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26 Simultaneous Correction ofPostpartum Breast/Belly Badness Utilizing TABA
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Fig. 26.5 Patient: A 43-year-old woman with a history of
three prior pregnancies presenting with bilateral
hypomastia and abdominal skin laxity around belly
button. Procedure: Transabdominal breast augmentation,
abdominoplasty, and a nipple reduction. Smooth, high-
prole saline implants were inserted bilaterally in the
subpectoral plane; a 270-cc implant was inserted on the
left and a 290-cc implant was placed on the right side. The
patient is shown here preoperatively (left) and at
20months postoperatively (right)
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R. J. Zienowicz and E. Karacaoglu
Fig. 26.6 Patient: A 39-year-old woman with a history of
cesarean delivery and one prior pregnancy presenting
with bilateral pseudoptosis. Procedure: The patient underwent transabdominal breast augmentation and abdomino-
plasty. Smooth round silicone implants were inserted in
the subpectoral plane; 350-cc implants were placed bilaterally. The patient is shown here pre-operatively (left) and
at 8years postoperatively (right)
26 Simultaneous Correction ofPostpartum Breast/Belly Badness Utilizing TABA
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443
the prevention of blood and uid collection in the
pocket. And nally this is a factor to decrease
predisposition to infection and capsular contracture as well. In addition, the technique for implant
placement is a no touch technique that ostensibly
prevents contamination of the implant or pocket
with breast-borne microorganisms. It is believed
that all these contributed to our minimal overall
capsular contracture rate of 0.8% (1 of 114),
which is among the lowest reported in the current
literature [1, 22–24].
We feel that caution should be exercised in
offering transabdominal breast augmentation to
those patients who are overweight, smokers, or
poorly controlled diabetics. Many authors have
commented on the elevated risk of wound complications in smokers and patients whose body
mass index is greater than 25kg/m
2
[25]. Smoking
cessation should be documented for a minimum
of 4weeks preoperatively, with consideration for
urine cotinine testing (nicotine levels), and ideally indenitely thereafter in these patients given
the association with increased postoperative morbidity described in this chapter.
It is highly recommended to have certain
selection criteria while choosing the patient.
These criteria should be as follows: implementation of preoperative urine cotinine testing, strict
observance of smoking cessation, and ltering
patients with high body mass index and high
smoking rates.
References
1. Bhatt RA, Iyengar RJ, Karacaoglu E, Zienowicz
RJ. Transabdominal breast augmentation: a review
of 114 cases performed over 14 years. Plast Reconstr
Surg. 2017;140:476.
2. Hinderer UT. The dermolipectomy approach for
augmentation mammaplasty. Clin Plast Surg.
1975;2:359–69.
3. Rinker B, Jack IM.Subpectoral breast augmentation
through the abdominoplasty incision. Ann Plast Surg.
2007;58(3):241–5.
4. Planas J.Maximizing the use of the abdominoplasty
incision. Plast Reconstr Surg. 2004;113:418.
5. Planas J.Introduction of breast implants through the
abdominal route. Plast Reconstr Surg. 1976;57:434–7.
6. Barrett BM Jr, Kelly MV II. Combined abdominoplasty and augmentation mammaplasty through
a transverse suprapubic incision. Ann Plast Surg.
1980;4:286–91.
7. Wallach SG.Maximizing the use of the abdominoplasty incision. Plast Reconstr Surg. 2004;113:411–7;
discussion 418.
8. Tramèr M, Moore A, McQuay H. Propofol anaesthesia and postoperative nausea and vomiting: quantitative systematic review of randomized controlled
studies. Br J Anaesth. 1997;78:247–55.
9. Gan TJ, Ginsberg B, Grant AP, Glass PS. Doubleblind, randomized comparison of ondansetron and
intraoperative propofol to prevent postoperative nausea and vomiting. Anesthesiology. 1996;85:1036–42.
10. Badrinath S, Avramov MN, Shadrick M, Witt TR,
Ivankovich AD.The use of a ketamine-propofol combination during monitored anesthesia care. Anesth
Analg. 2000;90:858–62.
11. Friedberg BL.Propofol ketamine anesthesia for cosmetic surgery in the ofce suite. Int Anesthesiol Clin.
2003;41:39–50.
12. Fletcher J, Blake D, Zienowicz R, etal. Ofce-based
operatory experience: an overview of anesthetic technique, procedures and complications. Med Health R I.
2001;84:117–118.
