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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_591_Библиотеки_им_академика_М_И_Перельмана

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J. M. Avelar
are not damaged during the operation, the blood supply to the remaining abdominal panniculus is maintained, whose multiple pedicles avoid dead space (Figs.5.9 and
5.10). This is my surgical contribution, and it comes with a minor rate of complica-
tions because the operation can be carried out without panniculus undermining and without resection.
Those surgical principles are essential in order for the lipoabdominoplasty pro­cedure to improve body contouring (Avelar 1999a, b, c, 2000a, b) and for it to include several other regions, as long as my original descriptions on aesthetic sur­geries on the axillary regions are followed (Avelar 1999d, e), even for ankplasty and torsoplasty (Avelar 1999f) and for medial tight lifting (Avelar 1999g). Also, I employ similar surgical principles to perform face lifts, ear reconstruction, reverse lower blepharoplasty, and surgeries on other segments of the human body. Such a combined approach is so important in plastic surgery because it doesn’t cut the arte­rial, venous, and lymphatic structures, thus yielding smooth and aesthetic results.
Finally, I was able to solve the problems that I identied 50years ago in the eld of abdominoplasty and surgeries on other regions to improve body contouring. Therefore, I described a new method to create the umbilical region during abdomi­noplasty (Avelar 1976a, b, 1979, 1983a, b). Also, I introduced new concepts to solve the problems of the unaesthetic aspect of the abdominal wall from the accumulation of local adiposities after liposuction combined with cutaneous resection (Avelar
1985a, b, 1986b). My recent contribution to abdominoplasty came in the last year of
the twentieth century, which was a new procedure for lipoabdominoplasty (Avelar
1999a, b, c, d, e, f, g, 2000a, b). Following this technique, there are minimal local
and systemic complications thanks to its maintaining normal blood supply to the remaining abdominal panniculus coming from the perforator vessels, which are pre­served in this technique (Figs.5.6, 5.9, and 5.10).
References
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Alegre– RS (Brazil) 81–82 Avelar JM (1976b) Umbilicoplasty – A istema without external scar. Cahiers de chirurgie
Esthétique. Journees internationals de Chirurgie Esthetique. Vendredi 21– Paris (France) mai. Avelar J (1978) Abdominoplasty– systematization of a technique without external umbilicalscar.
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J. M. Avelar
Chapter 6
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Personal Experience withAbdominoplasty Without Undermining andIts Modications
RicardoCavalcantiRibeiro, WilsonNovaes, andLuisFernandezde Cordova
Abstract Abdominoplasty is a very common aesthetic surgery performed world-
wide. Data from the American Society of Plastic Surgeons have shown that it ranks as one of the most cosmetic surgical procedures performed in the United States. With the appearance of liposuction in the 1980s, classical abdominoplasty was modied using both techniques to improve body contour. At the end of the 1990s and the beginning of 2000, Avelar (New concepts for abdominoplasty, 1999a, Rev Bras Cir 88/89(1/6):3–20, 1999b, Abdominoplasty: new concepts for a new tech­nique, 1999c) published several articles reporting a new approach called “abdomi­noplasty without undermine” that was proven to be safe, with good results. We have been using this technique since 2003 with excellent outcomes; however, some details were added because of signicant shortcomings, including the lack of treat­ment of the pubic area and anks, presence of a high-position scar, and, in some cases, a bulging inferior abdomen. Thus, after a long period of performing this technique, some improvements were made to the original surgical technique that included deep liposuction in the lower abdomen, pubic liposuction, liposuction of
R. C. Ribeiro (*) Plastic and Reconstructive Surgery, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil e-mail: rribeiro@centroin.net.br
W. Novaes Plastic and Reconstructive Surgery, Carlos Chagas Institute, Rio de Janeiro, Brazil
Brazilian Society of Plastic Surgery, Rio de Janeiro, Brazil
L. F. de Cordova Plastic and Reconstructive Surgery, Carlos Chagas Institute, Rio de Janeiro, Brazil
Division of Plastic and Reconstructive Surgery, Casa de Portugal Rio de Janeiro, Rio de Janeiro, Brazil
Division of Plastic and Reconstructive Surgery, Global Plastic Surgery, México City, Mexico
Switzerland AG 2023 J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_6
111© The Author(s), under exclusive license to Springer Nature
112
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the anks or dorsum with power-assisted liposuction (PAL), Scarpa’s fascia removal in the inferior abdomen, lipoplasty and Mons lipolifting, and pubic xation. We present a retrospective study since that time on patients who underwent surgery with these related improvements. For global harmonization of the body contour, abdominoplasty using Avelar’s principles was routinely associated with lipoplasty of the anks or dorsum and outer thigh and fat graft in the gluteal-trochanteric regions. Taking into consideration these key points, a multi-pedicle ap was cre­ated, vessels were preserved, and less dead space was created, reducing the number of most common complications. Using these advances allowed us to overcome dif­culties and optimize the outcomes.
