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Background: Suction-assisted lipectomy is an integral component of abdominoplasty for many surgeons. Its potential to affect the vascularity of the abdominal flap is usually offset by limiting the extent of undermining and not suctioning the central flap. The authors address whether these guidelines apply to direct excision of subscarpal fat and whether direct excision provides aesthetically superior abdominoplasty results with fewer complications. Methods: A 10-year review of consecutive abdominoplasty patients (n 181) was conducted. Undermining was done to the xyphoid and just beyond the lower rib margins superiorly and at least as far as the anterior axillary line laterally. Fat deep to Scarpas fascia was removed by tangential excision in all zones of the abdominal flap, including those considered at high risk for vascular compromise if subjected to liposuction after similar undermining. Concurrent liposuction of the abdominal flap was not done. Thirty patients had concurrent flank liposuction. Results: No patients experienced major full-thickness tissue loss. The incidence of limited necrosis at the incision line requiring subsequent scar revision was 0.7 percent in the 151 patients having abdominoplasty and 6.7 percent in the 30 patients having abdominoplasty combined with flank liposuction. Erythema and/or epidermolysis was seen in 4.8 percent of the abdominoplasty patients and 10 percent of the abdominoplasty/ flank liposuction group. The rate of seroma formation in both groups was approximately 16.5 percent. Conclusions: Direct excision of subscarpal fat does not subject any zone of the abdominoplasty flap to increased risks of vascular compromise. It is a safe technique that provides excellent abdominoplasty results. (Plast. Reconstr. Surg. 123: 1597, 2009.)
he first description of abdominal dermolipectomy in the American literature is attributed to Kelly1 in 1889. Many variations on the theme followed until Pitanguys2 classic description in 1967, which served as the prototype for the evolution of modern abdominoplasty. Neither Pitanguy nor his predecessors described removal of any adipose tissue beyond the confines of the resected segment. Grazer3 appears to be the first to have done so in 1980 when he described limited beveling of the flap in tangential fashion in heavier patients. In recent years, liposuction has become a standard component of abdominoplasty for many surgeons,4 9 and its use to thin the abdominal flap has supplanted tangential excision. The risks liposuction presents to the central zones of an abdominoplasty flap were described by
From the San Mateo Surgery Center. Received for publication September 16, 2008; accepted November 17, 2008. Copyright 2009 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3181a07708
Matarasso,10 who also advocated limited undermining to preserve perforators in the upper abdominal quadrants. The validity of limited undermining and zonal awareness as essential to flap survivability when liposuction is combined with abdominoplasty has been repeatedly confirmed.11,12 Many researchers have studied the blood supply of the anterior abdominal wall. In 1975, Taylor and Daniel13 reported that the superficial inferior epigastric artery traveled superficial to Scarpas fascia, which Hester et al.14 and Worseg et al.15 independently confirmed in 1984. Recently, Schaverien et al.16 have shown by three- and four-dimensional computed tomographic angiography and venog-
Disclosure:No grants or financial support have been received in conjunction with this study. None of the authors has any financial interest or commercial association with any of the subject matter or products mentioned in this article.
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Fig. 1. The two sets of arrows show Scarpas fascia and the large blood vessels running in the superficial fatty layer. There is no significant blood supply deep to Scarpas fascia. This photograph was taken after the deep fat was removed from the right half of the abdominoplasty flap in the zone considered at risk for liposuction (terrible abdominoplasty triangle), leaving the superficial fat in pristine condition.
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RESULTS
In the 10-year period between January of 1998 and December of 2007, 179 primary abdominoplasties were performed on patients who had had no previous transabdominal surgery and two patients who had had previous subcostal cholecystectomies. Within the group of 181 patients, there were 30 who had concurrent flank liposuction. This subgroup was analyzed separately to ascertain whether the addition of flank liposuction had any effect on the incidence of complications. All procedures were performed at the same outpatient facility under general anesthesia. In the first years of the study, the procedures were performed exclusively by the senior author, whose technique was adopted by the junior surgeon upon his arrival in 2003 without variation, except for six patients in whom tumescent solution was preinfiltrated to facilitate dissection. The average operative time in the main study group was 120 minutes for both surgeons. The entire study group of 181 patients experienced no deep vein thromboses, pulmonary embolisms, transfusions, or death. The addition of the tumescent wetting solution had no effect on the rate of any complication. One of the two patients with a cholecystectomy scar developed a seroma, but neither patient experienced any woundhealing difficulties. In the main group of 151 patients who did not receive flank liposuction, there were five instances (3.3 percent) of limited epidermolysis at the incision line that healed spontaneously, two instances (1.3 percent) of localized skin erythema suggestive of cellulitis treated with oral antibiotics with res-
DISCUSSION
The amount of abdominal wall fat varies in relation to body mass index. At any weight, the thickness of the superficial layer is commensurate with subcutaneous tissue in other locations (this can be confirmed with a standard pinch test after the deep fat is removed), and for this reason it is aesthetically unwise to manipulate it. The deep layer is much more variable, and its accumulation, as with
Table 1. Wound-Healing Complications
All Patients No. of patients Epidermolysis Cellulitis Necrosis Total 181 3.9% 1.7% 1.7% 7.3% Abdominoplasty Alone 151 3.3% 1.3% 0.7% 5.5% Concurrent Flank Liposuction 30 6.7% 3.3% 6.7% 16.7%
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Fig. 2. Patient 1 was 46 years old, 5 feet 5 inches tall, and weighed 194 pounds. No liposuction was performed. Note that deep fat removal facilitates matching the thickness of the superior and inferior edges of the incision.
