A Personal Approach for Abdominoplasty

Abstract

Abdominoplasty is a common cosmetic procedure. It addresses skin excess, excess fat, and muscular weakness. Complications of abdominoplasty may include hematoma, seroma, wound dehiscence, abscess, severe cellulitis, and venous thromboembolism. The aim was to perform abdominoplasty with minimal complications and accepted aesthetic results. Twenty-nine women aged between 38 and 59 years underwent full abdominoplasty with umbilical transposition at a single hospital from April 2012 to April 2015. Of the 29 patients, 26 cases showed acceptable results. The average amount of liposuction was 800 cc, the least amount was 400 cc, and the most was 1200 cc. The excised segment weighed between 900 and 2500 g. Umbilicus was viable in all cases. Three of the 29 patients showed partial flap necrosis and wound dehiscence. Complicated cases were treated conservatively. Hypertrophic scar was developed in 1 case. Two patients developed minor seroma that required a single aspiration in the office every week for 2 weeks. Abdominoplasty is a safe and an easy operation to execute by adopting some techniques in carefully selected patients.

Keywords

abdominoplasty liposuction plication

Introduction

Aesthetic plastic surgery has increased in recent years. Abdominoplasty is one of the most common cosmetic procedures.¹ It addresses 3 main problems: excess skin, excess fat, and muscular diastasis. Abdominoplasty can be combined with liposuction.^2-4 In addition, several techniques are used to plicate the musculofascial layer.^5-8

Patients who performed abdominoplasty may have complications. These complications may reach as high as 51.8%. It may present as hematoma, seroma, abscess, severe cellulitis, and venous thromboembolism. These can be managed through aspiration, intravenous antibiotics, surgical intervention, and hospitalization.^9-11

In this article, abdominoplasty was performed in 29 obese multiparous females. The aim was to perform abdominoplasty with minimal complications with good aesthetic results. Additional goals were to represent risk factors, management of complications, and some technical tips.

Patients and Methods

Twenty-nine women were included from April 2012 to April 2015. Their ages ranged between 38 and 59 years. They underwent full abdominoplasty with umbilical transposition at a single hospital. Women associated with paraumbilical hernia were evaluated during examination. Informed consent was obtained from all patients involved in the study. Separate consent for photography was taken from all patients.

Patient Inclusion Criteria

All included patients were multiparous obese female patients. Their ages ranged between 30 and 60 years.

Patient Exclusion Criteria

Patients with comorbid conditions such as acute attack of bronchial asthma and uncontrolled diabetes were excluded from the study. Also, patients with body mass index >35 or with history of deep venous thrombosis were excluded from the study. Recent upper transverse scars (less than 6 months) and patients with overexpectation were added to the exclusion list.

Surgical Technique

The abdominal incision was drawn over the abdominal crease with the patient in the sitting position (Figure 1, Movie 1). Actually, this crease was evident even with mild redundancy in the sitting position.¹² The marking was extended to both anterior superior iliac spins bilaterally.

Figure 1.

Shows the patient in the sitting position.

Movie 1.

Shows marking of the lower incision.

Then, the patient was turned to the supine position. The upper markings were made at the upper part of the fold. They were taken 1 cm more than the lower incision (Movie 2). This would make more tension laterally to improve the waist. Then, the upper and lower markings were connected in a triangular fashion bilaterally. Multiple markers were made above the umbilicus in the midline to determine the position for the future umbilicus (Figure 2).

Movie 2.

Shows marking of the upper incision.

Figure 2.

Shows markings in the midline.

Under general anesthesia, under complete aseptic technique, the abdominal area was sterilized and a urinary catheter was inserted. The markings were augmented by interrupted silk sutures. The flanks and areas of excision and dissection were infiltrated by tumescent technique (adrenaline 1/500 000). Saving the time, circumferential incision was made around the umbilicus and dissection was carried down to the rectus fascia. This took about 7 to 10 minutes which was a sufficient time for tumescent fluid to make hemostasis (Movie 3). Liposuction of the flanks was made through 2 incisions in the area of excision.

Movie 3.

Shows dissection of the umbilicus.

Incision was made for about 15 cm on each side from the midline. This area was adequate for dissection and prevention of future lengthening of the incision. Dissection was carried below Scarpa’s fascia on the area below the umbilicus leaving a thin layer of fatty areolar tissue. Above the umbilicus, the dissection was on the rectus sheath till xiphisternum. Dissection was limited to the linea alba on both sides below the umbilicus. Above the umbilicus, dissection was limited to an area allowing exposure of the medial borders of both recti (Figure 3).

Figure 3.

Shows the extent of dissection.

