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G. Borille and L. F. de Córdova
non- existing phenomenon in nature, which is a mass index of 25 or more with a
muscular hypertrophic abdomen.
Conclusion
MD lipoabdominoplasty allows the correction of eventual muscle aponeurotic
defects through suture plication and excess skin removal in order to produce a natural athletic look by ensuring the athletic triad is present.
References
Avelar JM.Abdominoplasty: A new technique without undermining and fat layer removal. Arq
Catarinense Med. 2000;29:147–149.
Juarez M.A., Illouz, Y Lipoaspiraçao (1986) Ed. Hipócrates
Ribeiro RC, Matos WN Jr, Cruz PF. Modied lipoabdominoplasty: updating concepts. Plast
Reconstr Surg. 2016;138:38e–47e.
Saldanha OR. Lipoabdominoplasty with selective and safe undermining. Aesthetic Plast Surg.
2003;27:322–327.
Avelar JM.Abdominoplasty: technical renement and analysis of 130 cases in 8 years’ follow-up.
Aesthetic Plast Surg. 1983;7(4):205–212
Callia W.Contribuição para o estudo da correção cirúrgico do abdome pêndulo e globoso—Técnica
original [dissertation]. Faculty of the Medical University of São Paulo, 1965.
IIlouz YG.Une nouvelle technique pour lês lipodystrophies localisées. Rev Chir Esth Franc 1980;
April: 6
Hakme F. Technical details in the liposuction associated with abdominoplasty. Rev Bras Cir
1985;75:331.
Avelar JM.Uma nova técnica de abdominoplastia—sistema vascular fechado de retalho subdér-
mico dobrado sobre si memo combinado com lipoaspiração. Ver Brás Cir 1999;13:3–20.
Wilkinson TS, Swartz BE.Individual modication in body contour surgery: the limited abdomino-
plasty. Plast Reconstr Surg 1986;779–784.
Chapter 11
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MILA-Minimally Invasive Robotic and
Endoscopic Lipo-Abdominoplasty
MarcoAurelioFaria-Correa
Abstract The author presents his insights concerning mini-abdominoplasty tech-
nique, introduces new concepts and reports his more than 30years’ experience in
treating the functional and cosmetic deformities of the abdominal wall by using
minimal incisions open methods and minimally invasive methods to treat rectus
diastasis and lipodystrophy in patients without redundant skin. In 1989, he realized that:
• The rectus plication should not be limited to the lower abdomen but in its exten-
sion at all from the pubic bone to the xiphoid process.
• No skin resection when there was no abbiness or redundant skin.
• Perform the entire procedure through the pre-existent scars, without adding lon-
ger scars.
In 1991, the author started research project adapting endoscopic methods to the
subcutaneous territory and started doing endoscopic gasless subcutaneous rectus
plication- endoscopic abdominoplasty to treat patients with no redundant skin and
no previous scar. With approximately 300 cases done from 1991 to 2016, observing
optimal functional and cosmetic results, in patients with more than 20years’ follow-up, it proved the efcacy and longevity of the endoscopic abdominoplasty
method, giving to the author the enthusiasm for bringing the technique to the next
level by introducing in plastic surgery the new emerging technology of robotic surgery, incorporating robotic da Vinci Surgical System in his practice to perform
muscle-aponeurotic rectus plication-robotic abdominoplasty.
M. A. Faria-Correa (🖂)
Singapore, Singapore
e-mail: drmarco@drmarco.com
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_11
189© The Author(s), under exclusive license to Springer Nature
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M. A. Faria-Correa
Keywords Robotic plastic surgery · Robotic rectus plication · Robotic
abdominoplasty · Rectus diastasis · Endoscopic rectus plication · Endoscopic
abdominoplasty · Muscle- aponeurotic plication · Abdominal wall · Minimally
invasive subcutaneous surgery · Subcutaneouscopic surgery
Introduction
We are seeing an increasing number of female and male patients presenting with
small- and medium-sized abdominal deformities coming to our clinics asking for
minimally invasive and scarless procedures that can effectively improve their core
muscle and the aesthetic appearance of the abdomen (Faria Correa 2023). In many
cases, the problem is not the cosmetic aspect of the skin, nor striae, nor the redundant
folds of the skin, nor overweight nor abdominal lipodystrophy, but rectus diastasis
(Figs.11.1, 11.2, 11.3, 11.4, 11.5, 11.6, 11.7, 11.8, 11.9, 11.10 and 11.11). They
complain that despite working hard at losing weight and having a strict and rigorous
workout regime, they cannot get rid of that bulging stomach and/or the peri-umbilical deformity (sad belly button). The weakening of the muscle-aponeurotic abdominal wall due to congenital conditions, weight variation, ageing or pregnancy is a
Fig. 11.1 Mini-abdominoplasty with mini-dermolipectomy done in 1986 caused an anatomical
deformity by lowering the umbilicus position
11 MILA-Minimally Invasive Robotic and Endoscopic Lipo-Abdominoplasty
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191
a
b
cd
e
Fig. 11.2 Minimal scar abdominoplasty: xiphoid-pubic rectus plication, lipectomy, and no skin
removal performing the whole procedure using the previous “C-section scar” with the aid of light
source retractors. (a) Xiphoid-pubic rectus plication done. (b) Lipectomy being performed. (c)
Closure of the previous C-section with no skin resection. (d) Pre-operative drawing/planning. (e)
Adipose fat tissue excised and placed on top of the skin for demonstration
frequent cause of rectus diastasis and/or umbilical hernia that can alter the cosmetic
aspect of the abdomen (Faria-Correa 2016; Nahas and Ferreira 2010). The rectus
abdominal muscle plays an important role, not only in the cosmetic appearance of
the abdomen but also in the stability of the spine. Depending on the degree of the
rectus diastasis, it can lead to a vicious posture, spine problems, back pain, slipped
disc, etc. Rectus plication can effectively restore function providing a balance
between the anterior and posterior muscle of the abdominal wall and improve the
cosmetic appearance of the abdomen (Faria-Correa 2016; Nahas etal. 2001). The
long-term evaluation by ultrasonography and CT scan of the plication of the anterior
rectus sheath (Nahas etal. 2004, 2011) as well as our long-term clinic follow-up
(Fig.11.6) as shown, the efciency of the recti plication when properly performed.
