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Lipoabdominoplasty
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JulianDuran
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21.1 Lipoabdominoplasty
Key Points
• Lipoabdominoplasty has been evolved and described as a
safe and functional procedure that allows liposuction and
abdominoplasty to be carried out during the same surgical
approach, enhancing the benecial effects of both
procedures.
• This technique does not just involve the addition of liposuction as a procedure while undertaking a tummy tuck. It
supposes a much higher conception that contemplates the
understanding of the complete anatomy of the abdominal
wall as a selective detachment and preservation of the
Scarpa’s fascia, which will be analyzed in this chapter.
• By preserving the vascular supply (arterial as well as perforating veins), the nerves, and the draining lymphatics,
this technique has reduced the complications
signicantly.
21.1.1 Introduction
1. There is a high morbidity rate associated with the tradi-
tional way of undermining and wide tissue separation in
cosmetic surgery of the abdomen.
2. Cosmetic and plastic surgeons had a level of unsatisfac-
tion with the traditional abdominoplasty due to the cosmetic results and the increased complication rate.
3. Surgeons prefer to offer procedures which have good
results with a low complication rate. In the 1990s several
studies were published regarding the decrease in detachment and the tendency to avoid performing a complete
liposuction in the abdominoplasty, due to the increase in
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_21].
J. Duran (*)
Corpo D’oro, Bogota, DC, Colombia
complications. Patient safety was our main goal when
lipoabdominoplasty was developed. The said procedure
established a limit on the detachment of the abdominal
skin ap, so that it is safe with regard to vascularity and
giving a much better aesthetic result. It is easy to understand for surgeons who are used to performing the discussed approaches, liposuction, and tummy tuck
separately [1].
21.1.1.1 Observations
About 80% of the blood supply to the abdominal wall comes
from the perforating vessels coming from the deep muscles
as per the published evidence.
Vascularity of the remaining area comes from the lumbar,
subcostal, and intercostal perforating branches, which are
located in the regions of the back and sides. Abdominoplasty
when associated with extensive liposuction (without selective detachment) is associated with complications caused
due to the ischemic process, with tissue necrosis and suture
dehiscence has been described.
21.1.2 Preoperative Preparation
1. Indications: The indications are the same as that for the
traditional abdominoplasty namely skin laxity, excess
deposition of adipose tissue, in addition to divarication of
the rectus abdominis muscles).
2. Surgeons who wish to apply this technique should start
by applying it to patients with excessive sagging skin and
overweight patients. They will soon develop greater condence regarding this approach, whose learning curve is
short.
3. The whole abdominal wall should be assessed for a weak-
ness or hernias in the abdominal muscle and it is important to rule out ventral, lumbar, and femoral hernias. I
recommend and routinely perform a preoperative
ultrasound of the abdominal wall for all patients wanting
an abdominoplasty to look for possible hernias.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_21
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21.1.2.1 Warnings
1. A previous abdominal liposuction will cause residual scar
and brous tissue, which can hinder the mobilization of
the abdominal ap.
2. Any surgical incision scar even caused by an endoscopic
intervention can cause an adhesion and a weakness in the
fascia, which may allow the cannula to pass through the
fascia of the abdominal musculature.
3. This intervention should never be performed in hernia
patients.
21.1.2.2 Observations
A high suprapubic incision should be planned in patients in
whom the abdominal ap cannot be mobilized adequately.
21.1.2.3 Anatomy
A complete reconstruction of the abdominal wall in the
lower abdomen extending between the navel and the pubis
can be achieved by the maintenance of Scarpa’s fascia and
the partial preservation of the deep fat layer in the lower
abdomen.
The detachment of the tunnel is carried out and the undermining is done between the medial edges of the rectus muscles, in correspondence with the area of diastasis, conserving
at least 80% of the perforating vessels, and preserving the
lymphatic vessels and nerves as well. Since the sensory
nerves of the abdominal wall travel along the perforating
vessels because of which this reduced detachment results in
increased sensation in the abdominal skin in the postoperative period.
21.1.3 Surgical Technique
This technique is based on the three fundamental principles
described below:
1. Supercial and deep liposuction:
Liposuction should be carried out in the deep as well
as the supercial plane so that the abdominal ap becomes
more mobile and it can be easily moved to the suprapubic
region.
2. Anatomical study of abdominal blood supply: [2]
The study of the exact location of the abdominal per-
forating vessels did lead to a selective detachment (creation of a tunnel) with the maintenance of at least 80% of
the blood supply to the abdominal wall, less trauma to the
nerves, and maintenance of Lymphatic drainage. This
approach results in fewer complications than traditional
tummy tuck even in post-bariatric surgery.
