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R. C. Ribeiro et al.
Table 6.1 Complications
Complications No. of patients %
Seroma 9 1.11
Skin necrosis 8 1.00
Hypertrophic scar 6 0.75
Scar revision (dog ear) 2 0.25
Hematoma 1 0.12
Infection 0 0
Thromboembolism 0 0
Suprapubic epidermolysis 0 0
Loss of sensibility 0 0
Discussion
Several body contouring techniques, including liposuction, combined with abdominoplasty have been developed in the last decades, making contributions and progress
in lipoabdominoplasty. Since 2003, we have been using lipoabdominoplasty and
have found that the procedure results in a broadened vascularized ap and decreases
the incidence of complications, such as hematoma, epitheliosis, and necrosis.
The principles and foundations of lipoabdominoplasty are based on preservation
of the anatomy of the vascular, lymphatic, and nervous systems of the abdominal
wall, involving the two layers of the adipose tissue and muscular groups (Ribeiro
2010; Graf etal. 2006; Saldanha etal. 2001). We observe the global improvement
of the technique with less seroma formation, more appropriate body contouring, and
a decrease in the incidence of devascularization in the central area of the abdomen,
associated with necrosis of the skin and dehiscence.
We used PAL (power-assisted liposuction) using the tumescent technique, which
has been shown to be effective and safe for small- to large-volume liposuction cases
for body contouring purposes, to be superior in the ease and speed of fat extraction,
and to demonstrate shorter procedure times with less surgeon fatigue and a lower
incidence of touch-up secondary procedures than traditional liposuction. The same
results were observed in studies performed by Fodor in the 1990s (Fodor and
Vogt 1999).
Through supercial and deep lipoplasty, we dissected the two layers of the
abdominal fat and reached the abdominal ap with fewer traumas than with dissection using a Bovie, which splits up the perforator vessels emerging from the rectoabdominal muscles. Currently, this principle is used in all of our cases. Even in
those cases in which the adipose tissue was thin (4% of cases), we preferred to
perform divulsion with lipoplasty suction cannulas without a vacuum for the ap
(Novaes and Cavalcanti 2006), a maneuver we called lipo undermining.
Selective undermining performed only in the diastasis region of the rectoabdominal muscle allowed plication, and this divulsion did not reach the perforator arteries, which were located 2 cm from the rectoabdominal muscle external edge.
Dissection using lipoplasty and selective undermining for plication replaced the
large-scale dissections of conventional abdominoplasty and lipectomy (Saldanha
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Fig. 6.3 Postoperative of
conventional
abdominoplasty, leaving a
high scar with an
unsatisfactory aesthetic
result
117
2003; Lockwood 1995). We maintained the same principles reported by Avelar
(1999a, b, c) because we believed that less dissection allows the preservation of
vascularity.
Lipoabdominoplasty is a safe and very effective technique, and its results led to
the reduction of complications, including seroma, hematoma, and skin necrosis,
caused by large skin detachments.
A multi-pedicle ap is created, vessels are preserved, and less dead space is
observed, reducing the number of complications commonly observed during
abdominoplasty. However, isolated selective undermining may restrain ap movement to the pubic area, resulting in higher scar positioning (Fig.6.3). To avoid this,
we made a modication to the original technique, creating lipoplasty, Mons lipolifting, and pubic xation.
We routinely associated lipoabdominoplasty with lipoplasty of the anks or dorsum and outer thigh and lipografting in the gluteal-trochanteric regions, allowing
global enhancement of the body contour. Additionally, 2000 units of hyaluronidase
were included to help improve the absorption of adipose tissue collected during
liposuction. In patients who had undergone great weight loss, lipoabdominoplasty
enables thinning of the skin ap, prevents wide undermining, improves the nal
result, and reduces the complication rate. We can also apply this technique in cases
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Fig. 6.4 Modied lipoabdominoplasty with removal of the Scarpa’s fascia below the navel
R. C. Ribeiro et al.
of secondary abdominoplasty, when it is necessary to remove the fatty tissue and
remaining excessive skin.
Saldanha’s technique advocated that it is necessary to perform deep liposuction
above the belly button and perform supercial liposuction below it (Saldanha etal.
