Enhancing the Lipoabdominoplasty Results by Preserving Epigastric Perforators

INTRODUCTION
The abdomen plays a leading role in the aesthetic
image of the upright human body, and is of
prime importance in defining the overall contour
of the individual [1].
Despite the good results obtained with a full
abdominoplasty, significant local complication
such as: seroma, infection, hematoma, skin slough,
scar formation, dog ears, umbilical malposition,
umbilical necrosis and systemic complications
such as: Deep vein thrombosis and pulmonary
embolism [2-5].
Lipoabdominoplasty combines two traditional
techniques, abdominoplasty and liposuction. The
new and conservative concept is based on the
preservation of the abdominal perforating vessels
(subcutaneous pedicle), which are branches of the
deep epigastric vessels [6,7].
The undermining in the upper abdomen is performed
exactly between the medial borders of the
rectus muscles, corresponding to the diastasis area,
preserving around 80% of perforating arteries,
239
veins, lymphatics, and nerves, as shown by Munhoz
and colleagues [8,9].
PATIENTS AND METHODS
10 Patients suffering from excess abdominal
skin and adipose tissue with muscle diastasis (Matarasso
type III and IV) were included in the study.
Exclusion criteria:
• Unrealistic expectations, body dysmorphic disorders,
eating disorders.
• Uncontrolled chronic medical comorbidities
especially respiratory as (COPD).
• Increased intra-abdominal pressure as ascites or
organomegally.
• Abdominal wall hernias.
• Morbid obesity with BMI more than 35.
• Previous liposuction or other abdominal surgeries
rather than cesarean sections.
Operative work up:
1- Marking and photographing:
• Marking was done in standing position with
relaxed skin tension.
• In this position, retraction of the skin demonstrated
the amount of skin to be removed.
• The midline from the xiphoid process to the Mons
pubis will be marked on the patient.
• Marking is done by drawing a 12-cm horizontal
suprapubic line that is 6 to 7cm from the vulvar
commissure, Two oblique lines of 8cm each are
drawn in the direction of the iliac crest, completing
the inferior incision line, or as a standard
abdominoplasty according to amount of skin
redundancy and to avoid post operative dog ears,
We try to incorporate the removal of any old
scars, such as cesarean sections, in our excision.
The upward pull helps to avoid a scar that is too
high by accounting for eventual upward scar
contraction or migration, the abdominal flap and
the liposuction areas are marked, including the
dorsal region, when necessary. For better orientation
at the beginning of tunnel undermining,
the diastasis area is previously marked.
• Finally, photographing of the marking for complete
evaluation of the technique.
Operative technique:
The abdomen up to the mid-chest and down to
the groins was prepared and draped.
Infiltration:
Following disinfection and sterile draping, Stab
incisions were made in the infraumbilical skin for
tumescent solution injection and subsequent liposuction.
The tumescent technique is used by infiltrating
the abdominal region with a 50ml of 1% lidocaine
and 1ml of 1:1000 epinephrine per liter of saline
or lactated ringer, were infused to attain adequate
skin turgor (super-wet technique).
Upper abdomen liposuction:
Liposuction was performed in all areas of the
abdomen and flanks “including the epigastric area”
until adequate contouring is achieved.
The patient is placed in a hyperextended position
on the surgical table so that liposuction can
be performed safely. Liposuction begins on the
supraumbilical region with 4-mm cannulas, removing
the fat of the deep and superficial layers,
extending to the flank as far as the submammary
fold. As in classical liposuction, the fat thickness
is maintained to about 2.5cm to avoid vascular
impairment and contour deformities.
Lower abdomen liposuction:
The superficial fat layer and part of the deep
layer need to be aspirated in the lower abdomen
using a 4-mm cannula. After evaluation of the flap
mobility and descent. If necessary, complementary
open liposuction is performed to remove fat above
and below Scarpa fascia and to create a homogeneous
surface to accommodate the superior flap,
which becomes thinner in its descent.
The volume of tumescent fluid injected and the
volume of the aspirate were recorded for each case.
Abdominoplasty:
Following the individually marked incision
line, a sharp incision was done as far as the Scarpa's
fascia.
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The scalpel was introduced at an angle of 30º
to bring the resection edges together later without
the formation of cavities below and depressions
above.
After identification of the abdominal fascia,
the flap was dissected cranially along the selected
fascia.
The abdominal flap was dissected in two different
planes; pre-superficial fascia (pre-Scarpa's
fascia) in infra-umbilical region except central area
needed for plication of muscle sheeth and preaponeurotic
(pre-muscular) in the supra-umbilical
region.
Umbilical incision and complete mobilization
of the umbilical stalk:
A circular incision was done around the umbilicus.
The dermo-fat flap was then mobilized away
from the umbilicus with ensuring that the umbilical
stalk would be sufficiently thick and that a wide
base would be created during the dissection to
prevent later perfusion disorders of the umbilicus.
Supra-umbilical dissection:
The dermo-fat flap will be then incised longitudinally
in the median line from the edge of the
wound to the umbilicus to facilitate further cranial
dissection as far as the xiphoid process.
Selective undermining:
Selective undermining is performed in the midline
of the upper abdomen, between the medial
edges of the rectus abdominal muscles. Tunnel
undermining may reach the xiphoid, depending on
the need for rectus muscle plication. The tunnel
width may vary with the distance of diastasis,
Discontinuous undermining performed using the
liposuction cannula facilitates the descent of the
flap.