13. Kahvanin N, Jordan SW, Vieira BL, Hume KM,
Mlodinow AS, Simmons CJ, Murphy RX Jr.
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.
2015;35(8):999–1006. https://doi.org/10.1093/asj/
sjv087. Epub 2015 Jul 9.
14. Buck DW II, Mustoe TA. An evidence-based
approach to abdominoplasty. Plast Reconstr Surg.
2010;126:2189–95.
15. Hensel JM, Lehman JA Jr, Tantri MP, Parker MG,
Wagner DS, Topham NS.An outcomes analysis and
satisfaction survey of 199 consecutive abdominoplasties. Ann Plast Surg. 2001;46:357–63.
16. Neaman KC, Hansen JE. Analysis of complications
from abdominoplasty: a review of 206 cases at a university hospital. Ann Plast Surg. 2007;58:292–8.
17. Stevens WG, Repta R, Pacella SJ, etal. Safe and consistent outcomes of successfully combining breast
surgery and abdominoplasty: an update. Aesthet Surg
J. 2009;29:129–34.
18. Davison SP, Venturi ML, Attinger CE, Baker SB,
Spear SL. Prevention of venous thromboembolism
in the plastic surgery patient. Plast Reconstr Surg.
2004;114:43E–51E.
19. Grazer FM, Goldwyn RM.Abdominoplasty assessed
by survey, with emphasis on complications. Plast
Reconstr Surg. 1977;59:513–7.
20. Venturi ML, Davison SP, Caprini JA. Prevention
of venous thromboembolism in the plastic surgery
patient: current guidelines and recommendations.
Aesthet Surg J. 2009;29:421–8.
21. Rohrich RJ, Rios JL. Venous thromboembolism in
cosmetic plastic surgery: maximizing patient safety.
Plast Reconstr Surg. 2003;112:871–2.
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R. J. Zienowicz and E. Karacaoglu
22. Unger JG, Carreras JM, Nagarkar P, Jeong HS,
Carpenter W.Allergan Style 410 implants for breast
reconstruction: a prospective study in efcacy, safety,
and symmetry. Plast Reconstr Surg. 2016;138:548–55.
23. Pompei S, Evangelidou D, Arelli F, Ferrante G. The
modern polyurethane-coated implant in breast augmentation: long-term clinical experience. Aesthet
Surg J. 2016;36:1124–9.
24. Wan D, Rohrich RJ.Revisiting the management of
capsular contracture in breast augmentation: a systematic review. Plast Reconstr Surg. 2016;137:826–41.
25. Vastine VL, Morgan RF, Williams GS, etal. Wound
complications of abdominoplasty in obese patients.
Ann Plast Surg. 1999;42:34–9.
Liposuction 360°
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IbrahimFakih-Gomez, AdriánSánchez-Balado,
andJesúsOlivas-Menayo
27
Take-Home Points
• Liposuction of the anterior area and anks in
supine position should achieve a at abdomen
and abdominal muscle marking. To achieve the
latter, it is necessary to remove more fat from
the midline (linea alba) and paramedian zone
(linea semilunaris) in women and complement
it with the transverse bands of the rectus
abdominis in men. In post-maternity women,
after C-section scar, care should be taken with
postoperative adhesion on the lower abdomen.
• In the posterior area (prone position), one
should treat the anks again, since from the
supine position it is difcult to access all the
adipose complex of this area. It must be nearly
“emptied” (minimal fat component) to achieve
an aesthetic waist.
• Bra roll is very common in overweight
women. It is essential to perform fat extraction
liposuction of the roll and release adhesions of
the thoracic area skin to the latissimus dorsi.
Supplementary Information The online version contains
supplementary material available at https://doi.org/
10.1007/978- 3- 030- 43840- 1_27.
I. Fakih-Gomez (*) · A. Sánchez-Balado
Private Practice, Alicante, Spain
e-mail: info@doctorfakih.com
J. Olivas-Menayo
Department Plastic Reconstructive and Aesthetic
Surgery, MS Medical Institutes, Lisbon, Portugal
e-mail: doctor@olivasmenayo.com
Eliminating these septal attachments, we will
achieve a homogeneous transition from the
thoracic area to the waist.
• “Venus Dimples “is considered to be an aesthetic ideal of health, youth, and beauty in
many cultures. Marking of dimples must be
done imperatively to reach a harmonic and
juvenile supragluteal zone.
