Lipoabdominoplasty:

Abdominoplasty is an important and common operation in aesthetic surgery. Since its original recorded description, several technical improvements have been made. Fundamentally, however, there has been no change in the essential concept of extensive undermining almost to the costal margin, followed by appropriate resection and closure. The operation is still associated with a significant complication rate, morbidity and prolonged convalescence. Complications have included flap necrosis, seroma, haematoma, infections, fat necrosis, dehiscence of wound and delayed healing. There is also a high incidence of aesthetic flaws and need for secondary correction, rates as high as 27.9 % being reported. Extensive undermining causes denervation and reduction in the vascularity of the flap. There is thus an intrinsic design flaw in the traditional operation, namely, a large random pattern skin flap, partly deprived of blood supply and innervation is stretched maximally and sutured under tension. This accounts for ischemia related complications. The lower abdominal skin also remains permanently numb.The traditional technique also results in several lymphatics being divided. Despite routine use of drainage, a high rate of postoperative seroma is still accepted as unavoidable. Despite such high complication rate even the end results may not be always aesthetically pleasing.

The problems increase significantly in obese subjects and hence patients are told to lose maximum weight in order to “earn” their abdominoplasty.

The best indication for abdominoplasty is still a patient with plenty of loose skin, rectus muscle diastasis and without too much fat in the local area. With the rising incidence of obesity in the world, such patients are rare in today’s practice

Many obese patients are unable to lose weight especially in the abdominal area and hence are denied abdominoplasty. In obese individuals unable to lose weight, a two step approach has been advocated consisting of abdominoplasty followed by liposuction six months later or vice versa. Both approaches are less than ideal. Reducing excess fat in abdominal wall by prior liposuction will induce fibrosis, making subsequent abdominoplasty difficult. Performing abdominoplasty first in these obese patients is associated with more complications and still leaves behind a fatty abdominal wall; subsequent liposuction can cause secondary skin laxity.

To circumvent these problems a new operation called Lipoabdominoplasty (LABP) has been practised by the author since 1995 with surprisingly low complication rate. Techniques have been refined over this period and in its present form it has proven to be trouble-free and versatile. Historically the concept of combining liposuction with abdominoplasty seems to have been proposed first by Cardoso de Castro in 1987[8] with later contributions by several surgeons.However this procedure has not been adopted universally yet. Part of the reason for reluctance is the fear that combining the two operations may be risky as was suggested in earlier writings where the concept of “danger zones” was proposed.Modern LABP is an entirely new operation and is not merely a combination of two procedures; this is important to understand in order to attain efficacy with safety.In this article the author explores the philosophy of this new procedure, laying emphasis on the essential steps for safety to shorten the learning curve

PATIENT ASSESSMENT AND INCLUSION
Consultation
During consultation due attention is paid to the following features. In the history it is important to elicit details of general fitness and functional capacity, lifestyle, smoking, co-morbidities, previous abdominal operations as well as evaluate risk profile for DVT and chest complications. Examination focuses on differentiating intra-abdominal obesity from obesity in the abdominal wall and the relative contribution of both components to the abdominal contour. This crucial factor decides if the obese patient is a candidate for LABP. Persons with predominant visceral obesity are counselled to lose weight and are not accepted for surgery.

Further examination in suitable patients will focus on measuring the thickness of fatty panniculus, evaluating the degree of skin ptosis and vertical mobility of the abdominal panniculus, skin tone/elasticity, muscle tone, presence/absence of rectus diastasis/hernia previous surgical scars including laparoscopy scars, presence and extent of skin striae, the position of umbilicus vis-á-vis the pubis and presence/absence of ptosis of mons pubis. An assessment is then made of the extent of dermolipectomy possible in order to forecast if the umbilical donor opening can be excised completely. The possibility of inverted T closure will have to be explained to the patients with lesser deformities. Other areas such as back, hips, and thighs are also assessed and the respective body contour problems discussed with the patients to clearly set out the goals of LABP and to indicate the need for other body contour procedures that may be needed in each case. This is especially important since patients with iliac and hip fat rolls will end up with lateral bulges if these areas are not addressed. Patients often complain bitterly about such bulges unless this is discussed and addressed either simultaneously or in a planned second body contour procedure.