3. Maintenance of the Scarpa’s fascia:
Although removal of Scarpa’s fascia is a norm in
lipoabdominoplasty, maintaining it is one of the most relevant principles of this technique.
21.1.3.1 Marking
1. The skin excision lines are rst marked (Figs.21.1 and
21.2).
2. Areas where liposuction is to be performed are then
marked (Fig.21.3).
3. Any weakness of the abdominal muscle (diastasis of the
recti) is then marked (Fig.21.3).
Fig. 21.1 Horizontal marking
Fig. 21.2 Demarcation of the previous diastasis
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Fig. 21.3 Initial distance to the pubis
Observations
Point A: A midline point 7cm from vulva (Fig.21.4)
Points B and C: Parallel horizontal line of 14cm marked
on point A.Point B: right side; Point C: left side of the patient
Point D: 7cm from point B in the direction of the patient’s
right iliac crest
Point E: 7cm from point C in the direction of the patient’s
left iliac crest
In summary, the distance between the points is:
A/B: 7cm
B/D: 7cm
C/E: 7cm
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Fig. 21.4 Oblique marking
The total length of the marking: 28cm.
21.1.3.2 Inltration
1. Tumescent technique (Fig.21.5).
2. Saline solution 1: 500,000 with epinephrine in the abdominal region (average of 1–1.5 Litres) (Fig.21.5).
3. Lidocaine is not used.
21.1.3.3 Upper Abdominal Liposuction
1. Position of the patient should be in hyperextension on the
operating table (safest position).
2. The diameter of cannulas used for the supercial and
deep liposuction should not be more than 3 and 4mm.
3. Liposuction extended to the sides as lateral limits and up
to the submammary sheet as upper limit (Fig.21.6).
Important Points to Note in This Step
The thickness of the skin left after liposuction should not be
less than 2.5 cm and it has to be maintained uniformly to
prevent vascular loss and contour unevenness.
Fig. 21.5 Inltration
Aggressive liposuction undertaken in the upper quadrant
of the abdomen not only helps in suctioning fat but also
mobilizes the abdominal skin(detachment with the cannula)
to help in the lowering of the ap. This is an important step
of the operation and is most important to achieving satisfactory results.
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Fig. 21.6 Upper abdominal liposuction
J. Duran
Fig. 21.8 Evaluation of ap descent
Fig. 21.7 Lower abdominal liposuction
21.1.3.4 Lower Abdominal Liposuction
1. Complete aggressive liposuction using a 6mm cannula is
carried out of the supercial fat layer in the lower abdomen (Fig.21.7).
2. Deep layer of fat in the lower abdomen now undergoes
partial liposuction with a 4mm cannula.
3. The loss of thickness and the movement of the upper
abdominal ap (Fig.21.8).
Observations on this Step
Lower abdomen liposuction is not considered necessary by
many surgeons, even considered a waste of time as the lower
abdomen tissue will be resected during abdominoplasty.
However, it is important to undertake liposuction of the
entire supercial layer in the infra umbilical area, which
allows a better visualization of Scarpa’s fascia (this is important and constitutes one of the most essential steps of this
procedure) followed by a partial liposuction in the layer deep
to the Scarpa’s fascia, which will reduce the fat layer, offering a fabulous body contour.
Fig. 21.9 Open liposuction being undertaken in the lower abdomen to
remove any prominent fat pockets
21.1.3.5 Incision andDetachment intheLower
Abdomen
1. Incisions are made as per the markings done
preoperatively.
2. The lower abdomen skin ap needs to be peeled above
the level of Scarpa’s fascia.
3. The navel is incised and skeletonized.
Points to Observe
If fat deposits are still found after skin excision then a complementary open liposuction can be undertaken to resect
adipose tissue and create a uniform surface on which to
apply the upper abdomen ap that is moved downward
(Fig.21.9).
21.1.3.6 Conservation ofScarpa’s Fascia
It is important to conserve the Scarpa’s fascia due to the following reasons (Fig.21.10):
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Fig. 21.10 Maintaining the scarpa’s fascia
Fig. 21.11 Lateral scar containment
1. Fewer hemorrhages and fewer seromas occur due to the
preserved perforators and lymphatics in the lower abdomen. This results in less morbidity.
2. A uniform support is created with chances of greater
adherence between the skin ap and the deeper tissues.
