Abdominoplasty

One of the most commonly performed aesthetic procedures, abdominoplasty, in which excess skin and fat are removed from the abdomen, has undergone significant evolution over the past several decades. Kelly was one of the first surgeons to attempt to correct excess abdominal skin and fat.[1, 2] Using a transverse incision, he was able to resect a 7450-g panniculus measuring 90 X 31 X 7 cm. Since that time, numerous variations have been suggested. Thorek was the first to devise a procedure that preserved the umbilicus.[3, 4]

In 1967, Pitanguy published a report of 300 abdominal lipectomies,[5] followed by Regnault, who published the W technique for abdominoplasty in 1972.[6] In 1973, Grazer was one of the first authors to describe the so-called bikini line incision,[7] and in 1967, Callia described a low incision that extended below the inguinal crease.[8] This also appears to be the first report of aponeurotic suturing. When the Saint Tropez bikini (with a very low waistline) was fashionable, the abdominoplasty incision was nearly horizontal in order to be concealed under such a garment. When the French-line bikini (with a very high leg cut) was popular, the abdominoplasty incision had to be converted from a nearly horizontal line to an incision line that accompanied the inguinal fold. Since the turn of the century, bikinis with very low waistlines have become more popular again. Therefore, proper adjustments in techniques are again necessary to achieve a tailor-made abdominoplasty.

In 1977, Grazer and Goldwyn reported the first complications using new techniques.[9] Although aponeurotic suturing in the midline was noted to be able to reduce anterior projection of the abdominal wall, it did little to reduce the diameter of the waist.

In 1978, Psillakis first suggested suture plication of the external oblique musculature after raising it in a beltlike fashion.[10] In this way, he was able to dramatically reduce the diameter of the waist. He also added refinements such as costal margin excisions in patients with a projecting upper abdomen. With the addition of liposuction, Matarasso in 1988 expanded the use of abdominal contour surgery to a classification based on variations in patients’ anatomy, from liposuction alone to limited and full abdominoplastic surgery.

In 1995, Lockwood described the high lateral tension abdominoplasty.[11] Its key features include limited direct undermining, increased lateral skin resection with high tension wound closure along lateral limbs, and 2-layer superficial fascial system (SFS) repair.

The abdominal deformity is excess skin and subcutaneous tissue and laxity of the abdominal wall musculature.

Frequency

Abdominoplasty was the fourth most common aesthetic surgical procedure performed in the United States in 2019, with over 140,000 of the operations carried out that year, according to the Aesthetic Plastic Surgery National Databank.[12]

The most common cause of abdominal deformity is pregnancy, most often multiple pregnancies. Pregnancy stretches the skin beyond its biomechanical capability to spring back and stretches the musculoaponeurotic structures of the abdominal wall. The result is stretching and thinning of these structures and diastasis of the rectus muscle. Postpartum weight loss also contributes to the process. If skin retraction has not occurred in approximately 6 months, it probably will not occur. Massive weight loss, whether from dieting or after a gastric bypass surgery, also plays a role in excess skin and laxity of the abdominal wall.

The pathophysiology of the abdominal deformity is 2-fold. It includes (1) excess skin and subcutaneous tissue and (2) laxity of the abdominal wall musculature.

The most significant area of the defect is around and below the umbilicus, where excess skin over a diastasis of the rectus muscles is most apparent.

In 1972, Georgiade and Katras classified fat deposits on the trunk as lower medial or upper medial, based on the umbilicus. Patients are divided into 3 categories: (1) those with normal weight, (2) those who have mild-to-moderate obesity, and (3) those with massive weight loss.

As with all major surgical procedures, a complete history and physical examination are mandatory.

History

The medical history is extremely important. Previous pregnancies and their effects on the abdomen should be noted. Previous surgical procedures (including laparoscopic procedures) should be documented. The patient's history of weight gain and loss should be discussed. Finally, any future plans for pregnancy should be noted. A detailed inquiry into the patient’s history of medical problems should be performed. Severe heart disease, diabetes, and a history of thromboembolic disease should be noted. Less severe but also important information is the occurrence of wound problems, either from infection or connective tissue diseases.

Ensure that patients aren't smoking and are exercising before the surgery to promote overall well-being. Advise patients to be as close as possible to their desired weight before surgery. If patients are planning another pregnancy or planning to lose more than 10 lb, advise them to postpone the procedure.