Keywords Abdominoplasty · Liposuction · Body contour · Flanks · Abdomen
R. C. Ribeiro et al.
Introduction
Demars and Marx reported the rst dermolipectomy in France in 1890; they reported it as an isolated procedure (Gemperli etal. 1992). Later, in 1899, Kelly, a gyneco­logic surgeon at Johns Hopkins University (Baltimore, MD, USA), published the rst attempt to correct excess abdominal skin and fat, making a horizontal wedge resection that included the umbilicus (Kelly 1899). Although abdominoplasty is a very common procedure, few modications have been observed over the last 50years. Most publications related to the subject have referred to the scar position, as well as the changing of its size and direction (Ribeiro 2010).
In 1965, the modern era of abdominoplasty began with the contribution of Callia (1965), who described the scar at the pubic area and lateral extension of the down crural arcades. Later, in 1967, Pitanguy indicated treatment of the abdominal rectus muscle without the approach to the aponeurosis. He published 300 cases of con­secutive abdominoplasty, referring to techniques, results, and complications (Pitanguy 1967). In 1975, he published a large study, which included 539 abdomi­noplasty cases (Pitanguy 1975).
In the mid-1980s, with the incorporation of liposuction, a signicant improve­ment of body contouring was observed in abdominoplasty. Hakme (1985) and Wilkinson and Swartz (1986), associated liposuction with abdominal plastic sur­gery involving a small skin resection. Avelar, in 1985, described a technique of liposuction associated with abdominoplasty for patients who have a prominent abdomen and muscular laxity (Avelar 1985). Bozola and Psilakis (1988) and Matarasso (1991), created a clinical abdomen classication, suggesting a specic treatment for each type. Later, in 1999 (Avelar 1999c), Avelar described abdomino­plasty without undermining and removal of fat through liposuction, with skin and fat resection below, in the belly button (Avelar 2000; Graf et al. 2006). In 2000, Matarasso described liposuction in combination with abdominoplasty to preserve the blood supply of the abdominal ap (Matarasso 1991, 2000).
Preservation of Scarpa’s fascia has been suggested in order to lower complica­tions associated with conventional abdominoplasty; thus, Saldanha et al. have
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proposed a new name for the procedure—lipoabdominoplasty (Saldanha et al.
2001)—according to the same principles previously proposed by Avelar (1999a).
With time and learning curve, some changes could be introduced to rene the technique. We have been performing this technique since 2003 with good results; however, over the years, some details and problems have been found. Therefore, in 2010, important approaches and improvements were introduced to optimize the postsurgical results, including the following: deep liposuction in the lower abdo­men; power-assisted liposuction (PAL) of the pubic region, anks, or dorsum; Scarpa’s fascia removal in the inferior abdomen; lipoplasty; Mons lipolifting; and pubic xation, where we observed a better harmony of body contouring.
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Selection ofPatients
In our experience, you can expect positive outcomes with women with an age rang­ing between 24 and 69years, and American Society of Anesthesiologists (ASA) Physical Status I (ASA I), with an indication of classical abdominoplasty or lipoab­dominoplasty. All the patients were treated using the lipoabdominoplasty technique and the abovementioned improvements, and fat removal by liposuction ranges from
1.5 l to 2.5 l, and surgical time ranges from 2 to 3h.