2001). The liposuction difference in the upper and lower abdomen in terms of depth
in the fatty tissue may present an inconvenience in many patients regarding uneven
surfaces. We believe this technique impedes the creation of a uniform junction
plane, particularly in the lower abdomen. To correct this alteration, we conducted a
supercial and deep lipoaspiration in the upper region of the abdomen, deep
lipoaspiration in the lower abdomen, and pubic lipoaspiration.
Saldanha etal. also reported complete Scarpa’s fascia preservation in the lower
abdomen because they believed that preserving the perforating and lymph vessels
reduces the complications, such as seroma, hematoma, epitheliosis, and necrosis of
the skin, caused by large detachments (Saldanha etal. 2001). However, this preservation can result in the union of the fascia with the superior abdomen, creating a
type of “sandwich fascia capsulation” and leading to prolonged edema and bulging. To correct these complications, we modied the surgical technique and performed deep liposuction in the lower abdomen and pubic liposuction. In addition,
we proposed that Scarpa’s fascia removal in the lower abdomen helps to accommodate the upper abdomen tissue and avoids creating “sandwich fascia capsulation” (Fig.6.4).
The preservation of structures in the lower abdominal deep fat is important for
superior ap accommodation, and it is another relevant foundation of the technique
because, anatomically and histologically, the lymphatic vessels are more numerous
in this region. We believe that maintenance of the lymphatic system using this
method is the main factor in the decrease in the incidence of seroma in the patient
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subgroup treated according to these principles, as evidenced by some studies (Kelly
1899; Ribeiro 2010; Graf etal. 2006; Marcello etal. 2010).
Conclusion
According to our experience, we have observed important key points that allowed
us to overcome difculties, as well as evolve and progress this technique. By introducing the treatment of anks with liposuction, an improvement in the quality of the
result and a more appropriate body contour have been shown. Using the same principle, patients with Mons pubis lipodystrophy and accidity must be treated because
it is important for the aesthetic result of this region.
Another fundamental principle in the modication of the technique is the removal
of Scarpa’s fascia in the inferior ap, thus avoiding the formation of the “fascia
sandwich capsulation.”
To reduce the number of complications related to the procedure, resection of
adipose tissue is recommended through the lipoplasty cannula and selective undermining, allowing the preservation of vascular, lymphatic, and nervous tissue associated with the abdomen. Similarly, the reduction in surgical trauma is the main factor
in the decrease in the seroma, hematoma, and necrosis rates.
Finally, the learning curve was fast because the described procedures use techniques and methods that are already familiar to most plastic surgeons.
References
Avelar JM (1999a) New concepts for abdominoplasty. (Novos conceitos para abdominoplastia).
Paper presented at the 36th congress of the Brazilian Society of Plastic Surgery, Rio de Janeiro,
November.
Avelar JM (1999b) A new technique for abdominoplasty– closed vascular system of subdermal
ap folded over itself combined to liposuction. (Uma nova técnica de abdominoplastia –
sistema vascular fechado de retalho subdérmico dobrado sobre si mesmo combinado com
lipoaspiração). Rev Bras Cir 88/89(1/6):3–20.
Avelar JM (1999c) Abdominoplasty: new concepts for a new technique (Abdominoplastia: Nuevos
conceptos para una nueva técnica). XXVI annual international symposium of aesthetic plastic
surgery, Chairman: Prof. Jose Guerrerosantos- Puerto Vallarta, pp10–13.
Gemperli R, Neves RI, Tuma P, etal. Abdominoplasty combined with other intraabdominal proce-
dures. Ann Plast Surg, 1992, 29(1):18–22.
Kelly, H.A.: Johns Hopkins Med. J. 10:197, 1899.
Ribeiro, RC.Evolution of Abdominoplasty. Baker And Gordon Symposium. 2010. EUA.
Callia W.Contribuição para o estudo da correção cirúrgica do abdome pêndulo e globoso—Técnica
original [dissertation]. Faculty of the Medical University of São Paulo, 1965.
Pitanguy I.Abdominal lipectomy: an approach to it through an analysis of 300 consecutive cases.
Plast Reconst Surg, 1967, 40(4):384–391.