• Control over skin retraction is essential. The
use of complementary intraoperative devices
such as ultrasound-assisted liposuction
(VASER®) or radiofrequency-assisted liposuction (BodyTite®, Renuvion®), as well as
postoperatively such as radiofrequency or
ultrasound and pressotherapy or massages
will reduce secondary brosis, favor lymphatic drainage, and achieve an adhesion of
the skin to the underlying tissues.
• Current devices for liposuction include:
– Suction-assisted liposuction (SAL): man-
ual reciprocation of a cannula that uses
shear forces to perforate fatty tissue for
removal by suction.
– Power-assisted liposuction (PAL): vibrat-
ing and reciprocating cannula controlled
by the surgeon manually, which reduces
operator fatigue sliding smoothly through
brous tissues.
– Water-assisted liposuction (WAL): intro-
duces high-pressure water jet to gently disrupt and dislodge fatty tissue during
liposuction.
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_27
445
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– Ultrasound-assisted liposuction (UAL)
involves the introduction of ultrasonic
energy into adipose tissue, which emulsies fat to provide easier and more gentle
suction with SAL in the second step.
– Laser-assisted liposuction (LAL): intro-
duces laser energy through a cannula or by
delivering laser energy via a quartz treatment tip without a cannula to disrupt adipose tissue and emulsify fat for easier
suction
– Radiofrequency-assisted liposuction
(RFAL): radiofrequency device that contracts the broseptal network seeking for a
greater skin retraction.
27.1 Introduction
Liposuction, as an isolated procedure or in combination with other surgeries, is one of the most
used techniques in plastic surgery. According to
the International Society of Plastic Surgery
(ISAPS), liposuction is the second most popular
procedure worldwide with more than 1.5 million
surgeries in 2018 [1].
Developed by Illouz in 1977 [2] liposuction
evolved greatly in the past decade, increasing its
sophistication in surgical approach and in development of new instruments. Improvement in
inltration designs and extraction cannulas, better knowledge of physiology and absorption of
local anesthetics, use of adrenaline and increased
tumescent volumes have greatly improved safety.
Better control of bleeding and postoperative pain
meant that we could perform larger volumen
extraction without increasing associated comorbidities, which in turn allows us to treat larger
body areas. Performance of circumferential or
360° liposuction becomes a controlled and safe
process, both for the surgeon and the patient,
obtaining superior aesthetic results, as we are
able to sculpt the abdomen and back region.
Treatment of bra roll, upper and lower anks,
creation of Venus dimples and release of brous
adhesions to the underlying musculature are just
possible with this technique, which added to high
denition liposuction of the anterior area, mark-
ing the abdominal muscles, achieves a at, outlined abdomen and an hourglass silhouette
considered an ideal of beauty. Likewise, current
intraoperative and postoperative management has
led to better skin retraction, decreasing bruising
and brosis [3].
Warning Deep knowledge of local
c
anesthetics, different instruments and
technologies cannot be overemphasized. It is
essential to control all the factors surrounding
this procedure.
27.2 Patient Selection
A detailed examination of the patient’s body is
essential to obtain good results. We must bear in
mind that presence of a sagging abdomen, a lax
skin that has lost its elastic and retraction properties, or weakness and herniation of the abdominal
wall will not be completely corrected without open
surgery. In these cases, combination of liposuction
with abdominoplasty would be our recommendation, thus obtaining better access to abdominal wall
repair or excision of cutaneous excess.
We will obtain better results if the patient can
be classied into one of the following groups.
1. Good elastic skin quality
2. Patients with normal weight or slightly overweight without marked excess skin
3. Existence of isolated fatty deposits in both the
abdomen and anks
4. Undened waist
5. Venus dimples (posterior iliac spine ligaments) not clearly dened
6. Presence of “bra roll” without marked excess
skin
7. Thin or normal weight patients seeking
greater muscular denition (360° high denition liposuction)
Warning To enhance your results, make sure
c
to select good skin quality patients. Do not
risk with obese or massive weight loss patients
due to poor skin quality and retraction. It will
lead to unhappy patient and surgeon.
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In post-maternity women, body shape will
change within months after delivery. We recommend performing liposuction once stability has
been reached, allowing the skin to adapt naturally. It may take up to one year, so patience is
advised. Early treatment might lead to good
results in the early postoperative period, but further body changes will obscure the treatment
with suboptimal results.