Exclusion criteria were as follows: post-bariatric patients, ASA III patients, BMI above 30, combined general or gynecological surgeries and patients with skin laxity and stretch marks above the umbilicus.
Surgical Technique
Prior to the surgery with the patient standing, the adipose tissue disposition esti­mated to be liposuctioned included the hypochondrium, pubic area, and anks. A skin fuse to be removed was calculated with the patient sitting down, and then a low abdominal curved line was designed 6 to 8cm from the labia major vertex. If the patient had previous scars, the size was maintained as best as possible and was increased to the necessary amount.
Saline solution and epinephrine (1:500,000) were inltrated in all areas previ­ously marked for lipoaspiration and undermined to help reduce bleeding.
Power-assisted liposuction (PAL) was performed increasing cannulas’ size from
3.5 to 4.0mm and, less frequently, 5mm. The liposuction began in the prone decu­bitus position, allowing access to the dorsal region and anks.
The patients were rotated to the supine position, and PAL was performed, reach­ing the medial and deep layer in the superior abdomen, including the ribcage. Deep fat excess was removed through liposuction. Liposuction was intensied at the tran­sition of the rectus and oblique abdominis muscles to achieve better body contour.
Pubic incision and undermining of the lower abdomen with Scarpa’s fascia removal were performed until umbilical region. From the supraumbilical region to
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the xiphoid appendix, narrow undermining was performed, just leaving a tunnel. Thus, a selective area of the diastasis region along the medial margins of the rectus muscles is undermined preserving the perforator vessels. The umbilicus was com­pletely isolated removing the entire fat surrounding its stalk.
From the xiphoid appendix to the suprapubic area, the rectus muscle diastasis was corrected in two lines of aponeurotic plications. The umbilicus was xated at the midline.
In the Fowler position, the superior ap was transported down to the inferior ap, evaluated, and then closed with sutures, trying to generate the least possible tension between the two aps. During that surgical time, excessive skin at the lower region was removed if required.
Prior to the closure, the pubic ap was immobilized and xed with 3-0 nylon sutures separated to prevent its ascent. When the patient had a signicant amount of fatty tissue on the pubis, liposuction was performed in this area, avoiding uneven surface between the region and lower abdomen.
An aspiration drainage was placed before closure of the abdominal wall and remained there until the collection was less than 30mL for the day. The superior and inferior aps were closed using subcutaneous and intradermic stitches, made with 3-0 and 4-0 sutures. In the supine position, the umbilicus was exteriorized and trimmed and placed back into the skin. The umbilical scar was closed, leaving a 3­to 4-cm scar at the hypogastrium region. Omphaloplasty was performed with differ­ent sketches according to the body contouring of the patient.
Sterile Micropore tape was placed over the scar, and the patient was dressed in a compression garment that covered the areas that were treated for 30 uninter­rupted days. The patient remained hospitalized for 1day. Early ambulation within 24h was encouraged for mobilization of third-space uid shifts to expedite recov­ery and prevent deep vein thrombosis. Antibiotics, analgesics, and anti-inamma­tory medications were used for 7days after surgery.
R. C. Ribeiro et al.
Clinical Data andResults
In the last 19years, we have performed this technique in more than 800 patients, all with indications for classical abdominoplasty or lipoabdominoplasty. The women ranged in age between 24 and 69years (Figs.6.1 and 6.2).
The complication rates were as follows 1.00% (eight patients, skin necrosis),
1.11% (nine patients, seroma), and 0.12% (one patient, hematoma) (Table6.1). The results improved due to correct positioning of the suprapubic scar and previously mentioned reasons. However, scar revision and “dog ear” correction were required in two (0.25%) patients. Late complications such as hypertrophic scars occurred in six (0.75%) patients. Another important result was absence of sensibility loss in the lower abdomen in all patients of the study.
Additional rare complications included fat embolism, thromboembolism, uid imbalance, perforation of the viscera, and death, which were not present in our patients.
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Fig. 6.1 Before and after pictures, 3 months post-op, woman in the fth decade of life
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Fig. 6.2 Before and after pictures, 3 months post-op, woman in the fourth decade of life