Further points for decision making in obese individuals
Obesity comes in different shapes; Body Mass Index (BMI) is an inadequate tool to decide on the inclusion for surgery. In a significant proportion of obese females the fat is predominantly in the abdominal wall. Such obese patients can be accepted for surgery provided a useful degree of improvement can be anticipated after surgery and provided that such improvement fits into the overall scheme of lifestyle changes and medical management. Decision making is easy in patients classified as overweight or with obesity grade I and II especially if the problem is more significant in the abdominal wall. Decision has to be individualized in obesity grade III and in the morbidly obese. In these the individual distribution of obesity in the body, functional status, motivation and lifestyle factors and repeated discussions may be needed to arrive at a decision. In male patients and in android female patients a very careful assessment of the sagittal abdominal diameter must be made to exclude patients whose apparent abdominal contour is due to visceral fat [therefore not correctable by surgery].

Contraindications
Patients who are medically at high risk like those with uncorrected coagulopathies, significant cardio-pulmonary compromise and viscerally obese patients, globally obese and functionally compromised patients and patients with unrealistic expectations are to be excluded. Smokers who cannot give up the habit need to be counselled carefully regarding risks and potential complications which tend to be higher in them.

Preoperative routine
The author has been using the following measures.

Complete medical evaluation and optimisation by a physician in patients with co-morbidities

A month of regular aerobic exercises in sedentary individuals to build up cardio-respiratory reserves and to unmask latent functional problems.

Full body scrub with Povidone iodine or Chlorhexidine preparations for 3 days prior to surgery, paying attention to intertriginous areas and umbilicus

Pre-anaesthesia evaluation and appropriate corrections where needed

Attention to diet

Routine use of low-molecular weight Heparins and anti-embolism stockings.

Measurements for postoperative garment based on hip size excluding the apron.

Markings are done on the previous day with the patient upright to mark the midline, xiphoid and pubic symphysis, proposed incision and estimated dermolipectomy. Any hernia sites are marked and the diastasis is similarly outlined.

Surgical procedure
Positioning and preparation
Patient is positioned supine on the table with a removable bolster under the lumbar lordosis to hyper-extend the abdominal wall. Catheterization is done if procedure is anticipated to exceed 150 minutes. Pressure points are padded and pneumatic calf compression pump is applied in high risk individuals. General endotracheal anaesthesia is induced. Draping is done widely with a sterile sheet tucked under the flank to give full flank access for liposuction. Drapes are placed above the xiphoid and below the pubis for adequate access. Prophylactic broad spectrum antibiotic of choice is administered; the author prefers 2g of Cefipime IV after induction of anaesthesia.

Liposuction
Procedure begins with infiltration of tumescent fluid (Klein formula) in all areas to render the tissues firm but not completely tumescent. Liposuction is done using standard technique by the surgeon’s preferred method. I do not recommend cannulae larger than 4 mm. Mercedes three hole cannulae are preferred. More aggressive cannulae can damage vasculature and are not recommended. Suction is done uniformly in all areas, there are no danger zones. Care is taken within the area of diastasis of recti and near hernias to avoid peritoneal entry; the canula is always kept tangential to the abdominal dome. Since the lower panniculus will be excised, only deep plane suction is done there for lipomobilization effect. The midline and paramedian upper abdomen is suctioned more vigorously to reduce the fat thickness to 1 cm pinch thickness, more fat is retained on periumbilical area and along linea semilunaris [1.5 cm pinch thickness]. Flanks and hips can be suctioned aggressively to sculpt the waist. Suction is also done below the final incision and into mons pubis as needed. Scarpa’s fascia is not violated. Generally liposuction may be continued till 1 cm pinch thickness is reached as long as care is taken to avoid aggressive scraping of the skin. The purpose of the exercise is to thin the subcutaneous fat and get maximum lipomobilization effect to enable the upper abdominal skin to slide inferiorly while retaining vascularity via the numerous perforators. Quantity of fat suctioned from abdomen alone has ranged from 50 ml to 4000 ml in my cases.

Abdominoplasty
After liposuction, the lumbar bolster is removed and the lower incision is made. Incision placement is a crucial step. In women with sufficient ptosis of the skin, the incision is placed in the abdominal crease whenever possible respecting the guidelines laid out by Baroudi and Moraes.Baroudi laid out a bicycle handle-bar type of low incision which enables the surgeon to resect more skin in the flanks and keep the final scar low and aesthetically pleasing. The flank line is tightened well while also ensuring a youthful separation of the umbilicus from the pubis. In women with less ptosis, it helps to keep the central part of the lower incision convex cranially to avoid tension in the midline at the time of closure. The gives the crucial 2 cm of extra lower skin to enable tension free closure at the midline. If not needed at the end, this extra skin can be trimmed. The final closure should be 7-9 cm from the top of vulval commissure for aesthetic result and patient comfort. The aesthetics of the pubic region must also be maintained, avoiding the distressing upward migration of the pubic hair triangle as well the pulled appearance of the vulva. In women with ptosis of the mons pubis, a mons-lift is planned and factored into the incision placement.