27.3 Preoperative Analysis
27.3.1 Previous Analysis
In our practice, we take a series of patient photographs that allow us to analyze the problems
we can solve (Fig.27.1) and the ones susceptible of improvement with other techniques. In
this way, we get the patients to understand and
actively participate in telling us what bothers
them the most and what would they like to
improve. With this dialogue, we also get a better
doctor–patient relationship, in which both of us
are aware of the objectives to be achieved with
surgery.
Presence of brous adhesions in the abdominal and throchanteric area is well known.
Anatomical studies veried the existence of areas
of skin adhesion to deep planes, producing folds
that cause excess fat to overlap and hang over
(Fig.27.2).
Knowledge and functionality is essential in
liposuction, being able to decide which areas of
adhesions we must respect and which to weaken
to achieve a better skin transition, eliminating
crease effect, and getting a smooth and homogeneous abdomen and back.
Transverse brous zones represent a real stop
in skin continuity, acting in a similar way to the
submammary fold or the nasogenian groove.
Excess fat will protrude above giving a hanging
abdomen aspect. Eliminating or weakening these
brous areas with liposuction cannulas releases
skin from its deep adhesions and allows us to balance the transition between different zones [4]
(Fig.27.3).
Previous scars are evaluated if present, and the
patient is informed about the difculties that can
be present to release the underlying brous tissues. Sometimes they can act as a x point where
skin can hang over if skin retraction is poor. If we
suspect this might occur, abdominoplasty may be
advisable. Also in case of adherences, fat grafting
under the scar can be done to further increase the
quality of tissues.
A complete blood test is essential. Nutritional
status, coagulation factors, water balance, and
patient’s general condition are evaluated. In case
of previous history of thromboembolism, deep
venous thrombosis, or hypercoagulability factors, it is advisable to evaluate the risk of postsurgical thrombotic complications using the
Caprini score (Fig. 27.4) [5]. If oral contraceptives or hormone replacement therapy are taken,
we recommend to discontinue treatment for a
minimum of 2weeks prior to surgery to reduce
risk of thromboembolic events. In procedures
where more than 6000 cc of lipoaspirate is to be
expected, we recommend the use of prior patient
autotransfusion. The use of blood substitutes in
the postoperative period in high volume liposuction procedures favors a more accelerated recovery and less post-surgical weakness [6].
27.3.2 Preoperative Markings
First, trace the midline in the front and rear positions. Then mark the most protuberant areas on
the abdomen and anks. Take your time to palpate and draw linea alba, linea semilunaris, and
inguinal ligament on each side, since they are the
key framing lines in a female. Also outline inframammary fold, adhesion zones and folds or previous depressed scars and fat grafting areas if
needed. In the back, mark the midline, lattisimus
dorsi and gluteus maximus limits, Venus dimples,
bra rolls, and all adhesion zones (usually under
bra rolls). Finally, we draw our planned liposuction incisions.
Use different colors to signal each treatment
area, so as to have a clear image of each zone during surgery (Video 27.1).
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Fig. 27.1 Series of patient photos: front, 3/4 left side, total left side, rear, 3/4 right side, total right side
Fig. 27.2 Adhesion zone under bra roll that causes
excess fat to hang marked with a red asterisk
Fig. 27.3 Hanging effect of the abdomen in areas of
transverse brous adhesions in woman after C-section
permission from Joseph A. Caprini.
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Each Risk Factor Represents 5 Points
Major lower extremity arthroplasty (<1 month)
Hip, pelvis or leg fracture (<1 month)
Stroke leading to immobility (<1 month)
Multiple trauma leading to immobility
(<1 month)
Acute spinal cord injury (paralysis) < 1 month
Major surgery lasting over 3 hours
Each Risk Factor Represents 3 Points
Age over 75 years
History of DVT / PE
Family history of DVT/PE (1st degree relative)
Major surgery lasting 2-3 hours
BMI > 50
History of Inherited Thrombophilia
History of Acquired Thrombophilia
Each Risk Factor Represents 2 Points
Active Cancer
Cancer diagnosed within the last 6
months (except skin and thyroid cancer)
Recurrent or Metastatic Malignancy
Patient on Active Cancer Treatment
Age 61-74 years
Central venous access
Laparoscopic surgery (> 60 minutes)
Arthroscopic surgery (> 60 minutes)
Major surgery (> 60 minutes)
Morbid obesity (BMI >40)
Each Risk Factor Represents 1 Point
Malignancy other than mentioned above
Age 41-60 years
Varicose veins (current)
Swollen lower limbs (current)
Medical patient currently at bed rest >3
days
Obesity (BMI >30)
Congestive heart failure (<1 month)
Sepsis (<1 month)
Serious lung disease including pneumonia
(<1 month)
COPD exacerbation
Leg plaster cast or brace (current)
Other risk factors (specify)
For Women Only (Each Represents 1 Point)
Oral contraceptives or HRT
Pregnancy or postpartum
History of unexplained stillborn infant or
recurrent spontaneous abortion ( 3)
Total Risk Factor Score:
Total Risk Factor Score Risk Level
2
3 - 4
5
Moderate
High
Low
DVT indicates Deep Vein Thrombosis; PE, Pulmonary Embolism; BMI, Body Mass Index; COPD,
Chronic Obstructive Pulmonary Disease; HRT, Hormone Replacement Therapy. Adapted with
Fig. 27.4 Caprini score to evaluate risk of DVT
27.4 Anesthetic Considerations
In supine position, an endotraqueal tube is placed
and securely xed to avoid unwanted complications. It is imperative to assess tube xation, as
during the surgery, movement of the whole body
is expected.
