Liposuction assisted Abdominoplasty (revisit)

Taha, Ahmed; Hota, Abd Elmonem; Zaki, Ahmed

doi:10.21608/aimj.2020.28808.1210

Liposuction assisted Abdominoplasty (revisit)

Al-Azhar International Medical Journal

Article 20, Volume 1, Issue 6, June 2020, Page 263-271 PDF (1.31 MB)

Document Type: Original Article

DOI: 10.21608/aimj.2020.28808.1210

View on SCiNiTO

Authors

Ahmed Taha

¹; Abd Elmonem Hota²; Ahmed Zaki

¹Plastic Surgery, Al-Azhar University, Cairo, Egypt

²Department of Platic and burn surgery, Faculty of Medicine- Al-Azhar University

³Plastic and burn surgery, faculty of medicine, AL_Azher university, cairo, Egypt

Abstract

Abstract
Background: Abdominoplasty is one a number of the principal common aesthetic operations. Wide research has revealed that we can combine each techniques adequately (liposuction and abdominoplasty) in the equal method.
Objective: Our study is to evaluate the abdominoplasty assisted with liposuction.
Patient and Methods: This study was done on 30 patients at Al-Azhar university hospitals, the patients was suffering from pendulous abdomen with fullness at love-handle and epigastric areas. we implemented lipo suction with three sorts of abdominoplasty (extended, complete, and mini abdominoplasty) it is possible to keep at the very least eighty percent of of the vascular supply within the wall, causing little worried harm, keeping the maximum of the lymphatics, and ensuing in much less complications as compared with conventional abdominoplasty,surgical operation procedures.
Results: The use of liposuction in combination with abdominoplasty shows marked improvement in postoperative results including belly rejuvenation, better contour, less extended scars, patient satisfaction and surgeon satisfaction.
Conclusion: Using abdominoplasty assisted liposuction techniques give us amazing results regarding scar length with high patient satisfaction.

Keywords

Liposuction; Abdominoplasty; Liposuction abdominoplasty

Full Text

Introduction

Abdominoplasty became the most common aesthetic surgical procedure with development of safe anaethesia and fast recovery.

In 1980s illoze¹ introduced liposuction in addition to abdominoplasty in the same procedure this give more contour enhancement in the same procedure. Articles on combining liposuction and abdominoplasty have been published during the 1990’s; but, the literature at that point became not generally supportive of this combination, advising warning.¹

In 2001, Saldanha et al.² defined lipoabdominoplasty technique much like Illouz’z Suction Abdominoplasty.

Liposuction assisted abdominoplasty became first executed in October 1996 by means of detaching an belly flap from the deep fascia with liposuction.²

Abdomioplasty procedure has developed for all patients and asking for contouring and reshaping of this body areas.³

Surgical abdominoplasty on my own is also insufficient within the obese affected person because the thickness of the belly panniculus isn't always reduced; in addition, secondary to tissue tension with wound closure, a few necrosis of pores and skin above the pubis isn't uncommon.⁴

The introduction of liposuction strategies has allowed surgeons to limit scar duration in positive applicants, remodeling abdominoplasty right into a minimally invasive manner.⁵

Using liposuction in addition with abdominoplasty has been controversial. The combination of techniques has been related to increased incidence of venous thromboembolism and wound-recovery complications. With using of thromboembolism prophylaxis, the risk of thromboembolism was decreased and so on increased rate of liposuction assisted abdominoplasty.⁶

So in our study we study the use of liposuction assisted abdominoplasty and monitoring its results.

Patient and Methods

This was a prospective study case series that included a total a total of 30 patients have been passed through assisted liposuction abdominoplasty.

All patients indicated for this technique were chosen from the plastic surgical treatment outpatient clinic; having belly lipodystrophy, and skin redundancy, and musculoaponeurotic divarication.

The patients classified according to Mattarasso classification to 3 groups, group (A) ten patients indicated to liposuction assisted extended abdominoplasty, group (B) ten patients indicated to liposuction assisted fullabdominoplasty, group (C) ten patients indicated to liposuction assisted mini abdominoplasty.

The study was performed into in al-Azhar university Hospitals (Al-Hussin and Sayed Galal) from October 2019 to April2020.