Plication was made in the midline above and below the umbilicus. Then transverse plication was made at the level of umbilicus. Consecutively, 2 to 3 sutures were made on radial fashion starting from the umbilicus at the 4 quadrants. All sutures were figure of eight and were made by nonabsorbable sutures (Prolene 1; Movies 4 and 5).

Movie 4.

Shows formation of figure of eight suture.

Movie 5.

Shows plication of the musculoaponeurotic layer.

At the middle of the pedicle of the umbilicus, the stalk was tacked to the rectus sheath by 3/0 vicryl at 12, 3, and 9 o’clock (Figure 4). The 6 o’clock position was freed to allow easy delivery of the umbilicus through the abdominal incision.

Figure 4.

Shows tacking the umbilicus to the rectus sheath.

The skin was incised in a T-shaped fashion in the midline to avoid retraction of skin edges (Movie 6). Key suture was taken in the midline by absorbable (Vicryl/0) suture.

Movie 6.

Shows T-shaped incision.

At the highest level of iliac crest, a longitudinal incision for 1.5 cm was made in the midline. The umbilicus was delivered by traction sutures. It was fixed by interrupted subcuticular sutures (4/0 Vicryl) and skin sutures (5/0 Prolene).

The 2 areas for excision were folded and excised on both sides (Movie 7). The inner layer was closed subdermally by interrupted absorbable (Vicryl/0) sutures. The second layer was closed by continuous 2/0 Vicryl subcuticular layer. The skin was closed by interrupted 5/0 Prolene sutures. The skin was dried and pressure garments were applied (Figure 5).

Movie 7.

Shows folding and excision of skin.

Figure 5.

Shows application of pressure garments.

Postoperative Care

On the bed, the patient laid with her back elevated 45° and a pillow below the knee to flex the knees. This would relief tension on the abdominal incision. Urinary catheter was removed on the next day. The patient was motivated to ambulate with slight bending of back to prevent tension on the incision line for first 3 days. Drains were removed on the third postoperative day, and the patient was discharged from the hospital. Sutures were removed on the 10th day postoperative. Garments were applied for 4 weeks.

Results

Of the 29 patients, 26 cases showed an acceptable result. The average amount of liposuction was 800 cc. The least amount was 400 cc, and the most was 1200 cc. The weight of the excised segments ranged between 900 and 2500 g. Umbilicus was viable in all cases. No patients had shown considerable weight reduction, but dress size was reduced up to 4 dress sizes in most cases. Symmetry was achieved in most cases. Three patients were repaired for paraumbilical hernia. No patients required blood transfusion. Cases were followed up to 9 months (Figures 6-13).

Figure 6.

Shows patient underwent abdominoplasty. (A) Anterior view: Preoperative. (B) Right lateral view: Preoperative. (C) Left lateral view: Preoperative. (D) Anterior view: Postoperative. (E) Right lateral view: Postoperative. (F) Left lateral view: Postoperative.

Figure 7.

Figure 8.

Figure 9.

Shows patient underwent abdominoplasty. (A) Anterior view: Preoperative. (C) Right lateral view: Preoperative. (C) Left lateral view: Preoperative. (D) Anterior view: Postoperative. (E) Right lateral view: Postoperative. (F) Left lateral view: Postoperative.

Figure 10.

Figure 11.

Figure 12.

Figure 13.

Three of the 29 patients showed partial flap necrosis and wound dehiscence. Complicated cases were treated conservatively. Hypertrophic scar was developed in 1 case. Two patients developed minor seromas that required a single aspiration in the office every week for 2 weeks.

Case Report

A female patient aged 42 years, diabetic under insulin therapy since 12 years. She had history of previous bilateral brachioplasty, bilateral breast reduction, and abdominoplasty 5 years ago. She was not satisfied with her previous abdominoplasty, and reoperation was scheduled for her. Unfortunately, the patient showed blisters over the lower central part of the flap (third day postoperative). After 7 days, partial wound dehiscence and wound necrosis developed in the lower part of the flap with mild seroma (Figure 14).

Figure 14.

Shows diabetic patient under insulin therapy with previous abdominoplasty and breast reduction. (A) Anterior view: Preoperative. (B) Right lateral view: Preoperative. (C) Left lateral view: Preoperative. (D) Local wound blistering (third day postoperative). (E) Local wound dehiscence (seventh day postoperative). (F) Wound disruption (14th day postoperative). (G) Wound debridement. (H) Granulation tissue after VAC therapy. (I) Closure by secondary sutures.

