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Fig. 27.1 The Avelar technique. (a) Liposuction is associated with minimal ap detachment. (b)
Three-umbilical-ap technique, which results in a scar hidden inside the umbilicus
P. R. Becker-Amaral et al.
ab
Fig. 27.2 Adhesion sutures in the abdominal wall. (a) Suture distribution in the abdominal wall.
(b) The ap is pulled during suturing
detachment areas (the Baroudi technique); these facilitate ap migration and reduce
the seroma incidence (Fig.27.2) (Baroudi and Ferreira 1998).
In-block resections (Xavier etal. 2019) are very practical but must be carefully
planned to avoid excessive resection. Usually, the ap surplus is estimated after
traction and the creation of adhesion points. Before surgery (thus during planning),
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if low-level accidity affects the navel opening, the inferior incision is moved
upward by 2cm. Very low scars from previous surgeries are not treated. If the navel
lies over 17cm from the vulvar furcula, a small vertical scar can remain. The ap
should not be tense.
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Mammoplasty
Breast augmentation is performed via an inframammary incision, with implants
generally placed in the retroglandular plane (sometimes the dual plane) but rarely in
the retromuscular region. Preferred implants are round with a high prole and either
coated with polyurethane or textured. Volumes above 300 mL are to be avoided. If
asymmetry is evident, the maximum between-implant volume difference should be
50 mL. If this does not correct the asymmetry, tissue from the larger breast is
resected. Mastopexies with augmentation are performed similarly, followed by
adjustment of the gland and skin over the implant. If the target area is very accid,
implants of volumes over 250 mL can be used in anticipation of the recurrence of
ptosis. In mastopexies without augmentation, the breast consistency, shape, and
position are corrected from the inside out; accid tissues are compacted by suturing
without excessive tension. Whenever possible, the use of implants is avoided.
Existing implants are removed via capsulotomy or capsulectomy and then replaced.
Capsulotomies remove thin dystopic capsules and those exhibiting contracture up to
Baker grade II.Capsulectomies are reserved for thick, calcied, or restricted capsules. Occasionally, we deploy Blake drains (bilateral or unilateral) and retain them
until the daily drainage is less than 50 mL of clear liquid. When dealing with retromuscular capsules, the anterior leaet is removed, and the posterior one is abandoned, because excision raises a risk of pneumothorax. The Pitanguy technique is
used for reduction mammoplasties (Pitanguy 1967). If necessary, all three dimensions of the breast can undergo internal resection. Then, pillars are approximated
and anchored to the thorax along the mid-breast line, remodeling and stabilizing the
new breast. Internal aps (Ribeiro etal. 2002) are sometimes required when assembling a new breast, but should not be under tension, because this raises a risk of steatonecrosis (especially in fatty breasts). The lower incisions of reduction
mammoplasty and mastopexy are located near the inframammary fold and are sufciently long to allow (optimal) skin nishes at the extremities. The areolar positions are dened after the breasts are set. A medially based areola ap is used (the
Silveira-Neto technique (Silveira Neto 1976) when the areolae must migrate by up
to 5cm. In these cases, the ap can be thin or up to 2cm thick and should rotate
freely, thus without twisting or compression. The Robbins technique (Robbins
1987) is used to treat cases of grade III gigantomastia. The areolar ap features a
10-cm-thick inferior base when the areolae must migrate 10cm or more. In breasts
that have already undergone areolar mobilization, careful planning and execution
are essential to ensure that areolar circulation is well maintained. After mastopexy
and reduction mammoplasty, the skin should cover the surgical site adequately.
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P. R. Becker-Amaral et al.
After abdominal procedures and mammoplasty, sutures are placed in several layers
(separate stitches of Mononylon 4.0–5.0), and wound edges at the surface are
approximated without tension (using a continuous suture of Monocryl 4.0). The
umbilicus is closed using separate Mononylon 5.0 sutures.
