Abdominoplasty Treatment & Management

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.