Rectus sheath plication:
Once the dissection is complete and after meticulous
hemostasis, plication of the aponeurosis
longitudinally was carried out with continuous
non-absorbable thread (Polypropylene® 0).
Defining the resection boundaries with upper
body flexed to 30°:
The entire dermo-fat flap was then pulled down
under traction with the upper body flexed 30º to
define the boundaries for later resection.
Umbilical transposition:
The umbilicus was then positioned outwardly
and fits into the correct new position in the external
cutaneous incision without tension.
Egypt, J. Plast. Reconstr. Surg., July 2018 241
Resection of the skin was performed with regular
checks on the tension of the remaining skin.
Skin closure in layers:
The wound was then closed in three planes, the
first being Scarpa's fascia with absorbable thread
(vicryl® 2-0) in separate stitches, the second being
the subdermal plane with absorbable thread
(vicryl®3-0) in continuous stitches, and the third
being the intradermal plane with continuous absorbable
thread (prolene® 4-0).
The wound was then covered by placing a
simple sterile dressing over the scar. Compressive
garment (Elastoplast® or abdominal wall binder)
was then used.
The duration of the whole procedure and of its
various steps was recorded.
Photographing the abdomen post operatively.
RESULTS
Assessment of aesthetic results:
A scoring system in which outcomes were rated
as excellent (0-2 points), good (3-5 points), fair
(6-8 points), or bad (9-11 points) using a cumulative
score of 0 to 11 points for nine variables, five
variables for abdominal contour and four factors
for umbilical contour. Each rated from 0 to 1 point
except two of them rated from 0 to 2 points.
The results of the present study demonstrated
that there were highly significant increase in aesthetic
results (which mean decrease in total score)
by increase Liposuction amount and decrease BMI
and Flap thickness. Also, there were significant
improvement of patients' waist (represented by
increased waist circumference reduction after lipoabdominoplasty)
and this correlate significantly
with aesthetic results (which mean decrease in
total score).
Fig. (1): Infiltration of tumescent fluid. Fig. (2): The abdominal flap dissection preserving scarpa
fascia.
Fig. (3): Tunnel undermining for perforating vessels preservation.
Fig. (4): Early post operative.
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Fig. (6): The patient has significant flank and anterior abdominal adiposity and upper abdominal rectus
diastasis she had a lipoabdominoplasty (a) Preoperative. (b) seven Months postoperative showing
improvement of waist definition, and a well-positioned umbilicus, the abdominal contour is
improved, epigastric bulging was corrected.
Fig. (5): The patient has significant flank and anterior abdominal adiposity, redundant lower abdominal
wall and upper abdominal rectus diastasis she had a lipoabdominoplasty (a) Preoperative. (b)
Three Months postoperative showing improvement of waist definition, a well-positioned umbilicus,
the abdominal contour is improved, epigastric bulging was corrected.
Table (1): Abdominal contour results.
1- The overall abdominal
contour:
Flat
Bulge
2- Flanks:
Well defined
Ill defined
3- A midline depression
from the xiphoid to
the umbilicus:
Well defined
Ill defined
4- Periumbilical contour:
Gentle concavity
Flat
Mild bulge
5- Thickness of subcutaneous
fat above and below
the scar:
Gentle transition
(no step deformity)
Step deformity
Total
Parameter
01
01
01
012
0
1
0-6
Score
50
50
40
60
10
90
10
90
0
90
10
Percentage
%
55
46
19
19
None
9
1
Number
of cases
I- The abdominal contour
Table (2): Umbilicus results.
Site:
Midline
Lateral to midline
At level of superior
iliac crests
Below or above
Shape:
Inverted
Flat
Everted
Size:
1.5-2 centimeters in
diameters
More or less
Total
Parameter
010
1
012
0
1
0-5
Score
100
0
100
0
10
90
0
100
0
Percentage
%
10
0
10
0
190
10
0
Number
of patients
II- Umbilicus
Table (3): Percentage of results.
Excellent
Good
Total
Interpretation of
aesthetic results
46
10
N
40
60
100
Percentage
%
Egypt, J. Plast. Reconstr. Surg., July 2018 243
DISCUSSION AND CONCLUSION
In conclusion, combining abdominoplasty and
abdominal liposuction is a safe procedure that
achieves gratifying results. It promotes a more
youthful abdominal silhouette, better matching
between the abdominal flap and the pubis, and a
shorter scar. We believe that it is a safer way to
treat the abdominal region than classical abdominoplasty
and has a fewer complications.
We emphasize that the foundation for this success
is central and limited undermining of the flap,
which enables preservation of the important flap
blood vessels and reduce the dead space this is
agreed by Antonetti JW, Antonetti A. and Saldanha
[10,11] who stated that liposuction of the anterior
abdominal wall is safe when combined with limited
dissection, in addition to obtaining a more harmonious
and aesthetic abdominal profile by sculpturing
the subcutaneous abdominal fat by liposuction.
As regarding the measurements for marking,
in the contrary of Saldanha et al., [12] we stress
that it should be personalized for each patient to
exclude dog ear deformity and maximize aesthetic
results.