Postoperative Considerations
Sutures are covered with two layers of gently applied microporous tape, and the
patient is dressed in a soft compression girdle. Compression girdles are unnecessary
and uncomfortable and increase the risk of venous thrombosis (Haidar and Nahas
2015). We recommend compulsory prophylactic analgesics for the rst 3 days and
then as needed. The patient should walk for 10min every 2 h during the day for 10
days. The team remains in constant contact with the patient, and two check-ups
weekly are performed for the rst 2 weeks. Each patient is told to contact the team
or to go to the hospital emergency room if she develops a fever (38 °C), pain, swelling other than what is expected, or dyspnea or chest pain.
Complications
A recent systematic review reported 5–14% risks of major complications such as
death, hematoma, bowel loop perforation, deep vein thrombosis, pulmonary thromboembolism, myocardial infarction, necrosis of the abdominal ap greater than 5
cm, extrusion of the implant, necrosis, suture dehiscence, infection, and need for
blood transfusion after the procedures described above (Michot etal. 2015). We
agree that cardiac, pulmonary, and anesthesia-related risks must be considered, but
the abovementioned risks are not statistically signicant. Also, certain complications (such as the need for blood transfusion) are associated with the liposuction
volume and not due to an association between lipoabdominoplasty and mammoplasty (Matarasso and Smith 2015). The most feared complication is deep vein
thrombosis that precedes a fatal pulmonary thromboembolism (Keyes etal. 2018;
Hatef etal. 2008) (Table27.4).
Table 27.4 Measures preventing venous thrombosis
Evaluate any personal (e.g., abortion) or family history of venous thrombosis
Maintain body temperature, hydration, and blood pressure during surgery and perform
intermittent lower limb compression
Limit the time and extent of surgery
Prescribe a soft compression shaper
Prescribe 40 mg/day of enoxaparin commencing at 12 h after the end of surgery for 10 days
Suspend hormones and oral contraceptives for 15 days prior to surgery
Encourage early ambulation for 10min every 2 h during the day for 10 days
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Fig. 27.3 A 38-year-old patient, with one previous pregnancy, BMI = 28 kg/m2, and no comorbid-
ity. Liposuction of the back, anks, and abdomen, 2.5 L; lipoabdominoplasty, 1550 g; reduction
mammoplasty, 1000 g. The results after 60 days
Results
We present the outcomes of two patients after the procedures described above
(Figs.27.3 and 27.4; Table27.5).
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P. R. Becker-Amaral et al.
Fig. 27.4 A 35-year-old patient, with two previous pregnancies, BMI = 28 kg/m2, no comorbidity,
and a history of weight loss of 12kg after dieting and physical activity. Liposuction of the back,
anks, and abdomen, 2.8 L; lipoabdominoplasty, 1900 g; augmentation mammoplasty with placement of textured implants 355 cc in volume (high prole). The results after 90 days
Table 27.5 Tips for
optimizing safety and
surgical results
1. Make careful diagnoses and
review the indications
2. Select patients and know how
to say “no”
3. Establish clear team routines
4. Operate in an appropriate
surgical environment
5. Limit the extent of surgery
6. Be attentive to the patient
postoperatively
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415
References
International Society for Aesthetic Plastic Surgery. Statistics Report. 2019.
Rao YV (1969) Augmentation mammaplasty and abdominoplasty in one stage. Plast Reconstr
Surg; 43(2):148—51.
Rohrich RJ, Broughton G, Horton B, etal (2004) The key to long-term success in liposuction: A
guide for plastic surgeons and patients. Plast Reconstr Surg; 114:1945–1952
Kaye BL, Gradinger GP (1984) Symposium on Problems and Complications in Aesthetic Plastic
Surgery of the Face. St. Louis, MO: CV Mosby
Pitanguy I, Ceravolo MP (1983) Our experience with combined-pro- cedures in aesthetic plastic
surgery. Plast Reconstr Surg; 71(1):56—65
Winocour J, Gupta V, Ramirez JR etal (2015) Abdominoplasty: Risk Factors, Complication Rates,
and Safety of Combined Procedures. Plast Reconstr Surg;136(5):597e-606e
Khavanin N, Jordan SW, Vieira BL etal (2015) Combining abdominal and cosmetic breast surgery
does not increase short-term complication rates: a comparison of each individual procedure and
pretreatment risk stratication tool. Aesthet Surg J; 35(8):999-1006
Hardy KL, Davis KE, Constantine RS (2014) The impact of operative time on complications after
plastic surgery: a multivariate regression analysis of 1753 cases. Aesthet Surg J; 34(4):614-22
Kaoutzanis C (2017) Cosmetic Liposuction: Preoperative Risk Factors, Major Complication
Rates, and Safety of Combined Procedures, Aest Surg J; 37(6)680-694
Klein J (1993) Tumescent technique for local anesthesia improves safety in large volume liposuc-
tion. Plast Reconstr Surg; 92(6):1085-100
Avelar JM (1978) Abdominoplasty: systematization of a technique without external umbilical scar.
