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 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. 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.
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 xyphoid 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.
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 slowabsorbing 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.
Wound closure is facilitated by the liposuction in the upper abdomen, which creates mobility of the sliding flap. 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.
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 less than 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.
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. The most frequent undesirable outcome is contour irregularity secondary to liposuction, occurring in 10% of patients. 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 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. The most frequent undesirable outcome is contour irregularity secondary to liposuction, occurring in 10% of patients.
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 non-existent. Postoperative skin necrosis has not been reported.
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