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1 Introduction

Current abdominal contouring procedures consist of suction-assisted lipectomy, dermolipectomy, musculoaponeurotic plication, or some combination of these approaches. Ideally, this results in sufficient reduction of subcutaneous adipose tissue volume, maximum resection of excess skin and tightening of musculoaponeurotic laxity to create an aesthetic contour of the abdominal wall. As with all aesthetic surgical procedures, the goals of abdominal contouring surgery are to maximize the aesthetic outcome, reduce recovery, and minimize morbidity.

2 History

The initial abdominoplasty procedures consisted of resecting a significant abdominal pannus. Kelly [1] described the use of a large horizontal midabdominal incision. A variety of incisions were subsequently described, but the lower abdominal transverse incision presented by Thorek [2] was the basis for the modern abdominoplasty incision.

The modern evolution of abdominoplasty as a contour procedure was described by Vernon [3]. It included not only musculoaponeurotic plication but also transposition of the umbilicus. Subsequent refinements and modifications were proposed, including variation in the specific incision design, musculoaponeurotic plication technique, and extent of dissection [4–6]. These techniques, however, are all limited because the contouring is achieved by surgical excision of tissue and closure, often under tension, which leave significantly visible scars.

Mini abdominoplasty uses a relatively small transverse lower abdominal incision to permit limited resection of redundant infraumbilical skin in conjunction with aggressive liposuction of the abdominal wall. The modified abdominoplasty elevates a skin flap from the pubic region to the subcostal margin. The umbilicus is detached from the fascial midline, fat resection is performed sharply or with limited liposuction, and the fascial midline is tightened both above and below the umbilicus. Standard abdominoplasty requires aggressive elevation of the upper abdominal flap to the level of the subcostal margin. It includes wide undermining of the superior flap, translocation of the umbilicus, and repair of diastasis recti. Traditionally, liposuction has been avoided with aggressive undermining to minimize necrosis of the elevated abdominal flap.

In contrast suction-assisted lipectomy can provide dramatic contour improvement with minimally apparent scars. Early techniques in the 1960s, as described by Schrudde [7], utilized sharp curettage and suction. Kesselring and Meyer [8] introduced the use of strong suction. However, the most significant advance in body contour surgery may have been the introduction of the blunt-tip cannulas by Illouz [9]. Another significant improvement in the safety of liposuction came with the utilization of the “wet techniques” to infuse dilute local anesthesia with epinephrine to the operative field [10]. Additional modifications include the use of ultrasound-assisted liposuction by Zocchi [11], as well as laser-assisted liposuction and power-assisted liposuction [12–14].

While liposuction uses minimal incisions to provide improved contour, it does not address the redundant skin redundancy or muscle laxity. Concerns regarding disruption of the abdominal wall vascularity limited liposuction in conjunction with the standard abdominoplasty procedure. The “marriage abdominoplasty” combines abdominoplasty with more conservative liposuction. As the traditional contour techniques were reevaluated, new concepts regarding the safety of prudent combinations of liposuction with abdominoplasty resection emerged [15]. Liposuction abdominoplasty is now understood to effectively preserve the neurovascular supply of the abdominal wall, facilitate mobilization of the upper abdominal wall, and improve aesthetic contouring [16]. In fact, some research has indicated that within 1 week of surgery, there is no significant impairment of skin perfusion following suction-assisted lipectomy [17]. This allows a new paradigm in body contouring, to combine extensive suction-assisted lipectomy with sharp lipectomy and surgical abdominoplasty techniques [18–20].

3 Clinical Anatomy

The overall shape of the abdomen varies depending on the fat distribution and musculoaponeurotic constitution. The ideal body shape for women is narrow at the waist and wider at the hips, while in men it should progressively narrow from the chest to the hips [21]. Fat accumulation also differs between the genders [22]. Women demonstrate weight gain in the lower abdomen, hips, and buttocks; in men fat accumulation occurs intra-abdominally and circumferentially around the mid-abdomen and flanks. While abdominal wall lipodystrophy can be contoured to obtain a desirable result, intra-abdominal adiposity will limit the level of improvement and should be recognized preoperatively.