3. It results in the containment of scars laterally (Fig.21.11).
Fig. 21.12 Selective detachment from the tunnel
Fig. 21.13 Selective detachment from the tunnel
21.1.3.7 Selective Peeling (Creating aTunnel)
1. The upper abdominal skin is detached from the muscular
abdominal wall in the midline between the medial edge of
the bilateral rectus abdominis muscles (Figs. 21.12,
21.13, and 21.14). Failure to dissect in a limited fashion
as mentioned can damage the perforating vessels, increasing the risk of necrosis due to reduced blood supply of the
abdominal ap.
Fig. 21.14 Perforator vessels supplying the skin
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2. Depending on the extent of plication needed of the rectus
sheath, the dissected tunnel can be created till the xiphoid
process is reached.
3. The dimensions of the tunnel vary depending on the
width of the muscular diastasis because the perforator
vessels emerge from the body of the rectus muscles.
In this phase of the surgery, we recommend using an
author retractor that has the following advantages.
• Better visualization of the tunnel and anatomical
structures.
• Greater ease of plication of the rectus muscle.
• Avoid trauma to the ap edges.
Observations on This Surgical Step
To facilitate ap descent, discontinuous peeling can be performed using the liposuction cannula without suction on the
upper abdomen.
Once the surgeon is sure of the ap transposition over the
pubic symphysis, he can section the excess skin in the lower
abdomen (Fig.21.15).
21.1.5 Postoperative Care
1. Change of dressing takes place on the third day and
8days postoperative. All stitches except those around the
naval area are removed on the eighth day while those
around the umbilicus are removed on day 12.
2. The drain is removed 1–2days postsurgery depending on
the amount of drainage.
3. Patients undergoing lipoabdominoplasty have an intermediate recovery period between that required for
abdominoplasty and liposuction (Fig.21.17).
This approach is minimally invasive, causing less neurovascular damage, and produces little or no dead space which
leads to less mortality and allows the patient to resume early
social and professional activity (Fig.21.18).
21.1.4 Optimization oftheResults
The combination of liposuction and tummy tuck has
improved over the years, is now safe, and leads to further
improvement of body contour due to reduced abdominal
measurements. Since the adoption of this technique, the
demand for surgical revisions has decreased (Fig.21.16).
Fig. 21.16 Resection of the infraumbilical fat from the deeper plane
Fig. 21.15 Resection of the infraumbilical skin
Fig. 21.17 Vertical plication of rectus sheath
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Fig. 21.18 Suture of the layers and scar reduction
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to abdominal skin excision but also due to aggressive liposuction causing reduction of the fat layers in the upper and
lower abdomen and anks.
The 100% increase in the demand for abdominal surgery,
not registered in other techniques, demonstrates the high
degree of acceptance of the technique by patients and their
recognition of the improvements involved.
There is a signicant reduction in demand for any surgical
revisions is another fact that has led other surgeons to apply
this procedure for other patients.
It is important to use closed vacuum suction drainage to
evacuate the inltrated uid during liposuction.
On the other hand, the technique has made it possible to
preserve suprapubic sensitivity, faster healing, also a shorter
postoperative recovery, lower morbidity, and a more aesthetic umbilical scar.
Lipoabdominoplasty has shown that it is especially indicated also in high-risk patients (smokers and patients with
previous abdominal scars) due to the preservation of the
abdominal perforating vessels.
Fig. 21.19 Drainage
21.1.6 Complications andIts Treatment [3–5]
By carefully following the surgical steps as proposed, lipoabdominoplasty considerably reduces difcult to treat complications, which can affect the doctor–patient relationship
(Fig.21.19).
A signicant reduction in complications, such as sero-
mas, bruises, and ap necrosis, has been demonstrated.
This technique avoids a two-stage intervention (abdominoplasty and liposuction isolated) in patients who are good
candidates for abdominoplasty. A body shape having harmony can be conservatively achieved by carrying out liposuction safely in the abdominal and rib region and with
minimal morbidity.
Lipoabdominoplasty has a greater effect on the abdominal measurements and reduction in body shape not only due
21.2 Lipoabdominoplasty inCombined
Body Remodeling Techniques
Key Points
• The combination of lipoabdominoplasty with secondary
cosmetic interventions can lead to an intense physical
transformation.
• Careful patient choice is essential to reduce the likelihood
of serious complications and unwanted episodes.
• A personal and family history of coagulopathies are
essential pieces of information when conducting preoperative evaluations.
• A satisfactory result is obtained when, on the one hand,
the requirements of the ideal patient and adequate technique are met, and on the other, realistic surgical objectives are set.