Pitanguy I Abdominal lipectomy. Clin Plast Surg, 1975, 2(3):401–410.
Hakme F (1985) Technical details in the liposuction associated with abdominoplasty. Rev Bras
Cir 75:331.
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Willkinson TS, Swartz BE: Individual modication of body contour surgery: the “limited” abdom-
inoplasty. Plast Reconstr Surg 77:779, 1986.
Avelar JM: Fat suction versus abdominoplasty. Aesth Plast Surg 9:265–276, 1985.
Bozola AR, Psilakis JN: Abdominoplasty: New concept and classication for treatment. Plast
Reconst Surg 82:983–993, 1988
Matarasso A (1991) Abdominoplasty: a system of classication and treatment for combined
abdominoplasty and suction-assisted lipectomy. Aesthetic Plast Surg 15:111
Matarasso A: Liposuction as an adjunct to full abdominoplasty revisited. Plast Reconstr Surg
106:1197–1206, 2000
Avelar JM: Abdominoplasty: A new technique without undermining and fat layer removal. Arq
Catarinense Med 29:147–149, 2000
Graf R, Araujo L, Rippel R, etal. Lipoabdominoplasty: Liposuction with Reduced Undermining
and Traditional Abdominal Skin Flap Resection. Aesth. Plast. Surg. 2006. 30:1–8.
Saldanha OR, de Souza Pinto EB, Mattos WN Jr, etal. Lipoabdominoplasty without undermining.
Aesthetic Surg J. 2001; 21: 518–526.
Fodor PB, Vogt PA. Power-assisted lipoplasty (PAL): A clinical pilot study comparing PAL to
traditional lipoplasty (TL). Aesth Plast Surg 1999; 23:379–385.
Novaes M.Wilson, Cavalcanti R.Ricardo. Classication for Indications of Lipoabdominoplasty
and its Variations; Aesthetic Surgery Journal. 2006: 417–431.
Saldanha OR. Lipoabdominoplasty with selective and safe undermining. Aesthetic plast Surg.
2003;27:322–327.
Lockwood T. High lateral-tension abdominoplasty with supercial fascial system suspension.
Plast Reconstr Surg 1995;96:603–608.
Di Martino Marcello, Nahas, F; Barbosa Marcus et al. Seroma in Lipoabdominoplasty and
Abdominoplasty: A Comparative Study Using Ultrasound. Plastic & Reconstructive Surgery.
2010;126:1742–1751.
R. C. Ribeiro et al.
Chapter 7
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Surgical Principles andClassication
ofLipoabdominoplasty
JuarezMoraesAvelar andRicardoCavalcantiRibeiro
Abstract Kelly is credited with the rst publication on abdominoplasty and pan-
niculus resection performed on the elliptical horizontal skin, a publication where he
coined the term abdominal lipectomy. Following his surgical principles, several
other authors have described other approaches. Moreover, remarkable improvements came with liposuction, introducing revolutionary concepts that improved
body-contouring procedures.
However, by employing liposuction, the accumulation of fat could be removed,
but the redundant skin required conventional resection, which did not cause new
sorts of complications. Such combined approaches have increased the rate of some
complications, such as seroma formation, the slough and necrosis of the panniculus,
and local infections, among others. Because of those uncomfortable situations, after
a short period of time, I made a radical decision to not perform both procedures
anymore. Nevertheless, I obsessively looked for a solution to those complex problems. In trying to solve such complications, I envisioned nding a new approach to
perform the combined procedures. Thinking about a safe technique, I returned to
my previous anatomical study of the abdominal panniculus and concluded that I
could combine liposuction with conventional abdominoplasty as long as the perforator vessels didn’t sustain damage. After 10years of intensive study and research,
I discovered new concepts in abdominoplasty that I presented and published, and
with them, I could combine both procedures: liposuction with abdominoplasty.
After such persistent research, I found new approaches for the treatment of the
abdominal wall that reduced complications. Thus, the aesthetic results for the
abdominal wall were improved in lower, upper, and lower and upper abdomino-
J. M. Avelar
Brazilian Scientic Institute of Plastic and Reconstructive Surgery, São Paulo, Brazil
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
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_7
121© The Author(s), under exclusive license to Springer Nature
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plasty and in full abdominoplasty. In all modalities of this operation, the surgical
principle of preserving the perforator vessels was the key to the procedure.
