eMedicine Specialties > Plastic Surgery > Body Contouring
Body Contouring, Abdominoplasty: Treatment
Updated: Sep 27, 2007
Treatment
According to the American Society for Aesthetic Plastic Surgery's 2004 Cosmetic Surgery National Data Bank, the number of abdominoplasty procedures performed has increased 344% in the last 7 years. A national report on abdominoplasty has not been published since 1977. Grazer and Goldwyn's study reflects the preliposuction era of abdominal contouring surgery.
Surgical Therapy
The large number of different excisional designs is an indication that abdominoplasty is not an exact science. However, some guiding principles must be noted. First, ensure that the incision and subsequent excision address the deformity. For patients with a small amount of lower abdominal skin and fat excess and a minimal amount of lower abdominal laxity, a miniabdominoplasty can be performed.20 This consists of a short suprapubic incision, elevation of abdominal skin to the umbilicus, plication of the fascia (if needed), and excision of excess skin.
Numerous designs for abdominoplasty are available. Recently, suction-assisted liposuction (SAL) has been added to the procedure. In 1990, Grazer was one of the first authors to integrate SAL into the procedure.21 He describes 9 major points: (1) incision selection, (2) panniculus elevation and SAL, (3) diastasis recti plication, (4) closure, (5) umbilicus tailoring, (6) upper abdomen suctioning, (7) adjacent deformity suctioning, (8) flap trimming, and (9) drain and dressing placement.
The type of incision is usually determined by the patient's body habitus or by the patient's choice of clothing, ie, bathing apparel or shorts. Most incisions are low on the abdomen, allowing the patient to wear fairly brief apparel. Most abdominoplasty incisions are variations of the Regnault,22 Grazer,21 or the bicycle-handlebar techniques described by Baroudi.23
Grazer also describes a so-called reverse abdominoplasty.21 This procedure is indicated more for patients whose deformity is limited to the upper abdomen.
Although most abdominoplasty procedures involve tightening of the rectus sheath, in 1978 Psillakis first described contouring of the abdominal wall by plicating the external oblique muscles.10 He noted that multiple pregnancies result in changes in the spinal column, pelvis, and ribs. These changes increase anterior abdominal wall projection, lower the pubis, and enlarge the inferior thoracic cavity. His technique has evolved into elevation and advancement of the external oblique muscles and resection of protruding ribs.
Lockwood states that the surgical principles developed from the 1960s through the 1980s led to the following unaesthetic results: (1) overtightening of the central abdomen, (2) residual laxity of the inguinal and lateral abdominal areas, (3) suprapubic scar depression with soft tissue bulging, (4) poor waist definition, and (5) elevation of pubic hair.24 Lockwood goes on to define ideal abdominal aesthetics further, as follows:
- Tight lateral trunk and inguinal tissue with deep waist concavity
- Central tissues not pulled tightly, with convexity of the hypogastrium and concavity of the epigastrium
- Midline epigastric valley between rectus muscles
- Vertical umbilicus
- Vertical valley lateral to rectus muscles
- S-shaped outlines of the anterior and lateral silhouette
Lockwood's design calls for tightening the lateral abdomen, waist, and inguinal regions more than the central abdomen, followed by circumferential "liposculpturing of the posterolateral trunk" performed in a single procedure.
