Lipoabdominoplasty: A versatile and safe technique for abdominal contouring

Abstract

Abdominoplasty is an important and common operation in aesthetic surgery. Since its original recorded description, several technical improvements have been made. Fundamentally, however, there has been no change in the essential concept of extensive undermining almost to the costal margin, followed by appropriate resection and closure. The operation is still associated with a significant complication rate, morbidity and prolonged convalescence.[1–4] Complications have included flap necrosis, seroma, haematoma, infections, fat necrosis, dehiscence of wound and delayed healing. There is also a high incidence of aesthetic flaws and need for secondary correction, rates as high as 27.9 % being reported.[1] Extensive undermining causes denervation and reduction in the vascularity of the flap. There is thus an intrinsic design flaw in the traditional operation, namely, a large random pattern skin flap, partly deprived of blood supply and innervation is stretched maximally and sutured under tension.[3,4] This accounts for ischemia related complications. The lower abdominal skin also remains permanently numb.[5] The traditional technique also results in several lymphatics being divided. Despite routine use of drainage, a high rate of postoperative seroma is still accepted as unavoidable. Despite such high complication rate even the end results may not be always aesthetically pleasing.[6] The problems increase significantly in obese subjects and hence patients are told to lose maximum weight in order to “earn” their abdominoplasty.[7] The best indication for abdominoplasty is still a patient with plenty of loose skin, rectus muscle diastasis and without too much fat in the local area. With the rising incidence of obesity in the world, such patients are rare in today's practice [Figure 1]. Many obese patients are unable to lose weight especially in the abdominal area and hence are denied abdominoplasty. In obese individuals unable to lose weight, a two step approach has been advocated consisting of abdominoplasty followed by liposuction six months later or vice versa. Both approaches are less than ideal. Reducing excess fat in abdominal wall by prior liposuction will induce fibrosis, making subsequent abdominoplasty difficult. Performing abdominoplasty first in these obese patients is associated with more complications and still leaves behind a fatty abdominal wall; subsequent liposuction can cause secondary skin laxity. Figure 1 Left: An ideal patient for abdominoplasty. Right: the type of obese patient that one often gets To circumvent these problems a new operation called Lipoabdominoplasty (LABP) has been practised by the author since 1995 with surprisingly low complication rate. Techniques have been refined over this period and in its present form it has proven to be trouble-free and versatile. Historically the concept of combining liposuction with abdominoplasty seems to have been proposed first by Cardoso de Castro in 1987[8] with later contributions by several surgeons.[9–12] However this procedure has not been adopted universally yet. Part of the reason for reluctance is the fear that combining the two operations may be risky as was suggested in earlier writings where the concept of “danger zones” was proposed.[12] Modern LABP is an entirely new operation and is not merely a combination of two procedures; this is important to understand in order to attain efficacy with safety.[13–16] In this article the author explores the philosophy of this new procedure, laying emphasis on the essential steps for safety to shorten the learning curve. Personal experience with a consecutive series of over 120 mostly obese patients is used to illustrate the points.