Aesthetic Plast Surg; 2:141-51
Baroudi R, Ferreira CA (1998) Seroma: how to avoid it and how to treat it. Aesth Surg J;
18(6):439-41
Xavier LB, etal (2019) Ronaldo Pontes’s in Block Resection Abdominoplasty Technique. Int J
Transplant & Plastic Surg; 3(2): 000135
Pitanguy I (1967) Surgical treatment of breast hypertrophy. Br J Plast Surg; 20:78-85
Ribeiro L, Accorsi A, Buss A etal (2002) Creation and evolution of 30 years of the inferior pedicle
in reduction mammaplasties. Plast Reconstr Surg; 110(3):960-70.
Silveira Neto E (1976) Mastoplastia redutora setorial com pedículo areolar interno. In: Anais do
XIII Congresso Brasileiro de Cirurgia Plástica e I Congresso Brasileiro de Cirurgia Estética
Robbins TH (1987) Reduction mammaplasty by the Robbins technique. Plast Reconstr Surg;
79(2):308-9
Haidar RB, Nahas FX (2015) Does the Use of Compression Garments Increase Venous Stasis in
the Common Femoral Vein? Plastic and Reconstructive Surgery; 135(1)85-91
Michot A, Alet JM, Pélissier P et al (2015) Morbidity in combined-procedure associat-
ing abdominoplasty and breast surgery: A systematic review. Ann Chir Plast Esthet;
S0294-1260(15)00131-4
Matarasso A, Smith DM (2015) Combined breast surgery and abdominoplasty: Strategies for suc-
cess. Plast Reconstr Surg; 135:849e–860e
Keyes GR, Singer R, Iverson RE etal (2018) Incidence and predictors of venous thromboembo-
lism in abdominoplasty. Aesthet Surg J; 38:162–173
Hatef DA, Kenkel JM, Nguyen MQ etal (2008) Thromboembolic risk assessment and the ef-
cacy of enoxaparin prophylaxis in excisional body contouring surgery. Plast Reconstr Surg;
122:269–279
Chapter 28
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Renuvion-Assisted Body Contouring
Surgery
JohnEdwinGarciaSerna, RicardoCavalcantiRibeiro,
andLuisFernandezde Córdova
Abstract Liposuction is one of the most frequently performed cosmetic surgery
procedures worldwide (Markey, Clin Exp Dermatol 26:3–5, 2001), the second most
commonly performed in the United States, and the most common procedure between
the ages of 35 and 64 years (Wu etal., Cleve Clin J Med 87(6):367–375, 2020).
Liposuction has rapidly evolved since the 1970s, when it was rst described by
Arpad and Giorgio Fischer, father and son, who developed the modern and popular
technique of body contouring. It is currently widely used in clinical practice for
many different aesthetic and reconstructive cases (Bellini et al., Ann Med Surg
24(August):53–60, 2017).
The aesthetics of the body is of great importance nowadays. Having a slim gure
has become a primary goal for most people. Liposculpture cases have increased in
recent years in an exorbitant way, in which bodies are subjected to transformations
aiming to improve their appearance. Trying to have a slender gure is a notorious
desire mostly for women, starting from an early age (García Cano, Tesis
May:31–48, 2016).