The patient was treated conservatively with frequent dressing and aspiration covered by broad-spectrum antibiotics. The patient was dressed twice per week. The condition became fulminated on the third week. The blood sugar was not controlled, in spite of taking the regular amount of insulin therapy. Below the umbilicus, there was a swelling on the right side of the flap. The patient was hospitalized and was shifted to the operating theater. All skin flaps below the umbilicus on the right side were removed. The diseased fascia was removed and fresh blood transfusion was given.

After 2 days, blood sugar was controlled and the general condition of the patient was stable. The wound was dressed with negative therapy for 3 weeks till healthy granulation tissue filled the wound. The patient was returned back to the operating theater, and the wound was closed by secondary sutures. The healing was good and the patient was discharged.

Discussion

More than 120 years, Kelly made the first abdominal dermolipectomy in North America.¹³ Nowadays, there are large numbers of patients with large abdomen who attend plastic surgery clinics for abdominoplasty. Indeed, multiple techniques are used such as limited abdominoplasty and full abdominoplasties. This can be done alone or combined with liposuction. The main concern of plastic surgeons is to achieve the best cosmetic results with the least complications.

No doubt, concealed position of the final scar is important. With putting the patient in the sitting position, the lower abdominal crease could be marked.¹² This incision has some advantages such as placement of the scar in the bikini line with elimination of previous cesarean scars. In patients with constricted base, the incision has to be high in the central area. This will avoid tension on the midline or the need for additional vertical scar (Figure 15).

Figure 15.

Shows patient with constricted base.

Usage of tumescent solution was an essential step. Vasoconstriction of vessels and decreased destruction of lymphatics are the main advantages.^14,15 Fortunately, none of our patients required blood transfusion.

In the 1980s, liposuction techniques were introduced in body contouring procedures.¹⁶ When liposuction was added to abdominoplasty, better aesthetic results, less undermining, and limited length of incision were achieved.¹⁷

However, the use of liposuction with abdominoplasty is still a matter of debate. There are 2 schools: The first one praises abdominoplasty with liposuction only to the flanks or to the flanks and dorsum,^18-20 and the second school predominates liposuction to be used extensively with limited undermining.²¹

It was proven experimentally and clinically that liposuction when used extensively during full abdominoplasty could lead to lower central flap necrosis and might damage abdominal perforators.^22-24 Actually, the redundancy in the epigastric region is common after massive weight loss (Figure 16). In such cases, vertical skin excision or reverse abdominoplasty yields good results rather than doing liposuction.^25,26

Figure 16.

Shows patient after bariatric surgery with redundancy in the epigastric region.

In this series, liposuction was used only in the flanks (Movie 8). Liposuction was a mean for better contouring of the flanks and for limiting lower abdominal incision to iliac crests. By folding both ends of skin flap, dog ears were eliminated.

Movie 8.

Shows liposuction from the flanks.

More than 50% of the anterior abdominal wall is occupied by the rectus sheath. The aims of plication of the rectus sheath are better waist lines, flat abdomen, and correction of paraumbilical hernia if present. Many techniques were addressed that vary from midline plication to 2 vertically oriented fusiform lines.²⁷ Also, plication was designed in various shapes like T shaped, H shaped, and mirror image L shaped.²⁸

In this series, plication in radial fashion from the umbilicus like sunrays was done in all patients. In addition to the merits of plication, this maneuver reduced the tension on plication made in the midline. No patients suffered from increased intra-abdominal pressure symptoms.

Natural scars in the body such as facial dimples and umbilicus are established as aesthetic units. The umbilicus was preserved in abdominoplasty since 1939.²⁹ The umbilicus is not always located in the midline but may lie lateral to the midline.³⁰ The umbilicus was marked easily in the midline as most our patients had linea nigra. The umbilicus was positioned transversely at the level of iliac crests.³¹

The umbilicus was released at the beginning of the operation. This had the benefits of saving the time till the tumescent technique made hemostasis. Also, this would protect the umbilicus from iatrogenic injury during dissection. The umbilical stalk was depressed by plication at the middle of the pedicle to the rectus sheath at 12, 3, and 9 o’clock. The 6 o’clock position was freed. This would allow easy delivery of the umbilicus and superior hooding of the umbilicus.

One important aspect for obtaining good result was symmetry. Symmetry was obtained in most cases (Figure 17). However, our observation showed that the right side is bulkier than the left side. So, excision in the right side was more than in the left side. Subsequently, the incision became more longer (3-4 cm) on the right side than on the left side (Figure 18). All patients were informed about this fact before operation with the help of photography.

Figure 17.

Shows symmetry of the excised segment.

Figure 18.

Shows excision on the right side more than on the left side.