The assessment which include operative time, hospitasl stay, general drain output, time of drain removal, aspirate volumet, weight of excised tissue, scar length, complications, return to work, and patient satisfaction.

All patients were consented about the operation, anesthesia, viable complications, dangers, photographing, and inclusion on this study. All patients have belly deformities marked skin excess, lipodystrophy without or with muscle laxity (Matarasso type 2, 3 and 4).All Patients have BMI

Preoperative exam, planning and marking:

Full investigations, radiology including u/s ,CBC, SGPT /CREAT, INR must be done, and then we cautiously have a examine the stomach for hernias and previous operation scars, mainly subcostal cholecystectomy scar. Images are normally taken in 6 cardinal views .

We mark the incision line while patient standing , it must be 7 cm above superior vulvar commissure This mark is prolonged laterally, along skin crease while patient manually elevate her belly. The length and region of this proposed incision is then measured to make certain symmetry, figure (1).

Figure (1) Preoperative markings are made with the patient standing.

Figure (2) All areas for liposuction are marked this includes the entire central abdomen, flanks, and hip rolls.

Lateral part of the incision is marked and agreed by the patient then the proposed upper incision is identified and marked by pinch test.

Operative procedures:

The patient lies supine, compression stockings iwrapped around both legs, sterilization, towling, , anesthesia is administered. Tumescent solution is infiltrated in the abdominal flap and liposuction areas (epigastric region, central abdomen, lateral abdomen, hip rolls and flanks), tumescent consists of lidocaine 2% 10cm and epinephrine solution (1/200,000). 1cm put on 500 ringers or saline. We infiltrate the loose areolar tissue between abdominal wall and skin flap to make easier dissection with 3mm infiltration cannula till achieving tissue turgor, 20miniutes are left ,then liposuction of deep plane with 4 mm cannula then final refining with 3mm cannula

Figure (3) Traditional liposuction with 4 mm diameter cannulas

We assess the equality of flap thickness by pinch test,lipo suction begins in the central abdomen between the 2 outer borders of recti, we leave athiccker flap(4cm) in the central abdomen and thinner flap(2cm) in the lateral abdomen and flanks , so as to simulate the youthfull abdomen, additional canula entry sites can be done in the excisional abdominal flap,, direction of cannulu should be inferosuperior to preserve much perforators, after completion of liposuction we made the incision with 15 blade, incision is better to be made 2 centimeters below the marked line to overcome the later upward scar migration, don’t forget fluid compensation of liposuction aspirate and blood loss.

Figure (4) Transverse incision of formerly marked is made with 15 blade

we use diathermy to open the dermis and cogulate blood vessles tissue (figure 5).

(figure 5).bevel dissection through the fat of the skin flap

We bevel dissection through the fat of the skin flap till reaching the rectus sheath at appoint midway between theumbilicus and the symphysis, this preserves more lymphatics and decreases seroma formation . meticulous homostasis should be done along the course of dissection. We incise THE UMBILICUS vertically with 11 blade and dissection scissors , we mark its upper and lower poles by threads , dissection is continued up to costal margins and xiphoid, then we plicate rectus abdominis muscle sheath by marking its medial border by methylene blue. This defines the diastasis, blication is don from xiphoid process superiorly and sumphusis inferiorly, and laterally from medial border of recti , plication is done by zero or 1 nilon looped suture, in one or two layers according to situation,at the level of the pubic symphysis, the knot tied and buried. Now it is time for flap resection, the patient is put in semisetting position by breaking operation table. The table is broken in forty five tiers to release tension off of the wound closure and allow excision of maximum skin excess (figure8).

Fugure (8) Towel clips are placed at the tips of the flaps to apply gentle suture before flap excision

Figure (6) umblicus seperation

Figure (7) Wide rectus abdominis muscle placation

it is forbidden to detach the the flap beyond costal margin to preserve its vascularity, but gentle cannula dissection is allowed to get more flap mobility and eliminate tissue ridge without affecting blood supply. This makes fibrous septa which contain vascular perforators, then we simulates linea alba of the youthful abdomen by traction sutures with vicryl 2/0 in the midline Figure (9) (figure9).Supraumbilical central portion adhesion sutures

this makes amidline deprssion like an athletic abdomen (linea alba). We apply gentle traction on the flaps by towel clips, mark the excision mark while counter pushing of the inferior edge, assess symmetry between both excision marks, then cutting. (figure 8).