Keywords Liposuction · Body contour · Power-assisted liposuction · Skin
tightening
J. E. G. Serna
Plastic and Reconstructive Surgery, Clínica Corpus and Rostrum, Cali, Colombia
R. CavalcantiRibeiro (*) · L. F. de Córdova
Plastic and Reconstructive Surgery, Federal University of the State of Rio de Janeiro,
Rio de Janeiro, Brazil
e-mail: rribeiro@centroin.net.br
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_28
417© The Author(s), under exclusive license to Springer Nature
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Liposculpture is an aesthetic surgical procedure that sculpts the body with the idea
of giving it an attractive and stylized shape. It is one of the most frequently performed procedures worldwide (Markey 2001), the second most commonly performed in the United States, and the most common procedure between the ages of
35 and 64 years (Wu et al. 2020). It is important to emphasize that liposculpture is
not a procedure for losing weight but for body contouring (Černauskis etal. 2020),
eliminating localized fat deposits that do not respond to diet and exercise currently
widely used in clinical practice for many different aesthetic and reconstructive cases
(Bellini et al. 2017). After liposuction, the redundant skin, when present, will retract
at some extent; when it does not readapt by itself to the new contour, surgical techniques with advanced energy technology such as RENUVION may be used.
RENUVION is the new treatment for maximum skin tightening based on the
effect of ionized helium plasma, which allows heating of the tissues (heat on the
tissue), applied in a minimally invasive procedure, combining the unique properties
of cold helium plasma with radiofrequency energy deep into the tissue during application (Renuvion cosmetic tecnology 2018).
Most of the energy is delivered directly to the network of brous septa allowing
a greater concentration of energy, a well-delimited area to be treated, and up to
65% of skin contraction, improving accidity in areas such as the abdomen, arms,
back, thighs, face, and neck. (It) is an alternative for many people who do not want
to undergo surgery due to undesirable scars. What makes this technology unique is
that it can rapidly heat (warm up) subdermal tissues without leaving a burn injury.
Helium plasma also (has a long-term stimulation) stimulates in the long term; during the following 6 to 9 months, the one session (will) keeps acting (settle) in the
production of collagen and elastin, essential for tissue regeneration and skin tightening (Gentile 2018).
J. E. G. Serna et al.
Preoperative Care
(The) Doctor-patient communication is of utmost importance. The (patient’s rea-
sons/inquiries) WHY of the patient must be understood thoroughly as well as the
expectations linked to the procedure. We, as plastic surgeons, should make sure that
only realistic expectations and attainable results are brought to (into) the conversation
and try to understand the unique concept of beauty of each patient (Tabbal etal. 2013).
The overall health status of the patient is evaluated by four specialists (psychologist, anesthesiologist, internist, and plastic surgeon) through a complete medical
history and a battery (various) of tests such as CBC, coagulation tests, pregnancy
test, blood sugar, HIV, urinalysis, EKG, and BMI, among others.
Routine preoperative recommendations in our practice include the following:
• No medications before surgery : stop taking anti-inammatories and anticoagu-
lants from 1 to 7 days prior to surgery unless otherwise instructed, oral contra-
ceptive pills or hormone replacement therapy should be suspended 2 months
prior to surgery.
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• No smoking, no drinking alcohol at least one month before the suregry.
• Full iquid diet for 2 days before the procedure.
• 12 H preop Fasting.
Surgical Technique
Markings must be done in front of a mirror, which allows (allowing) the patient to
be an active participant in the process, and (keeping a) proper standing position
(posture) and lateral decubitus (Figs.28.1, 28.2, and 28.3).
The patient is transferred (taken) to the surgical area to take (their) vital signs,
and venipuncture is performed to start prophylactic antibiotic therapy. The skin is
surgically washed with iodinated solution with (while) the patient (is) in a standing
position (on their feet).
The patient is placed on the operating (surgical) table in a sitting position under
sedation, and the anesthesiologist proceeds to place the epidural anesthesia.
Afterward, with the patient in supine position, we place intermittent pneumatic
Fig. 28.1 Markings for surgery
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Fig. 28.2 Surgical
marking in standing
position
J. E. G. Serna et al.
Fig. 28.3 Surgical
marking in lateral
decubitus
compression on the lower limbs and thermal insulation, urine output should be
controlled with a Foley catheter introduced with aseptic technique, and sterile surgical elds are placed.
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