Common postoperative complications after abdominoplasty are seromas, hematomas, and wound necrosis. Seroma formation following abdominoplasty is considered to be the most common complication (0.3%-90%).¹⁵ Seroma formation had been reported to increase proportionally to the amount of liposuction and wide undermining of the abdominal flap.³²

Lymphatic drainage of the abdominal wall can be divided by the level of the umbilicus: (1) the area above the umbilicus drains to the axilla and (2) the area below the umbilicus drains to the inguinal area.^33,34

Previous articles had reported lower rates of seroma following abdominoplasties by keeping a very thin layer of fat over the rectus sheath. This thin layer preserves deep lymphatics. This was adopted in this work. Above the umbilicus, the dissection plane was on the rectus sheath.^35,36 Other methods used to decrease seroma formation are tension sutures, quilting sutures, fibrin glue, and suction drains.^37,38

It has been stated in the literature that seroma can best be prevented by the placement of postoperative drains, yet drains constitute a source of infection and discomfort to the patient, and reduce mobility of the patient.³⁹ Also, drains when left for a longtime may be a source of infection.

In all cases, drains were removed on the third day postoperative. Keeping the drain may initiate seroma rather than prevention of seroma. Only 2 patients showed minor seroma. They were treated conservatively by aspiration once weekly in the clinic for 2 weeks.⁴⁰

Diabetes is epidemic in our society. No home is free from diabetes. One third of our patients were diabetic. Most of them were on oral hypoglycemic (5 patients), and the rest (2 patients) were on insulin therapy. All diabetic patients were controlled.

There were very few literatures talking about diabetes and its effect on abdominoplasty. Patients on oral hypoglycemic showed good healing, and even their blood sugar level decreased considerably after operation. Unfortunately, one patient on insulin therapy experienced necrotizing fasciitis (Figure 14).⁹ This patient showed uncontrolled diabetes due to infection of the flap that fulminated to necrotizing fasciitis. Long duration of diabetes (12 years) was a precipitating factor for poor wound healing. The appearance of blisters with high fever not corresponding to the amount of necrosis was a warning sign for necrotizing fasciitis.^41,42 With VAC therapy, the wound became clean and defects up to the umbilicus were closed by secondary intention without the need for skin grafting.

No patients develop deep venous thrombosis. Careful selection and early ambulation were important to guard against this complication. No antithrombotic prophylaxis was prescribed. Our patients were multiparous who can tolerate pain after abdominoplasty and consequently can ambulate early. Early removal of urinary catheter was essential for early ambulation.

In summary, the main reasons for doing abdominoplasty were functional. Multiparous women in our area were presented mainly with weakness in the musculoaponeurotic system. Skin redundancy came in the second place. Also, most of the women were obese due to the type of lifestyle.

A point for future research is the use of lower abdominal flap (below the umbilicus). This flap is based laterally and can be used for coverage of groin area, anterior area of the thigh, and lateral area of the thigh (Movie 9).

Movie 9.

Shows the potentially abdominal flap.

Pearls and Pitfalls

Before operation

Several measures must be taken before operation. These measures include withdrawal of anticoagulants, aspirin, nonsteroidal anti-inflammatory drugs, and smoking (10 days before operation). Also, tight control of diabetes and hypertension is needed. In addition, wearing of pressure garments 3 weeks before operation is preferable for adaptation.

During operation

During operation, adequate hemostasis combined with changing gloves during each step is essential to decrease hematoma and infection.

After operation

After operation, drains are removed at the third day postoperative and garments are applied for 3 to 4 weeks. If seroma occurred, aspiration can be done once every week for 2 to 3 weeks.

Conclusion

Liposuction of the flanks was preferred. This will craft the flanks and prevent the lengthening of incision and the appearance of dog ears. Plication of the rectus sheath in radial fashion like sunrays would produce good appearance of the abdomen.

There was no need to close Scarpa’s fascia. It was considered as a mark for the level of dissection rather than a layer for fixation. Avoiding taking sutures in the fatty layer had 2 merits: (1) no fatty necrosis and (2) good healing. Sutures were removed on the 10th day postoperative.

Finally, abdominoplasty is a safe easy operation to execute by adopting some techniques in carefully selected patients.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Ahmed Hassan El-Sabbagh serves as an assistant professor of plastic surgery at Plastic Surgery Center, Faculty of Medicine, Mansoura University, Egypt. He is interested in reconstructive surgery, body contouring surgery, and burns. He was a consultant of plastic surgery in Kingdom of Saudi Arabia (from 2011 to 2015) and research fellow at Duke University, NC, USA (2004-2005), and he took the fellowship of European Board of Plastic Surgery (2013). He is an editorial member and a reviewer in a number of international journals.

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