We vertically incise the new umbilicus at the position midway between symphysis and xiphoid, thin pulling the umbilical stalk and suturing it.

Then we finally revise our hemostasisis before puttin stay sutures to distribute tension, we put 2 drains laterally then we begin skin closur by suturing of scarpa′s fascia, it is th most important layer and must be closed under maximum tension so as to reliefe the overlying layers, it is closed with 0 vicryl suture , We advance upper flap medially to eliminate any dog ears then deep dermal 2/0 vicryl sutures is put before final sub cuticular4/0 prolene sutures. Then we dress the wound and dress the pressure bandage.

Fig(10) Immediate post-operative

Results

Patients are classified to 3 groups according to Mattarasso classification, each of 10 patiens ,1st group did extended abdominoplasty,2nd did full abdominoplasty,3rd did miniabdiominoplasty. All with liposuction we evaluated resultant contour, aspirate volume, excised tissue weight, drain output, drain removal ,hospital stay complications and patient satisfaction in each group.

(group A)

The weight of excised skin and subcutaneous fat in the 10 cases under group (A) ranged from 2500 to 4000gm. with a mean of 3.070 kg. Operative time was ranged from 3.5 to 5 hours with a mean of 4 hours. The volume of Aspirate in 10 cases ranged from 3000 to 4000 cm with mean of 3.6 liters each case. The total drain output in the 10 cases under group (A) ranged from600 to1500 ml. with a mean of 885 ml per case. The days needed for drains removal in the 10 cases under this group ranged from 3 to 7 days with a mean of 4.8 days per case. The days of hospital stays in the 10 cases under this group ranged from 2 to7days with a mean of 3.8 days per case. Bad patient satisfaction occurred in one post bariatric patient showed recurrent protrusion of ant. abdominal wall which needed revision.

Figure (11) Pre and post operative view of liposuction assisted extended abdominoplasty

Group (B)

Operative time was ranged from 2.5 to 4 hours with a mean of 3.25 hours. The weight of excised skin and subcutaneous fat in the 10 cases under group (b) ranged from 2000 to3000g, with a mean of 2.37kg. The total aspirate volume in group B ranged from 3000 to 4000 ml, the mean was 3.65. The total drains output in the 10 cases under group (B) ranged from 3000 to 4000ml. with a mean of 676.5 per case. The total days needed for drain removal in the 10 cases under this group ranged from2 to 3 days with a mean of 2.9 days per case. The total days of hospital stays in the 10 cases under ranged from 2 to 3 days with a mean of 2.9 days per case. Fair patient satisfaction was achieved in single case (5%) due to asymmetric scar along the incision line. Others are fully satisfied.

Figure (12) Pre and post operative view of liposuction assisted full abdominoplasty

Group(C)

Operative time was ranged from 2 to 3hours with a mean of 2.6 hours. The weight of excised skin and subcutaneous fat in the 10 cases under group (C) ranged from950 t0 1300 kg. with a mean of 1.24kg. The aspirate volume ranged from2500 to3500 ml, the mean volume was 2.8l per case The drain output in the 10 cases under group (C) ranged from 250 t0 500 ml. with a mean of 445ml per case The days needed for drains removal in the 10 cases under this group ranged from 2 to 3 days with a mean of 2.5 days per case The days of hospital stays in the 10 cases under this group ranged from 1 to 2days with a mean of 1.7 days per case.

Complications

In group (A) there is wound dehiscence an recurrent protrusion of the ant. abdominal wall, in group (B) there is minimal dehiscence in one case and scar asymmetry in another case, in group(C) there is acase of dog ear. The reduced incidence of epitheliolysis to 0 percent, seroma to 0percent, and necrosis to 0 percent dehiscence 1.1percent, has statistical significance. Because the previous known worldwide percent with traditional abdominoplasty alone was 50, 3.8,5.1 for seroms epithiliolysis and dihescence respectively as published by saldanha2007 Although the incidence of hematoma was reduced to 0 compared to 0.6 percent and the incidence of deep venous thrombosis/pulmonary (0 percent compared to 0.2 ), we cannot consider these findings as statistically significant due to the small number of cases.