The surface landmarks of the abdomen include the costal margin superiorly, the anterior iliac crest and the mons pubis inferiorly, and the umbilicus. Located approximately midway between the xiphoid and the pubis, the umbilicus is the most prominent surface feature of the abdominal wall. In the youthful abdomen, the lateral border and inscriptions of the rectus muscles are visible as well; the umbilicus is hooded superiorly and tightly adherent to the deep fascia.

The subcutaneous tissue consists of superficial and deep fat, separated by Scarpa’s fascia. The superficial layer is typically dense and fibrous in nature with what has been described as a superficial fascial system [23]. This pervasive system of connective tissue encases and shapes the fat of the trunk and extremities. Scarpa’s fascia is a fibrous layer of connective and adipose tissue that forms a discrete layer in the lower abdominal wall. The deep adipose layer is loose with poorly organized septae [24]. It is the disproportionate enlargement of this deep layer in the torso and upper thigh which characterizes fat accumulation even in thin women.

When planning abdominal contouring, careful consideration should be given to the three major vascular zones of the abdominal wall. The mid-abdomen is supplied by the superior epigastric and inferior epigastric arteries, which form the deep epigastric arcade in the region of the umbilicus. Perforators extend through the anterior fascial sheath to supply the overlying skin. The external iliac artery supplies the lower abdomen. The lateral abdomen is supplied by both the intercostal and subcostal arteries. The intercostal arteries originate from the thoracic aorta and extend to the internal mammary between the external and internal oblique. The superficial external pudendal artery, the superficial epigastric artery, and the superficial and deep circumflex iliac arteries are branches of the femoral artery, which also contribute to the lower abdominal wall skin. The venous drainage system runs parallel to the arterial system. Subsequent consideration will be given to the blood supply to the abdominal wall as related to planning abdominoplasty techniques with particular regard to concomitant liposuction.

The abdominal lymphatic drainage is to the axillary lymph nodes above the level of the umbilicus. Below the level of the umbilicus, drainage is to the superficial inguinal lymph nodes. Disruption of the inferiorly directed drainage will result in postoperative swelling, just above the incision, which with time will resolve.

Innervation of the upper abdomen is predominantly from the intercostal nerve. Because both the nerves pass deep into the abdominal musculature and there is overlap of these dermatomes, it is unusual for patients to experience significant paresthesias in the mid and upper abdomen. Sensory abnormalities are commoner in the lower abdomen and pubis, inferior to any incisional disruption of the sensory nerves.

4 Patient Evaluation

The three key elements to consider when evaluating abdominal contour patients are skin quality, musculoaponeutic laxity, and degree of lipodystrophy. With rapid weight gain or pregnancy, significant abdominal wall stretching can occur, leaving persistent skin excess and loss of elasticity. In addition, striae or stretch marks are visible where the dermis has been disrupted. Diastasis recti are often present: a weakness of the fascia is almost always identifiable in multiparous females. Moderate lipodystrophy typically results from hypertrophy of the existing adipocytes; however, with weight gain, adipocyte hyperplasia will occur [25]. This results not only in undesirable adiposity but also in the formation of cellulite as the fibrous septae within the subcutaneous adipose cause changes in the reticular dermis indentations on the skin surface [26, 27].