21.2.1 Introduction
It has been demonstrated that lipoabdominoplasty allows us to
obtain aesthetic results equivalent to or greater than those
achieved by traditional abdominoplasty with minimal complications. There has been a signicant reduction in revision surgery due to greater patient satisfaction as compared to
traditional abdominoplasty. When lipoabdominoplasty is combined with other cosmetic procedures, there is no increase in
complications related to the abdominoplasty, such as seromas,
bruises, or scarring, while the surgical areas are barely visible.
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In the past, there was a higher risk of complications when
abdominoplasty was undertaken as part of a combined
technique.
The relatively recent addition and use of patient- controlled
pain relief pumps in all cases of tummy tuck have enabled
patients to walk earlier and more easily. A decrease in opiate
use, earlier mobilization, and faster physical recovery have
also been observed in patients.
By better preserving the innervation and vascularity of the
anterior abdominal wall, lipoabdominoplasty probably
reduces many of the more frequent and aggravating complications of traditional abdominoplasty, including seromas and
necrosis of the lower skin ap. This approach can be applied
in combination with other aesthetic techniques to achieve a
more spectacular transformation.
21.2.2 Preoperative Preparation
Liposuction of adjacent areas and breast remodeling are the
most demanding surgical operations along with abdominoplasty in this context, although patients may also request secondary interventions in distant areas, such as facial
rejuvenation. Approaching several areas in the same surgical
procedure is an exciting possibility that, in appropriate cases,
may be acceptable. With the right selection of patient and
appropriate planning preoperatively, lipoabdominoplasty
can be undertaken safely along with additional aesthetic
approaches.
Given the decision to perform a technique combined with
lipoabdominoplasty, the selection of the patient has consequences of great importance. Any pre-existing health disorder that can prevent prolonged general anesthesia should be
ruled out prior to surgery. Likewise, before any combined
approach to several regions, it is convenient to carry out the
appropriate preoperative laboratory tests. Cardiac or lungrelated conditions need intervention by relevant specialists
during preparing for the surgery, in addition to the anesthesiologist. An approximate surgery duration based on past
experience should be honestly communicated by the
surgeon.
Patients being considered for this surgery must have a
stable weight for a few months prior to surgery along with
nutritional stability. Achieving a normal BMI may always
not be a realistic goal, although the patient with higher BMI
should be advised to lose weight prior to any surgical intervention without which these patients may not have an optimal result.
Evaluation should also include a detailed discussion about
personal and family history of bleeding tendencies and coagulopathy, including information on spontaneous abortions.
Smokers should not undergo combined techniques due to the
high probability of wound complications and lung involvement. Oral contraceptives and hormone replacement therapy
may increase the risk of thrombosis and should be discontinued weeks before surgery.
In the population undergoing the combined technique, the
dedication of the patient to complete body transformation is
very high, and expectations are no less so. The result of the
surgery is expected to be transformative and impactful, given
the nancial outlay and time dedicated by the patient.
For all these reasons, extensive preoperative discussions
are required, using photographs of the patient himself and
highlighting the realistic objectives of the surgery.
When photographs of previous surgeries performed on
other subjects are shared with the patient, representative
images should resemble, by age and body constitution, those
of the patient.
It is imperative for the treating surgeon to inform the
patient who undertakes any cosmetic surgery that there is
always a chance of a touch up procedure with room for
improvements.
21.2.3 Surgical Technique
Many people go to the plastic surgeon with the desire to
improve the aesthetic appearance and various regions of their
body. Among our cases of lipoabdominoplasty, the other procedures that are frequently requested include liposuction of
associated areas such as the thighs, buttocks, back and anks
and/or breast cosmetic procedures.
In our practice, it is usual for us to add liposuction to the
areas of the back and sides to the lipoabdominoplasty that we
carry out. From a cubitoprono position, the adiposities of the
back and sides are rst addressed, before starting with the
anterior trunk. The circumferential reduction of excess adiposity produces a total transformation of the torso and
improves visual aesthetics from all angles. Liposuction of
the back and sides also helps to further dene the waist,
when the traditional tummy tuck can erase your line. The
residual adiposity on the sides and back sometimes prevents
the tummy tuck from achieving a harmonious overall result.
When an anatomical location has been well contoured, it
can cause unnecessary visual attention to other problematic
areas, which might look more prominent due to excess fat.