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M. A. Faria-Correa
Fig. 11.3 Before and after minimal incision abdominoplasty
Evolution oftheThought
By analysing the results of mini-abdominoplasty in the treatment of small- and
medium-sized abdominal deformities, I have drawn the following conclusions:
• Plication of the lower abdominal rectus may cause a protrusion of the upper
abdomen; therefore, rectus plication from the pubis to the xiphoid process is
required.
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Fig. 11.4 Endoscopic abdominoplasty scars hidden inside the navel/umbilical area and inside the
pubic hair-bearing area
• Small skin resections in the lower abdomen will not help in the abbiness of the
abdomen and may cause dog ears and/or long scars, so I recommend no skin
resection and working through the smaller incision possible in patients present-
ing with good skin elasticity.
• The reposition of the umbilical scar below its original position may cause a dis-
tortion of the patient original anatomy, an unnatural and weird appearance, so I
recommend reinserting it in its original site.
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Evolution oftheMethod: FromtheLight Source Retractors
toEndoscopic andtoRobotic Methods
In 1989, I started performing mini-abdominoplasty without removing any skin, just
using the previous C-section scar, with the aid of light source retractors freeing the
umbilical scar, performing a xiphoid-pubic rectus plication and lipectomy and reinserting the umbilical scar in its original site (Figs.11.2 and 11.3).
Minimal Scar Abdominoplasty Technique
The beautiful results achieved by effectively treating the cosmetics and functional
deformities through minimal incisions, without adding new scars, but just by using
the previous scars and even improving it, gave me the enthusiasm.
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M. A. Faria-Correa
Fig. 11.5 Before and after endoscopic abdominoplasty
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Fig. 11.5 (continued)
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Fig. 11.6 Endoscopic abdominoplasty 20years’ follow-up showing the maintenance of the result
of the rectus plication even after patient aging 20years and put on 8kg
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Fig. 11.7 Long-term follow-up of endoscopic abdominoplasty after 35days showing a very fast
recovery with minimal swelling. After 2years, showing maintenance of the result of the rectus
plication and fat plication
M. A. Faria-Correa
In 1991 came to me one patient without previous “C-section” asking me if I
could treat her using a very small scar hidden inside her pubic hair-bearing area.
Attentive to the emerging video-endoscopic method, that was so promising, allowing the surgeons working through very minimal incisions, I had the idea of using
endoscopic methods in plastic surgery (Faria-Correa 1992a, 1994, 1995, 2008).
Then, at the University Hospital PUC Porto Alegre, I started a research project to
adapt endoscopic methods to the subcutaneous territory for treating patients presenting with rectus diastasis and no redundant skin, working through incisions as
small as 4cm hidden in the pubic hair-bearing area and inside the umbilical area
(Faria-Correa 1992a, b, 1994, 1995, 2008) (Fig.11.4). Those days there was a concept that we should not use pressured gas in the subcutaneous to develop the optical
cavity, the working space, due to the risk of gas embolism when cutting perforator
veins during the ap dissection and also the risk of gas dispersion causing the subcutaneous emphysema. For circumventing those risks, I developed a set of instru-
the muscle (Faria-Correa 1994, 1995, 2008) (Fig.11.12).
Attentive to the development of new instruments, machines and methods in surgery that can facilitate and improve our task and result and with more than 20years
of follow-up showing the effectiveness of the technique and the beauty of restoring
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Fig. 11.8 The before photo showing patient had abdominal deformities after delivering twins and
8kg overweight. 1-year follow-up after patient cut down 8kg. After 5years post-op, patient put
back 5kg. We observe the long-term maintenance of the result
the original anatomy leaving minimal and inconspicuous scars (Fig.11.4), in 2013,
I started studying and training robotic surgery with the enthusiasm of going for the
next level, using the robotic da Vinci Surgery System to perform rectus plication in
minimally invasive abdominoplasty (Faria-Correa 2016; Faria Correa 2023).
Robotic surgery is the “gold standard” of the minimally invasive surgery in many
surgical elds. The robot high-denition three-dimensional view and the amplication of images give us a much better depth sensation of the surgical eld than the 2D
endoscopic view, and it is even better than our naked eyes. Laparoscopic instruments have a limited range of motion; the robot EndoWrist range of movements is
comparable to the human wrist. The surgeon’s hand tremor is transmitted through
the rigid laparoscopic instrument, and this limitation makes delicate procedures
more difcult (Lee etal. 2014; Morris 2005). The superb precision and stability of
the robot arms, surgical eld and instruments, all controlled by the surgeon seated
at the console in a comfortable ergonomic position, without the need of coordinating camera and instrument movement with a surgical assistant, makes the surgery
much easier, more precise and less stressful (Faria-Correa 2016).
In urology, robotic prostatectomy is such a solid application, presenting so many
advantages over the open methods as well as over the endoscopic methods
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