Patients seeking abdominoplasty can be classified on the basis of the physical examination and the plan for operative management [28, 29]. Type 1 patients are usually younger, with good skin elasticity and minimal lipodystrophy and good muscle tone. Good results can be obtained with suction-assisted lipectomy alone. A type 2 patient has mild skin excess, a normal musculoaponeurotic layer, and mild to moderate lipodystrophy, particularly inferior to the umbilicus. Minimal lower abdominal skin resection in combination with liposuction is effective for these patients. A type 3 patient has mild skin excess, lower abdominal laxity with diastasis of the recti, and mild to moderate lipodystrophy inferior to the umbilicus. In addition to the skin resection and liposuction, plication of the rectus sheath from the pubis to the umbilicus is required. A type 4 patient has skin excess, significant laxity of the musculoaponeurotic layer, and lipodystrophy. Skin resection, liposuction, and plication along the entire rectus sheath offers improvement but may require transaction of the umbilical stalk. A type 5 patient presents with severe upper and lower abdominal skin excess and laxity. Diastasis of the rect is severe and the patient is often moderately obese. Traditional standard abdominoplasty with placation of the rectus sheath and defatting is necessary.

5 Surgical Technique

5.1 Preoperative Treatment

Aesthetic improvement of the abdomen is achieved with a continuum of procedures ranging from liposuction alone to multistage belt lipectomy with repair of musculofascial defects. Modern abdominoplasty is a concept-oriented procedure to address lipodystrophy, musculoaponeurotic laxity, and redundant skin (Fig. 59.1). It combines aggressive liposuction of the abdomen and flanks with dermolipectomy in the suprapubic region. Undermining is limited to the midline to allow plication of the fascia.

Fig. 59.1
figure 1

(a) Preoperative lipodystrophy, musculoaponeurotic laxity and loose skin. (b) Postoperatively

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Preoperative evaluation and markings (Fig. 59.2) are made with the patient in the standing position. The anticipated area for skin resection is marked as are the areas for liposuction. Prior to induction of general anesthesia, lower extremity compression devices are placed and preoperative antibiotics are given. Once the patient is asleep and the Foley catheter has been placed, several small-access incisions are made. Usually these are placed at the umbilicus, the top of the pubic hairline, and laterally within the bikini or underwear line to minimize visible scaring; however, additional incisions are often used. Liberal placement of access incisions permits infusion of Klein’s solution and facilitates fat aspiration with the greatest control to improve the contour while limiting irregularities and asymmetries. Standard Klein’s solution is infused into the areas of planned suction-assisted lipectomy and dermolipectomy. The infusion volume is 1:1 with the anticipated aspiration volume.

Fig. 59.2
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(a) Preoperative evaluation in the standing position. (b) Markings in the standing position

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5.2 Suction Lipectomy

After allowing the epinephrine to take affect, liposuction is performed deep to Scarpa’s fascia beneath the planned skin resection. Major contouring of the remainder of the abdomen is performed by suctioning in both the deep and the superficial fat layers. A 4-mm cannula is typically used, with either the Luer Loc syringe system or vacuum aspiration. Aspiration volumes for the abdomen are usually between 2 and 4 L. If more than 4 L of fat is aspirated, in-patient observation is recommended. Once the result of the liposuction has been checked for irregularities and asymmetries and has been found to satisfactory, resection of the redundant skin is performed.

5.3 Dermolipectomy

The skin is incised with a scalpel along the preoperative markings. Sharp dissection is performed through the subcutaneous tissue continuing down through Scarpa’s fascia. The infiltration of the Klein’s solution minimizes bleeding and permits rapid dissection with serrated Mayo scissors. With the incision complete to each lateral margin, the ends of the skin paddle are grasped with Kocher clamps and the segment is avulsed. Even when aggressive suction lipectomy has been performed, some adipose tissue will remain deep into Scarpa’s fascia (Fig. 59.3). Additional deep contouring can be performed on the abdominal wall fascia using a flat cannula with the vacuum aspirator. However, to minimize the risk of seromas, the fascia should not be stripped clean, but rather at least a fine layer of overlying soft tissue should be left intact.

Fig. 59.3
figure 3

Dermolipectomy

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5.4 Fascial Repair

Management of the fascia is of even greater importance when skin resection and undermining is limited. Dissection is performed sharply to elevate the subcutaneous tissue from the midline fascia, creating an area 4–5 cm in width. The use of a lighted retractor or an endoscope allows visualization of the diastasis and facilitates the fascial placation. This can usually be performed while preserving the umbilical attachment to the fascia.

