows, replacing
the role of external energy devices in skin retraction as shown in a 12 months postop
abdominal CT scan (Fig.10.3)
Patient Selection
Careful patient selection is critical to achieve ideal aesthetic results consistent with
medium-denition abdominal etching liposuction. The patient should follow a consistent exercise and diet routine and must have an overall athletic look with a lack of
abdominal denition due to muscular diastasis and the resultant muscular and skin
sagging (Table10.1).
Selection Criteria
1. Patients with hypertrophic and palpable rectus abdominis muscle under isomet-
ric contraction
2. Body fat index of 23% or less
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Table 10.1 Similarities and differences between lipoabdominoplasty, from its rst published
description, and medium-denition lipoabdominoplasty (Avelar 2000; Juarez and Illouz 1986;
Ribeiro et al. 2016; Saldanha 2003; Avelar 1983; Callia 1965; IIlouz 1980; Hakme 1985; Avelar
1999; Wilkinson and Swartz 1986)
Types of lipoabdominoplasty
Characteristic
Lower abdomen Supercial liposuction Deep liposuction Deep and supercial
Pubic liposuction No Yes
Areas of
liposuction
Type of liposuction Conventional Power-assisted Conventional
Scarpa fascia Complete preservation
Narrow undermine
in midline
Mons & lipoplasty No mons approach Lipoplasty and
Pubic xation No Yes No (progressive adhesion
Original Modied Denition abdominoplasty
liposuction
Inferior abdomen Flanks or dorsum Flanks and inferior abdomen
Removal in the
in inferior abdomen
Yes Yes No
inferior abdomen
mons lipolifting
Removal in the inferior
abdomen
No (Pubic dermolipectomy)
sutures in abdominal ap
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Skin Markings
Skin markings are guided by palpation of the muscular tendinous intersections of
the rectus abdominis muscle, linea alba, and linea semilunaris. The patient’s individual anatomy must be taken into account, because there are several different tendinous intersections between the abdominal muscles among patients. This is
fundamental to prevent an articial disconnection between the subcutaneous etched
shape and the muscle layer in the deeper plane.
Inltration
Less tumescent uid is used compared to the regular wet or tumescent liposuction
approach (700 cc solution in total containing saline 0.9% + adrenaline 1 mg/ml).
Medium-denition liposuction is preferentially performed when the abdominal
muscle outlines are still visible. This amount of tumescent uid is sufcient to prevent distortions and postoperative swelling and still prevent bleeding.
Access Sites forLiposuction Cannulas
The sites of the incisions for the access of the liposuction cannulas are systematically
and srategically planned to follow the skin markings and produce less visible scars.
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G. Borille and L. F. de Córdova
Cannulas
Two regular cannulas (3.5 and 4mm caliber) are used to perform the liposuction
according to the location of abdominal fat levels. The cannulas are perforated on
one side of the tube (3in line perforation) as previously described.
Liposuction
The abdominal musculature is topographically visualized according to the skin
markings guided by the palpation of the linea alba, the linea semilunaris, and the
tendinous intersections of rectus abdominis muscle. These landmarks are enhanced
with localized supercial liposuction to deepen the natural grooves or furrows, creating curves, light, and shadow effects on the skin (Fig.10.4).
The authors start debulking the deeper layers of fat just above the abdominal
muscles with 4mm cannulas and continuing to the mid-lamellar layer and between
muscle groups with 3.5mm cannulas.
Supercial liposuction, to dene the abdominal muscle that is outlined and
marked, is then performed. Each treatment area undergoes liposuction by using a
3.5mm cannula. It is very important to remove all the fat in the intersection areas,
creating a delicate transition zone between the abdominal muscular intersections, to
dene the supercial anatomy landmarks. Creating smooth transition surfaces and
avoiding sharp edges is key during this portion of medium-denition liposuction.
Abdominoplasty is performed, after liposuction, by an incision at the suprapubic
area and tissue detachment up to the xiphoid process and lateral edges of the rectus
muscle whenever necessary to achieve adequate tissue release with no tension nor
retractions. After the abdominal ap undermining, a vertical plication is performed
on the anterior rectus sheath, bringing the medial edges of the recti muscle together.
An additional horizontal plication is made on the suprapubic region, at the end of
the vertical plication (two layers with nylon 2-0 and Vicryl 1-0). After the plication,
progressive adhesion sutures are used, taking supercial bites from the ap into the
muscular wall.
Fig. 10.4 Examples of pre- and post-op cases of MD lipoabdominoplasty
10 Medium Denition Lipoabdominoplasty: ANatural Evolution ofHigh-Denition...
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To prevent umbilicus sagging after liposuction, due to the upper abdomen skin
losing tension and rolling over the umbilicus, creating a horizontalized shape even
if excess skin surgically removed, we created an umbilicus suspension system using
a temporary immobilization suture performed with a modied Reverdin’s needle
and 3-0 nylon suture.
Compression is of utmost importance. The authors place handcrafted pads, prepared in the operating room, to produce specic pressure points of contact between
the skin and the underlying rectus abdominis fascia right under the traditional compression garment.
At 48h post-op, patients remove and change the original compression pads for a
new customized compression kit (pads and garment). Our recommendation is to use
the pads and the garment for at least 1month after surgery.
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Discussion
A common concern when denition liposuction is performed is the pigmentation
complications related to supercial liposuction; however, the author reports less
than 1% of cases with dyschromia over the last 5years.
Medium-denition lipoabdominoplasty aims to create a t, natural look in
selected patients who already have a regular exercise routine, muscular hypertrophy, and low body fat. The idea is to create an athletic and t aesthetic look in
patients who lack abdominal denition in relation to their whole body even under
diet and exercise routines.
This approach is an alternative to denition techniques that need external energy
devices resulting in a lower rate of seroma, dyschromia, and necrosis when compared with VAHDL cases.
Being the main source of vascular nutrition of the ap, knowledge of the characteristics of the subdermal plexus and its preservation, using the adequate cannulas,
is critical for designing thin aps. The subdermal or cutaneous plexus is considered
to be the junction between the deep reticular portion of the dermis and the underlying subcutaneous fat tissue. The subdermal vessels have a kind of axiality, which
plays an important role in the development of a thin ap. Several thin aps in the
abdominal region have been reported since Nakajima proposed the concept of thin
ap in 1988. Furthermore, the author does not recommend the use of any type of
external energy in these types of aps, at risk of tissue damage and safety issues.
Using the proper approach, it is safe and feasible to produce thinner aps than in
previously described lipoabdominoplasty techniques, giving room for the surgeon
to apply a handcrafted and individual dressing that connects the skin and the underlying subcutaneous tissue to the deeper muscle layer exposing the muscle
denition.
The main idea is to reproduce the anatomical pattern of the “real six-pack” (muscle hypertrophy, small amount of subcutaneous fat, and tight skin) and mimic the
physiology; therefore, we, plastic surgeons, do not stimulate the creation of a
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