Similarly, in multiparous and weight-loss patients, ptotic
and involved breasts can prevent the achievement of a harmonious nal result. Breast augmentation, mastopexy and a
combination of both procedures are the most frequent operations that are performed to rejuvenate and reestablish the
body proportions in relation to the breast, which is only possible when liposuction of adjacent areas along cosmetic
breast surgery is undertaken.
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Facial cosmetic surgery can also be combined with
lipoabdominoplasty, although with caution given the long
duration of the intervention. Patients often request a combined face technique (rhytidectomy and forehead lift) that
would require considerable operation time and would result
in excessive intervention time if combined with body remodeling techniques.
If the patient also wishes to undergo breast surgery and/or
extensive liposuction, it will be preferable that the other cosmetic surgery interventions be scheduled for another date.
21.2.4 Optimization ofResults
The promotion of safe surgical practices and the prevention
of unwanted episodes are the best guidelines to optimize
results. Before arriving in the operating room, a careful history of thrombotic events in the patient or his/her family
should be taken and analyzed.
A spectacular result on the operating table is not a sure
shot that the patient will be satised with the result as a lot
depends on an event-free postoperative period with quick
healing without undesired episodes greatly increases patient
and surgeon satisfaction.
21.2.5 Postoperative Care
A semicompression bandage has to be worn by all patients
after lipoabdominoplasty and other secondary techniques.
The initial bandage with Reston foam is appropriate on the
areas undergoing liposuction and the abdominal bands. In
our consultation, our patients are recommended to acquire
compression belts that include the abdomen and hips and
they usually have to wear it for at least 6weeks post-surgery. Both customized and standard size commercially
available girdles can be used but with the caveat that they
have to be worn continuously. Postsurgery edema usually
remains for many months specially if the pressure garments
are not used regularly with frequent tightening of the garment. Scars massage is often used among our patients, lymphatic massage and topical treatments such as silicone
sheets, always bearing in mind that the therapeutic results
are highly variable. A frequent revision of the scars and the
hygiene of the same ones, as well as the periodic visits to the
specialist are essential to avoid the problems related to the
surgical wound.
It is common for us to discuss with our patients the need
to control weight in the postoperative period, in order to
maintain the results of the surgery. This aspect is particularly
more important during the healing period as patients usually
adopt a more laid-back and sedentary habit due to restrictions in activity and intense physical exercise.
21.2.6 Complications andIts Treatment
Performing lipoabdominoplasty as part of a combined
approach to body remodeling can lead to increased postoperative pain that limits early ambulation, and may also, in
theory, increase the incidence of thrombophilia, due to the
longer duration of the intervention and the prolonged immobilization. After carrying out the indicated preoperative tests
and limiting the number of hours under general anesthesia,
the combined techniques take advantage of the potential
advantages of the same anesthesia and reduce the patient’s
total recovery time and nancial outlay. We aspire to establish that the combination of lipoabdominoplasty with other
cosmetic interventions is safe for the patient and results in a
low rate of complications.
The risk of deep vein thrombosis and pulmonary embolism in this situation is probably multifactorial, depending on
the length of the intervention, the increase in the compression of the pelvic veins caused by the repair of diastasis of
the rectus muscles, which increase the intra-abdominal pressure of the recovery time also prolonged, with the corresponding immobility.
With the use of extensive preoperative testing, assessing
clinical risk factors, early mobilization, and use of methods
to reduce chances of deep vein thrombosis both during and
after surgery, there has been a signicant reduction in the
risk of thromboembolic events in abdominoplasty with combined approaches.
21.2.7 Conclusions
Ultimately, a combined technique must be undertaken after
an impeccable preoperative study and must be carried out by
a surgical team that is in a position to complete multiple
approaches in an efcient and timely manner. Postoperative
care should include early ambulation instructions and adequate analgesia. Overnight stay and monitoring are essential
for patients who have undergone combined procedures with
lipoabdominoplasty or traditional abdominoplasty even if
done at a daycare center. Likewise, patients with previous
medical condition, bleeding, pain, or difcult recovery from
anesthesia require at least an overnight stay. The ASPS
Patient Safety Committee guide details the guidelines that
must govern proper preoperative work, patient selection, and
perioperative approach to risk factors. The continued application of safe practices is essential to maximize positive
results and minimize negative episodes.
Lipoabdominoplasty can be considered a safe but a very
powerful body reshaping tool specially when combined with
other body shape improvement procedures which can lead to
anatomical, physiological and psychological transformation
in a patient.
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With careful patient screening, preoperative planning, and
intense postoperative treatment, we can carry out lipoabdominoplasty effectively and safely in combination with
other techniques.
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