Fig. 3. Patient 2 was 49 years old, 5 feet 2 inches tall, and 155 pounds. No liposuction was performed. Continuous wide undermining to the xyphoid and beyond the lower rib margins ensured correction of laxity in the superior abdomen.
that of intra-abdominal fat, may be genetically determined.18 At any thickness, removal of deep fat is aesthetically beneficial as it slenderizes the abdomen without risking the contour deformities associated with manipulations of the superficial layer. Although the deep layer is completely expendable, we have been unable to accomplish its entire
removal using liposuction without inadvertent damage to the superficial layer. Our limitations in this regard do not appear to be unusual. Examination of resected abdominoplasty specimens of patients who have had previous abdominal liposuction elsewhere have consistently revealed incomplete removal of the deep fat and nearly
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Fig. 4. Patient 3 was 38 years old, 5 feet 8 inches tall, and 205 pounds. No liposuction was performed. Even in obese patients, removal of just the deep fat is sufficient to slenderize the abdomen.
universal violation of the superficial layer with resulting contour irregularities. The inherent inability of liposuction to discriminate deep from superficial fat provides the justification for caution when using it during an abdominoplasty. The real danger zone, however, is not the terrible abdominoplasty triangle,10 from which deep fat can be removed with impunity, but the entire superficial layer. The 0.7 percent incidence of limited fullthickness healing problems we report in our main group of 151 patients is lower than that of most previous reports9,18 21 and substantiates the safety of direct resection of deep fat from all areas of the abdominoplasty flap, including the central zone considered dangerous for liposuction. In fact, the central danger zone provides the majority of the harvested fat, a fact that underscores the maladaptation of liposuction to abdominoplasty. Limited peri-incisional full-thickness loss requiring scar revision occurred in two of the 30 patients who had abdominoplasty combined with flank liposuction. Although these two problems caused the rate of this complication to escalate from 0.7 percent in the main group to 6.7 percent in this group, the small sample size (n 30) makes this difference insignificant (two-proportion z test, z 1.572; two-tail confidence level, 88.4 percent). In addition to these two patients, three others in the group of 30 having concomitant flank liposuction experienced cellulitis or epidermolysis not
requiring surgical intervention. Again, although the percentage of these combined problems escalated from 4.6 percent in the main group (n 151) to 10 percent in the smaller group (n 30), there is no statistically significant difference between the two frequencies (two-proportion z test, z 0.0736l; two-tail confidence level, 53.8 percent). When all three categories of wound-healing problems in each group are taken together and the overall rates compared using the same two-proportion z test, the difference (somewhat surprisingly) is just barely significant (z 1.816, two-tail confidence level, 93.1 percent). A brief discussion is warranted. Aggressive multidirectional liposuction of the flanks may damage collateral flow,10 especially if it is done widely enough to extend above the waistline, and it is generally acknowledged that woundhealing problems escalate when procedures are combined,9 operative times are prolonged, or core temperature drops.22,23 Both patients requiring scar revision had ultrasonic liposuction over extended areas of the posterolateral flanks, and one had inner and outer thigh ultrasonic liposuction as well. Operative times were prolonged to 3.5 hours and 4.5 hours, respectively, from an average time of 2 hours. Neither patient was a smoker, but both were overweight (body mass index of 26.5 and 27.4, respectively) and both developed postoperative seromas. The small sample size and the multiplicity of risk factors make it impossible to
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CONCLUSIONS
Just the adipose tissue located deep to Scarpas fascia needs be removed to attain the aesthetic goals of abdominoplasty, and this can be accomplished safely with an open, direct approach. Because liposuction easily compromises flap survivability, it presents risks that are not associated with direct tangential resection of subscarpal fat during abdominoplasty.
Robert R. Brink, M.D. San Mateo Surgery Center 66 Bovet Road Suite 101-103 San Mateo, Calif. 94402 drbrink@yahoo.com
REFERENCES
1. Kelly HA. Report of gynecological cases (excessive growth of fat). Case 3. Bull Johns Hopkins Hosp. 1889;10:197.
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