Figure (13) pre and post operative view of liposuction assisted miniabdominoplasty

N	Total drains output volume	Time to drains removal	Hospital stays	Aspirate volume	Weight of excised tissue	HB 2^nd day postoperative	Complications			Patient satisfaction
N	Total drains output volume	Time to drains removal	Hospital stays	Aspirate volume	Weight of excised tissue	HB 2^nd day postoperative	early	late		Patient satisfaction
1	600	3	3	3000	3500	7.5(2 units packed RBCs)	NIL	NIL		Excellent
2	650	3	4	3500	4000	11	NIL	Wound dehiscence		Fair
3	700	4	4	3000	3000	11	NIL	Recurrent protrusion		Good
4	810	5	3	4000	2800	11.6	NIL		NIL	Excellent
5	930	5	3	3500	2500	11.3	NIL		NIL	Excellent
6	1100	7	4	3500	2700	10.2	NIL		NIL	Excellent
7	1050	4	3	4000	3200	11.4	NIL		NIL	Excellent
8	1150	5	5	3500	2100	11.5	NIL		NIL	Excellent
9	1500	7	7	4000	2900	11	NIL		NIL	Excellent
10	1250	5	5	4000	3800	12	NIL		NIL	Excellent

Table (1) Summary of postoperative results in group A

N	Drain output volume 400-1000	Time to drain removal	Hospital stay	Weight of excised tissue 2000-3000	Aspirate volume 3000-4000	HB 2^nd day post-operative	Complications		Patient satisfaction
N	Drain output volume 400-1000	Time to drain removal	Hospital stay	Weight of excised tissue 2000-3000	Aspirate volume 3000-4000	HB 2^nd day post-operative			Patient satisfaction
1	430	3	3	2600	3000	11.5	NIL	NIL	Excellent
2	400	2	2	3000	3500	11.6	NIL	NIL	Excellent
3	490	3	3	2000	3000	11.7	NIL	NIL	Excellent
4	600	3	3	2300	4000	11.6	NIL	Scar assymetry	Good
5	1000	3	3	2200	3500	11.3	NIL	NIL	Excellent
6	750	3	3	2500	3000	12.2	Minimal dehiscence	NIL	good
7	620	3	3	2400	4000	11.3	NIL	NIL	Excellent
8	730	3	3	2300	4000	11.8	NIL	NIL	Excellent
9	820	3	3	2500	4000	10.3	NIL	NIL	Excellent
10	965	3	3	2200	4000	13	NIL	NIL	Excellent

Table (2) Summary of postoperative results in grop B

N	Total drains output volume 250-500 mm	Time to drains removal 2-3 days	Hospital stays 2-3 days	Aspirate volume 2500-4000 mm	Weight of excised tissue 950-1300mm	HB 2^nd day post-operative 11.5-13 mm	Complications		Patient satisfaction
N	Total drains output volume 250-500 mm	Time to drains removal 2-3 days	Hospital stays 2-3 days	Aspirate volume 2500-4000 mm	Weight of excised tissue 950-1300mm	HB 2^nd day post-operative 11.5-13 mm	early	late	Patient satisfaction
1	500	3	3	2500	1100	11.2	NIL	NIL	Excellent
2	400	3	3	3000	1300	11.6	NIL	Dog ears	fair
3	330	3	3	3000	1250	11.7	NIL	NIL	Excellent
4	250	2	2	3500	1270	11.6	NIL	NIL	Excellent
5	360	3	3	4000	1100	11.3	NIL	NIL	Excellent
6	400	3	3	2500	1050	10.2	NIL	NIL	Excellent
7	330	2	2	2500	1060	11.3	NIL	NIL	Excellent
8	340	2	2	3000	950	11.8	NIL	NIL	Excellent
9	290	2	2	4000	970	11.3	NIL	NIL	Excellent
10	310	2	2	4000	1030	12	NIL	NIL	Excellent