Lockwood was one of the first authors to determine that vertical truncal laxity is greatest along the lateral body contour and is smallest in the anterior and posterior midline as a result of superficial fascial system adherence. Therefore, Lockwood's procedure is based on the following points:
- Limited direct undermining
- Wide discontinuous undermining
- Lateral skin resection
- Superficial fascial system repair
- Truncal liposuction
Ramirez attempted to combine elements of many previously described techniques. His technique is divided into 4 parts: (1) U-M dermolipectomy, (2) V-umbilicoplasty, (3) rectus abdominus myofascial release and repair, and (4) SAL.25
Ramirez is careful to note that the myofascial release portion of the procedure is not without some risk. A plication that is too tight can lead to pain, wound dehiscence, ileus, compression of the inferior vena cava, and, possibly, pulmonary embolus. Postoperatively, patients experience decreased bowel motility due to narcotic use, having undergone general anesthesia and abdominal plication. Steps should be taken perioperatively to minimize this issue. Ramirez performs a formal bowel preparation on his patients and prescribes chlorpropamide (Reglan) preoperatively and postoperatively. The authors routinely place the patient on a clear liquid diet the day before surgery, as well. Routine bowel preparation optimizes the outcome by decreasing colonic weight and minimizing the possibility of complications after abdominal plication.
Male patients tend to have less realistic goals and are more frequently dissatisfied with the final outcome of their body contouring procedures. The thicker male skin has less elasticity and is less likely to have cellulite. Also, the male pubic hair distribution requires the transverse abdominal incision to be placed higher than in female patients.
Follow-up
These procedures are now frequently performed on an outpatient basis, which is a big change from the traditional inpatient hospitalization for up to 2 days. A recent report highlights and supports the safety and effectiveness of abdominoplasty performed on an outpatient basis. Their results showed no correlation between complication incidence and inpatient/outpatient status.26
Abdominoplasty as outpatient surgery has become possible because of the significant advances in the safety of anesthesia and effective pain and nausea management. Although the recent increase in use of infusion pumps for postoperative pain control is popular in the authors’ surgical specialty, Bray et al showed no significant improvement in pain management in abdominoplasty patients. On the other hand, others have shown the infusion of local anesthetics to be effective in various breast reconstructive procedures.27,28 Mentz et al showed decreased pain reduction in patients following abdominoplasty with the use of regional infusion pump, leading to earlier ambulation.29 This shows that the differences in perception of postoperative pain may be patient-specific. The goal following each surgery is early ambulation and improved pulmonary physiology. If pain pumps have a role in decreasing the discomfort that may be experienced with ambulation following abdominoplasty, their use may bewarranted.
Complications
As with all body contouring procedures, complications can occur. In an article from 2000, Pitanguy discusses his complication rates over 3 periods, 1955-1960, 1961-1979, and 1980-1998.30 The most common complications were wound dehiscence, seroma formation, infection, hypertrophic scarring, residual deformity, and wide umbilical scars. As noted from this article, the incidence of complications dropped dramatically with experience.
The most devastating complication of an abdominoplasty is pulmonary embolus, which is described to be a risk factor at 0.8%.31 This complication is thought to be directly related to the severity of plication of the rectus fascia, which can cause intra-abdominal hypertension (ie, >20 mmHg).32,33,34 The increased pressure has deleterious effects on the venous circulation by causing stasis and decreasing the return, therefore predisposing the patient to deep venous thrombosis (DVT).32 Communication with the anesthesiologist at this point can help address this problem by early detection of any changes in the peak inspiratory pressure. Cases of pulmonary compromise and gastroesophageal reflux following rectus plication have been reported in the literature due to intraabdominal hypertension; some cases required release for resolution of symptoms.35,36,37 .
After appropriate patient selection, all attempts are made to decrease the risk of developing a DVT. Patients receive 5,000 units of heparin 30 minutes prior to induction of general anesthesia. In addition, while in the preoperative holding area, patients are placed in thromboembolic disease (TED) hose and sequential compression devices. The orthopedic and trauma literature has shown that low molecular weight heparin (LMWH) is more efficacious in the trauma patient population; however, to date, no literature supports the superiority of LMWH over unfractionated heparin in patients undergoing abdominoplasty for aesthetic purposes. Recently, a retrospective review of 126 patients who underwent rhytidectomies with LMWH prophylaxis for DVT reported a rate of postoperative bleeding that was higher than is generally expected.38
Other complications include skin loss (major or minor), loss of umbilicus, elevation of the pubic escutcheon, and painful neuromas. From 1975, Regnault reports hematomas and/or seromas in 3% of patients, skin necrosis in 0.5%, hypertrophic scars in 3%, and scar revisions in 4%.39
In 2001, van Uchelen et al reported a series of 86 patients (14 male, 72 female) who underwent abdominoplasty.40 Complications were classed as wound complications (ie, infection, dehiscence, seroma and/or hematoma, marginal necrosis) or "complications after surgery" (ie, deep vein thrombosis, pulmonary embolism, ileus, nerve damage, death). Of the 14 male patients, 9 (64.3%) had a wound complication and 2 (14.3%) had a postoperative complication. Of the 72 female patients, 11 (15.3%) had a wound complication and 10 (13.9%) had a postoperative complication.