Physical examination

The abdominoplasty is targeted at addressing abdominal deformities characterized by excess skin and subcutaneous tissue and laxity of the abdominal wall musculature.

Preoperative planning

The physical examination should be thorough. Concerning the abdomen, the location of all scars should be documented and the presence of abdominal hernias should be noted. Diastasis of the rectus muscles should be noted. The condition and strength of the abdominal wall should be evaluated. The amount, quality, and elasticity of the abdominal wall skin should be thoroughly evaluated.

Preoperative photographs should be taken and printed on 8.5 X 11-in paper. These can be used when discussing the procedure with the patient. Alternatively, an imaging system can be used.

Mass media influences drive what patients expect and desire from an abdominoplasty. Inflated patient expectations must be addressed.

Therefore, understanding the patient's aesthetic goals prior to the procedure is critical. For instance, the patient should understand that the excision of excess skin and fat does not flatten an abdominal wall distended from inside by a large omentum. In addition, multiparous patients with striae should not expect results exactly as they see in magazines. The patient should be as close to his or her ideal body weight as is practical prior to the surgery.

The location of scars should be marked directly on the patient’s skin or, at minimum, on the photographs. Candid discussions regarding the quality of these scars and potential wound problems should occur. Early wound problems include hematoma, seroma, marginal necrosis, and dehiscence. Late wound problems include hypertrophic scars, keloids, umbilical malpositions, and thromboembolic events.

Patients usually seek abdominoplasty for abdominal wall laxity, excess skin, striae, or diastasis of the rectus muscles. The ideal patient is within normal limits for his or her weight and height (ie, body mass index), has no plans for future pregnancies, has a moderate amount of excess of skin and fat, and has a mild diastasis of the rectus muscles.[13] Patients who seek body contouring following massive weight loss have their own set of criteria. They need to be evaluated regarding their candidacy for a belt lipectomy instead of abdominoplasty.

The abdominal wall is embryonically derived in a segmental manner, and this is reflected in blood supply and innervation. The transition of the embryo from a trilaminar disk to a 3-dimensional structure on the 22nd day of gestation initiates formation of the abdominal wall. The development of the abdominal wall has multiple crucial stages; if the abdominal wall fails to undergo any stage in the sequence of events, congenital defects of the abdominal wall develop (ie, gastroschisis, omphalocele). The abdominal wall becomes a definitive structure after the umbilical cord is separated.

The musculature of the abdomen includes the paired rectus abdominis, which meet in the midline at the linea alba. These muscles originate at the infracostal margin, attach at the pubis, and are enclosed by a fascial sheath. In the upper two thirds of the rectus fascia, the anterior sheath is formed by the external and internal oblique aponeurosis, and the posterior sheath is formed by the internal oblique and transversalis aponeurosis. In the lower third, the posterior sheath is absent, and all 3 aponeurotic layers pass anterior to the rectus muscle, except the internal lamina of the transversus abdominis, the transversalis fascia, and the peritoneum, which pass posteriorly. This transition, known as the arcuate line, the linea semicircularis, or the semicircular line of Douglas, is present halfway between the umbilicus and pubic symphysis. At the caudal aspect of the rectus muscles, the pyramidalis muscles are present in 80-90% of patients.

The blood supply of the abdominal wall has been exhaustively described by Taylor and Palmer.[14] They introduced the concept of angiosomes, or vascular territories of the body. They describe 2 types of cutaneous blood supply: (1) direct vessels that directly supply the skin and (2) indirect vessels that "emerge from the deep fascia as terminal spent branches of arteries whose main purpose is to supply the muscles and other deep tissues." In a subsequent study in 1988, Moon and Taylor were able to demonstrate connections between the deep superior and deep inferior epigastric systems and their relationship to the cutaneous circulation.[15] The contributions of the superficial inferior epigastric vessels and the intercostal vessels were also delineated.

A clear understanding of the arterial supply of the abdominal wall is crucial to operative planning, especially when the patient’s history includes prior abdominal or chest wall surgeries. Huger’s description of the different zones of the blood supply guides the surgeon in planning and performing a safe operation. Huger defined zone I of the abdominal wall as the area that is fed anteriorly by the vertically oriented deep epigastric arcade. Zone III was described as the lateral aspect of the abdominal wall (flanks) that are fed by the 6 lateral intercostal and 4 lumbar arteries. The lower abdominal circulation is provided by the superficial epigastric, superficial external pudendal, and superficial circumflex iliac systems (zone II). A rich plexus between these systems allows collateral flow.