Table (3) Summary of postoperative results in group C

Discussion

The Liposuction assisted abdominoplasty method is not only using liposuction with abdominoplasty, but it is wider concept including enhancing abdominal contour with least complications. . Total results of liposuction assisted abdominoplasty obtained in this series were satisfactory, 90% of the patients showed excellent to good results, while 10% showed fair results and this is consistent with Daniel Brauman (2018)⁷ which noted that 92% are fully satisfying. As regard patient satisfaction 27 of the 30 pt. were fully satisfied and this is conductive with the study of Kim et al. (2006)⁸ with 87% of patients achieving satisfactory results. 2 of 3 unsatisfied patients became satisfied after revision. Hospital stay was maximum 1 week in group A, 3 days in group b, 2 days in group c, actually this is longer than prescribed methods but we needed this for strict follow up. As regard blood loss and needing blood transfusion, only on case of group needed this consistent with Espinosa-de-los-monteros 2006⁹ which needed no blood transfusion in his 55 cases study. In this series, the timing for return to work or resumption of everyday life activities achieved by 84% these patients were 3 weeks in group A and B ,2weeks in group C consistent with the study of brauman 2018 where 89% of patients were able to resume working 3 weeks post-operative.We observed a decrease in the final scar extension when compared with the initial marking in10, 50, 50 percent of patients, in the mini, full, extended abdominoplasty respectively which is conducted with saldanha 2007¹⁰which reported 2cm decrease in scar in 30% of cases. Only 2 patients needed revision (6.6 %) which is superior to Saldanha 2007 which reported 10% needing revision. As regard complications one of the patients developed seroma which was discovered clinically and confirmed by ultrasonography, it was managed intraoperatively by aspiration after cannula dissection of fibrous septa and pressure garment and f

References

Illouz YG. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg. 1983;72:591–597.
Saldanha OR, Pinto EB, Matos WN Jr, et al. Lipoabdominoplasty without undermining. Aesthet Surg J. 2001;21:518–526.
Matarasso A. Abdominoplasty. Aesthetic Plast Surg 1989; 16:289–303. Back to cited text no. 1
Ramirez OM. Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach. Plast Reconstr Surg 2000; 105:425–435. Back to cited text no. 2
Matarasso A, Matarasso SL. When does your liposuction patient require an abdominoplasty? Dermatol Surg 1997; 23:1151–1160. Back to cited text no. 3
Ousterhout DK. Combined suction-assisted lipectomy, surgical lipectomy, and surgical abdominoplasty. Ann Plast Surg 1990; 24:126–132; discussion 132–133. Back to cited text no. 5
Brauman, Daniel. "Liposuction abdominoplasty: An evolving concept." Plastic and reconstructive surgery 112.1 (2003): 288-298.
Kim, James, and Thomas R. Stevenson. "Abdominoplasty, liposuction of the flanks, and obesity: analyzing risk factors for seroma formation." Plastic and reconstructive surgery 117.3 (2006): 773-779.
8 Espinosa-de-los-Monteros, Antonio, et al. "Abdominoplasty with total abdominal liposuction for patients with massive weight loss." Aesthetic plastic surgery 30.1 (2006): 42-
Saldanha OR, De Souza Pinto EB, Mattos WN Jr, et al. Liposuction assisted abdominoplasty with selective and safe undermining. Aesthetic Plast Surg.007;22:322–327.. 10.
Bromley, Miluska, Walter Marrou, and Luiz Charles-de-Sa. "Evaluation of the Number of Progressive Tension Sutures Needed to Prevent Seroma in Abdominoplasty with Drains: A Single-Blind, Prospective, Comparative, Randomized Clinical Trial." Aesthetic plastic surgery 42.6 (2018): 1600-1608.
Baker, Mona, and Gabriela Saldanha, eds. Routledge encyclopedia of translation studies. Routledge, 2009.
Sozer, Sadri Ozan, Karaca Basaran, and Hasan Alim. "Abdominoplasty with circumferential liposuction: a review of 1000 consecutive cases." Plastic and reconstructive surgery 142.4 (2018): 891-901.
Whiteman, David, and Gabriele C. Miotto. "Abdominoplasty with Scarpa's Fascia Advancement Flap to Enhance the Waistline." Aesthetic Surgery Journal 36.7 (2016): 852-857.

Statistics

Article View: 411

PDF Download: 448