Keywords Abdominoplasty · Lipoabdominoplasty · Surgical principles ·
Classication · Lower abdominoplasty · Upper abdominoplasty
J. M. Avelar and R. C. Ribeiro
Introduction
Abdominoplasty was quite a new procedure in plastic surgery at the end of the nineteenth century, when some publications reported on the aesthetic treatment of the
abdominal wall while still searching for a harmonious balance for the body. The
credit was given to Kelly (1899), but Demars and Marx published a procedure earlier, in 1890 (Sinder 1979).
In his rst publication, Kelly (1899) performed elliptical horizontal skin resection
on the adipose tissue of the abdominal wall, including the umbilical area, and in this
publication, he coined the term abdominal lipectomy. His original publication popularized the operation, and his name is a symbol of abdominoplasty. That marks the
beginning of a long history of abdominoplasty, which has since been followed by
many other scientic publications all over the world. Abdominoplasty has undergone a remarkable evolution of improving the surgical results for body contouring.
Following Kelly’s resection, several other authors have since published in the
medical literature different modalities of panniculus resection for the reparation of
the abdominal wall and the abnormalities of the torso, as described by Sinder
(1979). The various types of incisions can be classied into ve modalities: horizontal incisions, vertical incisions, circular incisions, submammary incisions, and
half-moon skin resections on the bilateral submammary folds.
1. Horizontal incisions are the most frequently performed in abdominoplasty, rst
because the majority of patients present with some sort of scars from previous
operations on the lower segment of the abdominal wall in the suprapubic area
and second because the rst description of abdominoplasty, by Kelly, was a type
of horizontal incision for the reparation of unaesthetic scars to rebuild the
abdominal wall. Several authors, such as Jolly (1911), Malbec (1948), Callia
(1965), Pontes (1965, 1982), Pitanguy (1967a, b, 1982), Planas (1982), Serson
Neto (1970, 1982), Sinder (1975, 1982), Guerrerosantos (1982a, b), and Avelar
(1976a, b, 1983a, b, 1985a, b, 1999a, b, 2000a, b), have since described their
approaches to the aesthetic surgery of the abdomen wall, among other procedures introduced by other surgeons.
2. Vertical incisions have been credited to Babcock (1916), but they leave long
scars on the midline of the abdomen. With this approach, the abdomen can be
reshaped, particularly for patients who’ve undergone severe weight loss.
3. Circular incisions were introduced by Gonzales-Ulloa (1959), the rst author to
describe such an approach, which he called belt lipectomy (1967, 1982), and
few years later, Vilain (1964, 1982, 1986) called it lipectomie circulaire. Such a
procedure is performed quite often for remodeling the entire body on patients
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who have undergone severe weight loss, achieving well-balanced body
contouring.
4. Submammary incisions are part of an unusual approach described by Thorek
(1942a, b) to remove the excess panniculus on the superior segment of the abdomen. The author did not precisely draw the skin resection on the submammary
fold, but the objective of the operation was to remove the panniculus on the
upper abdomen below the breasts. Three decades later, Rebello etal. (1972) and
Rebello (1982) described the submammary incisions in selected patients presenting with abnormalities on the panniculus of the upper abdomen. In their
descriptions, a wide undermining on the supra-aponeurotic level is performed,
followed by superior traction for resection.
5. Half-moon skin resections on the bilateral submammary folds constitute the
nal modality. When I introduced a combination of abdominoplasty with liposuction, I had several patients presenting with unaesthetic bilateral abnormalities
on the submammary folds. Since my previous scientic publications (Avelar
1999a, b, 2000a, b, 2001a, b, 2002) on abdominoplasty associated with liposuc-
tion, a new approach has been designed and new concepts described. So far, my
incisions have not joined the midline of the sternal region but rather isolated ones
on each side of the submammary folds (Fig.7.1).