During abdominoplasty, the cutaneous blood supply to zone I and much of zone II is divided, with the abdominal flap circulation fully dependent on zone III. If a scar, such as a subcostal cholecystectomy incision, crosses the elevated flap, the circulation to the tissue distal to the scar is in jeopardy. A vertical midline incision can further jeopardize flap circulation.

The supporting structures of the abdominal wall have been elegantly described by Hartrampf.[16] He describes 2 static vertical supporting structures (linea alba, 2 linea semilunaris ligaments) and 2 static transverse ligaments (anterior rectus sheath, transverse tendinous inscription).

The superficial fascial system (SFS), the connective tissue network that resides below the dermis, has been implicated as a pivotal structure in body contouring procedures. Surgical repair of the SFS has been claimed to increase wound strength and decrease seroma formation. In a porcine model, Song et al showed that repair of the SFS layer in addition to dermis repair significantly increased the initial biomechanical strength of wound repair. This could lead to a decrease in early and late wound dehiscence, less widening of the scars, and lasting aesthetic results.

This in vivo model confirms Lockwood's idea that repair of the SFS results in a stable scar that heals without migration. This has the potential of changing or enhancing postbariatric body contouring outcomes, as the surgeon is dealing with large surface areas of tissue that need to be approximated under significant tension. According to the American Society of Plastic Surgeons statistics, approximately 68,000 body contouring procedures were performed in 2005 on patients who had experienced massive weight loss.

The nerve supply to the abdominal wall is via intercostal nerves VIII-XXII. These nerves pass between the internal oblique and transversus abdominis muscles. The motor branches pass behind the rectus muscles and enter the muscles at the junction of the lateral one third and medial two thirds.[15]

The skin of the infraumbilical and suprapubic areas of the abdomen is supplied by the iliohypogastric, ilioinguinal, and genitofemoral nerves. The skin of the abdomen is usually quite loose, except at certain points of adherence, ie, the anterior superior iliac crests and the linea alba. The subcutaneous tissue is divided by 2 layers of fascia, the superficial fascia (Camper) and the deep fascia (Scarpa), which is continuous with the fascia lata of the thigh.[17] With aging and pregnancy, fat tends to be distributed in the lower (infraumbilical) abdomen.

Striae are common, especially after multiple pregnancies. Striae are reported to be the result of rupture and separation of dermal collagen with resultant thinning.[18] Striae are not treatable except by excision.

The female body habitus follows a gynoid or hourglass shape. It is narrow at the waist and wider at the hips, with fat accumulation in the lower trunk, hips, thighs, and buttocks. Ideally, the female waist-to-hip ratio is approximately 0.7. The ideal male trunk contour has an android pattern, becoming narrower with descent from the chest to the hips in a V shape. Fat accumulation tends to occur circumferentially around the abdomen and flanks.

For more information about the relevant anatomy, see Regions and Planes of the Abdomen.

Contraindications to abdominoplasty include right, left, or bilateral upper quadrant scars (relative); severe comorbid conditions (eg, heart disease, diabetes, morbid obesity, cigarette smoking); future plans for pregnancy (relative); a history of thromboembolic disease (relative); morbid obesity (BMI >40); and unrealistic patient expectations.

The prevalence of obesity in health care settings is increasing to alarming levels. Plastic surgeons need to be aware of the comorbidities that are associated with obesity. In addition, only 5% of Americans are candidates for bariatric weight loss surgery. According to the American Society of Bariatric Surgery (ASBS), 200,000 patients will undergo massive weight loss surgery this year, and 75% of them will seek a plastic surgeon for body contouring after the weight loss surgery.

Current weight demographics in the United States include the following statistics:[19, 20]

• 66% of adults are overweight.

  • 31% are obese (categories I and II).

  • 5.1% are morbidly obese (category III).

• 32% of teens are overweight.

The most commonly accepted criterion for measuring obesity is the body mass index (BMI). This is defined by weight in kg divided by height in meters squared. The BMI categories are as follows:

• 20-25 healthy

• 26-29 overweight

• 30-34.9 obese (category I)

• 35-39.9 obese (category II)

• >40 morbidly obese (category III)

Additional relative contraindications include moderate obesity in a patient who expects a perfectly flat abdomen. Also, patients who tend to form keloids or hypertrophic scars should not undergo an abdominoplasty unless they are willing to accept the scarring associated with these conditions.