Comorbid factors play a significant role. Patients who smoke or have diabetes, hypertension, a body mass index greater than category I, or asthma have significantly higher complication rates.
As the public call for multiple simultaneous procedures increases, so do the concerns for potential complications as a result of these combined procedures. Since the institution of a temporary moratorium in 2004 in the state of Florida on abdominoplasty combined with SAL in the office setting, the safety of combined procedures was revisited nationwide. Matarasso et al report the largest series of local and systemic complication rates and compare them with those of previously published abdominoplasty surveys.41 With respect to full abdominoplasty, lower complication rates were seen with DVT (0.04%) and pulmonary embolus (0.02%). No deaths were reported. No correlation was evident between a surgeon's years in practice and complication rates, in concordance with the earlier study by Grazer and Goldwyn. Despite more extensive abdominal contouring techniques and the addition of liposuction to abdominal contouring, the local and systemic complication rates coincided with previous complication rates as outlined in other studies. Furthermore, several reports showed that the complications associated with combined abdominoplasty and lipoplasty did not correlate with an increased morbidity as compared to abdominoplasty alone.42,43,44Seroma formation following abdominoplasty continues to be a frustrating problem for both surgeons and patients. In a retrospective study, Kim et al reviewed 118 consecutive patients who underwent abdominoplasty with or without flank liposuction from 1992-2002 and concluded that liposuction of the flanks in concert with abdominoplasty does not increase the risk of seroma formation.27 However, patients who are overweight or obese present a statistically significantly higher risk for developing seromas postoperatively than patients of normal weight. Quilting sutures have been shown to decrease the rate of seromas in a recently published study.45 The average BMI in this study was 28.5 kg/m2; this demonstrates the importance of patient selection, as decreased risk factors can help prevent complications. The risk factors that have been shown to lead to higher rates of complications include smoking, diabetes, malnutrition, excess body weight, and male sex.46,47
Obesity is yet another well-known risk factor for wound complications in this procedure. Recent data show that 66% of adult Americans are overweight, as defined by BMI of greater than 25.0 kg/m2.18,19 This includes the approximately 31% of the adult population that is classified as obese (ie, BMI ≥30 kg/m2). Rogliani et al evaluated the effect of obesity on the incidence of complications after abdominoplasty and showed that obesity at the time of abdominoplasty has a profound influence on the wound complication rate following surgery, regardless of any previous weight reduction surgery.47
Despite their mention by numerous authors, deep vein thrombophlebitis and pulmonary embolus seem to be rare complications.
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| Workup: Body Contouring, Abdominoplasty |
 Treatment: Body Contouring, Abdominoplasty |
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Further Reading
Keywords
tummy tuck, abdominal wall contouring, mini-abdominoplasty, high-lateral-tension abdominoplasty, HLT abdominoplasty, suction-assisted lipectomy, SAL, abdominal deformity, W technique, abdominal lipectomy, abdominoplastic surgery, abdominal plastic surgery, abdominal liposuction, abdominal deformity, deformed abdomen, pregnancy recovery, pregnancy effects, suction-assisted abdominoplasty, reverse abdominoplasty, excisional body contouring surgery, excisional body contouring, marriage abdominoplasty, abdominal liposculpture