A half-moon skin is resected on each side of the hypochondriac region in
order to treat the upper abdominal wall by making upper incisions without panniculus undermining (Figs.7.2, 7.3, and 7.4).
a
bc
d
Fig. 7.1 Squamatization of upper lipoabdominoplasty technique. Drawing (a) surgical demarcations of the operation delimitating two areas of full-thickness of liposuction below the submammary sulcus; (b) liposuction procedure is rstly done on area for skin resection; (c) afterwards it is
done on lamellar layer, on superior panniculus below the fascia supercialis; (d) nally the wounds
are sutured by layers leaving two scars on submammary sulcus
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cd
cd
a
bc
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J. M. Avelar and R. C. Ribeiro
de
Fig. 7.2 Perioperative photos demonstrating the technique of upper lipoabdominoplasty. Photo
(a) surgical demarcations of a half-moon area on submammary regions; (b) after full-thickness of
the panniculus on the half-moon “island”; (c) deep liposuction (below the fascia supercialis) is
done on remaining panniculus from up downwards; (d) the border of the wound is already sutured
on right side; (e) suture was performed on both sides
ab
Fig. 7.3 Correction of superior region of the abdominal wall through upper lipoabdominoplasty.
(a, c) Before operation showing localized adiposities on superior abdominal wall; (b, d) after
upper lipoabdominoplasty
ab
Fig. 7.4 A 39-year-old patient underwent lipoplasty of the abdominal wall performed elsewhere
presenting irregularities caused by previous liposuction performed elsewhere. Photos (a, c) before
surgery; (b, d) after operation of upper lipoabdominoplasty
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New Concepts forAbdominoplasty Associated
withLiposuction Without Panniculus Undermining
Until 1999, all the types of abdominoplasty were performed through the wide
undermining of the abdominal panniculus in order to resect its excess. Such a concept was employed no matter which incisions were made in all techniques. In this
way, in the traditional procedures, all the perforator vessels coming from the muscular level are cut to reach the wide area of the abdomen.
The liposuction technique, created and popularized by Illouz (1980, 1983a, b,
1984, 1986a, b), is one of the most revolutionary surgical techniques for the aesthetic treatment of the abdominal wall after abdominal lipectomy, which was rst
described by Kelly in 1899. The use of liposuction bought substantial improvements
to the aesthetic treatment of the abdominal wall, with excellent and suitable results
and very low rates of complications during and after surgery. The liposuction
method is very useful for removing localized adiposity because the correction of
excess skin on the abdominal wall used to be resected through panniculus undermining; I have previously described such a combined procedure (Avelar 1985a, b,
1986a, b, c). So far, the associated approaches have not presented new sorts of com-
plications, but they have greatly increased the rate of seroma formation, the slough
and necrosis of the panniculus, local infections, and other uncomfortable complications. Given such very high incidences of local complications after abdominoplasty,
I decided after a short period of time to not perform it anymore (Avelar 1988).
However, isolated liposuction on the submentonian and submandibular regions
combined with rhytidoplasty did not present any new kinds of complications,
although they have been encountered on the abdomen (Avelar 1983b, 1985c).
Although I did not perform such associated procedures of liposuction with traditional abdominoplasty during that time, I devoted considerable study and thought to
devising a technical solution that would avoid those uncomfortable complications. I
worked obsessively for several years on my previous anatomical research (1986a, b,
c, 1987, 1989), looking for an appropriate way to remove the excess skin associated
with liposuction.
At the end of nineteenth century, Kelly (1899) published the rst abdominoplasty method, and at the end of twentieth century, I (Avelar 1999a, b, c) published
a combination of abdominoplasty with liposuction that preserves the perforator vessels to avoid all those complications (Fig.7.5). Those are the roots of lipoabdominoplasty that developed from intensive and deep study and research (Avelar 1999a,
b, c, 2000a, b).
Over the course of 10years of studying the anatomy of the abdominal panniculus
(from 1988 to 1998), I developed and published a new method, which is a new surgical procedure that removes the excess skin of the redundant panniculus with minimal rates of complications. Therefore, the surgical principles of conventional
abdominoplasty through lipectomy are not performed in my method, because in
mine, the perforator vessels are preserved to provide adequate vascularization to the
remaining abdominal panniculus (Fig.7.5) (Avelar 1999a, b, c, 2000a, b, 2001a,
b, 2002).
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