The studies below are performed at the surgeon’s discretion. Each institution’s preoperative anesthesia workup protocol should be followed to minimize cancellations.

• CBC

• Basic metabolic panel

• Beta human chorionic gonadotropin (bHCG) level

• Albumin level, pre-albumin level, and total protein level (if indicated)

• Prothrombin time (PT), activated partial thromboplastin time (aPTT), international normalized ratio (INR) (if indicated)

• Urine cotinine level to gauge patient compliance with smoking cessation (if indicated)

Chest radiographs (if indicated)

If the patient to be operated upon has diabetes mellitus, appropriate tests should be performed to assess glucose control. If the glucose control is poor and levels are greater than 180 mg/dL, surgery should be delayed until the patient’s primary care physician can address the underlying issues and better control the patient’s glucose levels.

At times, if a hernia is encountered, a referral to general surgery is warranted for repair of the hernia at the time of abdominoplasty. If the hernia is periumbilical, then complication (eg, umbilical necrosis) associated with the umbilicus is increased if the surrounding vascularity is compromised. For more information on hernia repair, see Medscape Reference articles Open Inguinal Hernia Repair and Laparoscopic Inguinal Hernia Repair.

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.[21] 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.[22] 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,[23] Grazer,[22] or the bicycle-handlebar techniques described by Baroudi.[24]

Grazer also describes a so-called reverse abdominoplasty.[22] 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.[25] 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.[26]

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.

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.[27]

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.[28, 29] Mentz et al showed decreased pain reduction in patients following abdominoplasty with the use of regional infusion pump, leading to earlier ambulation.[30] 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 experienced while reaching this goal, their use may be warranted.

Physicians in the author's facility have begun to implement pulsed electromagnetic field (PEMF) therapy (Ivivi Technologies, Inc, Montvale, NJ) following each abdominoplasty in lieu of pain pumps. This has served patients well because of its noninvasive nature, and catheter-related complications (eg, retention, infection, accidental dislodgement) are reduced. This device has been widely used in other fields for pain control and improving the healing process, and it is now gaining popularity in plastic surgery.[31] The studies in breast augmentation are encouraging, and more exciting developments should be available this topic in the near future.[32]

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.[33] 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%.[34] 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).[35, 36, 37] 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).[35] 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.[38, 39, 40] .

A retrospective study by Bucknor et al, using information from the American Association for Accreditation of Ambulatory Surgery Facilities database, found that of 42 deaths linked to cosmetic plastic surgery between 2012 and 2017, 54.8% occurred following abdominoplasty. Out of all deaths, the greatest percentage (38.1%) resulted from thromboembolisms.[41]

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.[42]

In one series, 247 abdominoplasty procedures were performed alone and 157 were combined with additional procedures. Under the Caprini/Davison risk assessment model (RAM), 297 patients were considered "high risk," and 17, "highest risk." Graded compression stockings and intermittent pneumatic compression devices were placed on all patients, and perioperative and intraoperative warming was strictly applied. Progressive tension suturing technique was performed in all cases and drains were eliminated. All patients received pain pumps, ambulated within 1 hour of surgery, and were discharged home the same day. Only one case of deep vein thrombosis (DVT) occurred, in the calf. Even though not practiced by all clinicians, this report shows that outpatient abdominoplasty can be safely performed without VTE chemoprophylaxis in patients with fewer than 6 risk factors.[43]

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%.[44]

In 2001, van Uchelen et al reported on a series of 86 patients (14 male, 72 female) who underwent abdominoplasty.[45] 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.

A study by Bassalobre et al found that, following abdominoplasty, patients showed significant changes in the lymphatic drainage pathway in the infraumbilical region. The investigators, who reported on 20 female patients, determined that preoperatively, all of the subjects displayed abdominal lymphatic drainage toward the inguinal lymph nodes. Postoperatively, 65% of the patients showed drainage toward the axillary lymph node chain, and 10%, toward both the axillary and inguinal lymph nodes. In another 10% of patients, the lymphatic drainage was indeterminate, and the remaining 15% retained the same drainage pathway found preoperatively.[46]

Comorbid factors play a significant role in complication risk. Patients who smoke or have diabetes, hypertension, a body mass index greater than category I, or asthma have significantly higher complication rates.