Use of local anesthetics with adrenaline in the
inltration phase may help the anesthesiologist to
decrease the amount of intraoperative analgesia
and opioids, which will reduce postoperative
nausea and vomiting.
Close blood pressure control cannot be overemphasized, especially if large volume liposuction is planned. Recommended systolic pressure
is around 100 mmHg. If we reach this goal,
lipoaspirate will get more fatty and less bloody,
increasing safety procedure, reducing postoperative bruising and leading to a faster recovery.
Controlled hemodilution can also be added to
prevent blood loss. It should be noted that postoperative hemoglobin might be lower than
expected within the rst 24h, but will raise to the
real value after this period.
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Some authors advocate for intravenous use of
tranexamic acid to control postoperative hematoma, but in our practice, we have not seen a clear
difference. Nevertheless, more research should
be done in order to elucidate whether it might be
helpful.
27.5 Surgical Technique
27.5.1 Current Devices
forLiposuction
Since the rst attempt of performing fat extraction through minimal incisions, by the French
surgeon Charles Dujarrier in 1921, technological
advances have appeared to make liposuction easier and more predictable. Sophistication of surgical materials and the surgeon’s desire to improve
liposuction procedures in search for best results
made development of different devices possible
till date [7].
27.5.1.1 Suction-Assisted Liposuction
(SAL)
In 1977, brothers Arpad and George Fisher were
the rst to use suction together with sharp curettes
for fat extraction. They ended up having large
number of postoperative complications due to tissue damage with this aggressive method. Years
later, Frenchman Yves-Gerard Illouz introduced
the use of blunt tip cannulas, helping standardize
the surgical technique and dramatically decreasing number of complications. It is from this
moment when demand for SAL increases, technique is rened, and a wide variety of cannulas
appear, with different tips and distinct distribution and sizes of holes in the distal part. Curved
or straight cannulas were developed, with a great
variety in length and diameters, from 0.9 mm
cannulas widely used in facial surgery, to ones
larger than 5 mm used in body contour
liposuction.
Likewise, suction can be achieved from
adjustable vacuum systems, where it is possible
to control the pressure applied throughout the
system, or manually by performing vacuum with
syringes, obtaining lower pressures. The latter
helps reduce damage on the adipocyte, a method
focused on fat graft extraction through liposuction process. Introduction of fat grafting in a plastic surgeon’s arsenal caused a radical change in
body contouring surgery: its complementary use
with liposuction led to a consistent improvement
of postoperative results and developed a new
concept of liposculpture. The capacity of body
modeling through liposuction and minimal incisions was born, something impossible to perform
previously without large surgeries or tedious dissections, along with its scar sequelae.
Today SAL is the most used system in the
world, being a low cost method with a less pronounced learning curve. Post-surgical results are
very technical-dependent based on fat extraction
and production of subcutaneous tunnels, creating
a three-dimensional dense brous septa network
called retinacula cutis supercialis (RCS) and
retinacula cutis profunda (RCP) (Fig.27.5) that
later, in the healing process, produces retraction
of the dermis and the skin [8].
A major disadvantage of this system is that it
is time and energy consuming if large volume
liposuctions are performed, as well as a higher
rate of blood loss. In addition, it might be more
challenging when extracting fat in more brous
areas, or in cases of secondary liposuctions in
which scar tissue is present. Finally, cutaneous
retraction is little compared to other techniques,
which will be described later in this chapter [9].
Fig. 27.5 RCS and RCP a true retaining connective network between skin and deep tissues after liposuction
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