Correction of the diastasis is achieved by approximating the fascia at the medial border of the rectus muscles; however, additional tightening can be performed. The amount of additional tightening which will be tolerated can be evaluated by grasping the fascia with two Kelly clamps and approximating the margins. The fascia can then be marked with methylene blue to allow precise placement of the sutures, tapering the amount of planned plication at the cephalad and caudal limits. The midline is closed using several 0 Prolene simple interrupted sutures both above and below the umbilicus. Using interrupted sutures offers additional control over the degree of plication achieved. A running suture of 2-0 looped nylon is placed to imbricate the midline. The midline fascia can be plicated and imbricated from the level of the xiphoid to the suprapubic region.

When no undermining of the superior flap is performed, transverse plication of the musculoaponeurotic tissue can be readily performed within the area that has been exposed by dermolipectomy. The fascia is readily exposed and significant abdominal wall tightening can be obtained. Plication and imbrication is performed along a transverse line inferior to the umbilicus. Although this method avoids undermining the superior flap, it tightens the abdomen in a longitudinal direction. Although it will not correct rectus diastasis, it is however helpful to further emphasize the desirable contour of both the lateral and the anterior aspect of the lower abdomen.

5.5 Management of the Umbilicus

Plication around the location of the umbilical stalk may compromise vascularity of the umbilicus and should therefore be performed carefully or avoided. Placement of the plication can be discontinued just above the umbilicus and then restarted below it. Permanent knots should be buried using a smaller slow-absorbing suture such as Vicryl or polydioxanone. This avoids any palpable sutures in the thin tissue around the umbilicus.

The umbilicus usually remains attached; however, if additional exposure is required, it can be “floated.” The periumbilical depression is re-created by using liposuction with a flat cannula 2–3 cm surrounding the umbilicus. If the umbilical stalk is long, tacking sutures can be used to attach the deep dermis of the umbilicus to the facial midline. If the umbilical stalk must be detached, use of landmarks, such as the iliac crest, is helpful to avoid resetting it too low.

5.6 Wound Closure

Wound closure is facilitated by the liposuction in the upper abdomen, which creates mobility of the sliding flap [30]. In addition, because the subdermal thickness of the upper flap is reduced, the wound edges align properly and give an aesthetic closure. Staples are used to temporarily approximate the skin edges and ensure that no dog ears are created. Closure is in layers including the superficial fascial system and deep dermal layers.

If any final touch-up contouring is required, it can be performed at this point prior to the subcuticular closure. If needed, closed suction drains can be brought out through the lateral aspect of the incision and secured with nylon sutures.

6 Postoperative Care

Immediately following the procedure, a light dressing and a compression garment are placed. This serves to hold the dressing in place without tape, decreasing edema, seroma formation, and contour irregularities. Drains are removed when drainage is <30 mL per 24 h and the binder can be discontinued a few weeks later. Rarely is Fowler’s position required, except for comfort. Ambulation is encouraged early and typically patients resume regular activities in 3–4 weeks. Activity restrictions are for comfort only.

7 Complications and Contraindications

Complications following modern lipoabdominoplasty can range from minor undesirable aesthetic outcomes to potentially life-threatening problems. In general, they occur less frequently than with the standard abdominoplasty [31, 32]. The most frequent undesirable outcome is contour irregularity secondary to liposuction, occurring in 10 % of patients [33]. Careful cross-hatching and liberal access sites will limit this problem. The rate of seromas with standard abdominoplasty techniques is over 20 %, while with the lipoabdominoplasty technique, it is 2–4 %. In addition, rates of hematoma formation, wound separation, and wound infection are similarly decreased. Since the umbilicus is not reinserted, the umbilical necrosis is almost nonexistent. Postoperative skin necrosis has not been reported.