A study by Schlosshauer et al indicated that age, body mass index (BMI), and resection weight are complication risk factors in postbariatric-patient abdominoplasty but that in performing abdominoplasty alone in postbariatric patients, the complication rate is acceptable. Among the patients in the study, 29.1% and 12.8% experienced minor and major abdominoplasty complications, respectively, with an increased risk of wound healing problems being associated with a BMI of 30 kg/m2 or greater.[47]

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.[48] 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 increased morbidity as compared with abdominoplasty alone.[49, 50, 51]

Similarly, a study by Vieira et al indicated that when performed by board-certified plastic surgeons, a combination of abdominoplasty and truncal liposuction leads to a lower complication rate than does abdominoplasty alone (10.5% vs 13.0%, respectively). The investigators also found that use of a higher liposuction volume (1000 mL vs 500 mL) in the abdominoplasty/liposuction procedure did not lead to greater complications.[52]

Nonetheless, a study by Winocour et al, based on data from 25,478 abdominoplasties, reported a higher complication risk when abdominoplasty was performed in combination with one or more other aesthetic procedures, such as liposuction, a breast procedure, or body contouring.[53]

Seroma 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.[28] 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.[54] 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.[55, 56]

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.[19, 20] 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.[56]

Despite their mention by numerous authors, deep vein thrombophlebitis and pulmonary embolus seem to be rare complications.

A retrospective study by Massenburg et al indicated that, based on multivariate regression analysis, independent risk factors for 30-day hospital readmission following abdominoplasty include an American Society of Anesthesiologists patient classification above 3, preoperative cardiac comorbidities, pulmonary comorbidities, wounds or wound infections or complications, postoperative thromboembolic complications, and a need to return to the operating room during the primary admission period. The study employed data from 2946 abdominoplasties.[57]

See the images below for an example of preoperative and postoperative appearance.

Without question, the development of SAL/ultrasound-assisted liposuction (UAL) has changed the face of excisional body contouring surgery. Almost all plastic surgeons use SAL/UAL as an adjunct to excisional abdominoplasty. In 1999, Shestak reported the so-called marriage abdominoplasty that combined "aggressive super wet liposculpture with standard open surgical techniques" to treat the "majority" of patients with abdominal deformities.[58]

Abdominoplasty has undergone significant evolution over the past several decades, and the era of liposuction alone is becoming more obsolete as plastic surgeons evaluate the 3-dimensional aesthetic features of the trunk. The art of trunk body contouring is continuously evolving and will continue to evolve, as Matos et al have proposed a new classification for candidacy of lipoabdominoplasty and its variations.[59]

The Department of Plastic Surgery at Loma Linda University recently completed a detailed analysis of the lifestyle outcomes of massive weight loss (MWL) patients undergoing body contouring.[60] Their assessment of 25 patients showed that the vast majority of these patients experienced positive lifestyle outcomes as a result of having undergone the procedure. Body contouring in patients with MWL represents the final stage in the surgical transformation and health restoration of obese patients. Little doubt exists that these procedures are invaluable to the patients and, as plastic surgeons, the authors will continuously be involved in this transformation.

Endoscopic techniques will probably be more involved in abdominoplasty. Numerous authors now use endoscopes for abdominoplasty.[61, 62]

Combined aesthetic and gynecologic surgery is an attractive option for both patients and surgeons. A case-control study of 25 patients undergoing combined abdominoplasty and intra-abdominal gynecologic surgery was performed. These combined patients were compared with control group patients undergoing abdominoplasty alone and gynecologic surgery alone. In this study, no major complications, including the need for blood transfusion or pulmonary embolus, were noted in any of the patients. The authors concluded that abdominoplasty combined with gynecologic surgery can be an acceptable option for carefully selected patients.[63]

Combined procedures appear to be increasingly performed in the same setting by an array of physicians. The authors’ patient population has developed considerable interest in such combined procedures to reduce operative time, anesthesia, recovery time, and overall cost. As stated above, combining abdominoplasty with additional surgical procedures does not lead to increased complication rates and is safe with carefully selected patients, appropriate DVT prophylaxis, and an operative/general anesthesia time of 6 hours or less.

Clearly, a primary focus for the future is to minimize the amount of surgery necessary to maximize the surgical result.