Using cutting diathermy, incision is deepened to incise Scarpa’s fascia but no deeper. The plane of dissection then turns cephalad, closely hugging the under-surface of Scarpa’s fascia. The adipose tissue on the external oblique aponeurosis is left intact; this has been shown to be rich in lymphatics. Any violation of these tissues increases lymphorrhea and results in seroma. Flap elevation is continued to the level of umbilicus. Sharp dissection stops at this level. Beyond this the honeycombed under surface of the flap and intact fibro vascular connections can be visualised The umbilicus is circumscribed and the stalk dissected with a thin layer of fat on it. Some peri-umbilical fat is also retained on the rectus fascia. Rectus perforators are pre identified and securely tied [not merely cauterized]. These perforators are in spasm due to the effect of adrenaline and can slip inward, causing rectus sheath haematoma. Supra-umbilical perforators are preserved as far as possible. Flap elevation then proceeds above umbilicus but only in the midline and paramedian areas to expose the rectus sheath for an inch beyond the respective medial borders [stretched linea alba]. Midline plication is done only if there is diastasis; plication is continued inferiorly till the pubis. I routinely use PDS loop suture but have recently switched over to No 2 Ethibond® which is a soft non-absorbable permanent suture. The operating table is then flexed about 30 degrees and a trial closure is done to assess the extent of dermolipectomy possible. Further selective blunt digital flap elevation is performed going between the intact fibrovascular connections to mobilise the sliding flap further. An occasional fibrous strand may need to be divided sharply. Maximal dermolipectomy is then performed mirroring the pattern of the lower incision; it is important to plan this carefully to avoid excessive tension on closure, it is better to err on the side of safety. Further trimming can always be done where needed. Closure is tested with a few trial sutures.

Inner surface of lipomobilized flap after selective undermining. Note the umbilicus in the centre and the retractor cranial to that. Midline plication is easily possible. Note the long strands of fibro-neuro-vascular connections and also the intact layer of adipose tissue left behind on the external oblique aponeurosis. This tissue is rich in lymphatics

Umbilicoplasty
The umbilical stalk is telescoped with four quadrant sutures tacking it to the rectus sheath. This step is important to give a proper inversion to the future umbilicus. The umbilical location is projected on the skin flap and marked with ink. The new umbilical opening is planned 1.5 to 2 cm cranial to the upper border of the projected point. The new site is de-epithelialised and the dermis incised in tri-radiate fashion. A divergent cone of fat is then removed beneath this area. This step is important for a nice concave umbilicus. Two strong vicryl sutures are taken from the dermal fringes at 3 and 9 ‘o’ clock positions and anchored to the rectus fascia on either side of the umbilical stalk. This important step further advances the abdominal flap downwards and puts higher tension on the upper part where the flap vascularity is better while simultaneously relaxing tension at the lower closure. It also achieves an ink-well effect of a concave umbilicus. A suture may also be taken at 12 ‘o’ clock position if needed.

After this, the dermal fringes of the umbilical opening are sutured to the umbilical stalk to take the tension off the final skin closure which is done with interrupted 4-O rapide Vicryl®.

Obliterating the dead space
The skin flap is advanced and the dead space is obliterated with 4 to 8 quilting sutures per side of 2-O Vicryl rapide® taking bites from the dermis to the external oblique fascia and going through the iliac adipolymphatic pads. Drains are not necessary. The incision is closed in 3 layers compensating the superior [longer] flap medially to correct any length disparity. It is important to close the superficial condensed fascia properly taking all the tension there and avoiding any tension on the skin closure.

Postoperative regime
After extubation and postoperative recovery, the patient is assisted into the appropriate postoperative compression garment.

The patient is nursed in the Fowler position i.e. with head end of bed propped up and a pillow under the knees to flex the hips. Urinary catheter, if any, is retained for a day. Patients are routinely ambulated the same day and mostly discharged the next day. In cases of significant midline plication or hernia repair, patients stay for 2 days. Low molecular Heparin is continued the next day, stockings are worn for 5 days and the first visit is also on the 5th day. Compression garment is worn for 3 weeks and strenuous exercises are avoided. Guided exercises are begun thereafter.