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Successfully perform one of today's most frequently requested plastic surgery procedures. Written by a leading authority on the subject, this heavily illustrated operative guide examines all of the aspects and variations of abdominoplasty. Examines the practice of liposuction in. Atlas of Abdominoplasty (Techniques in Aesthetic Plastic Surgery). Home · Atlas of Abdominoplasty DOWNLOAD PDF. is an afﬁliate of Elsevier Inc. © Ebook Pdf Atlas Of Abdominoplasty 1e Techniques In Aesthetic Plastic Surgery contains important information and a detailed explanation about Ebook Pdf Atlas.
This may be more important than for full abdominoplasty patients. The extended abdominoplasty may involve all of the components of a full abdominoplasty. Dissection continues superiorly to the costal margins and the xiphoid Fig. Hunstad is lead author of all chapters of this book, but the sixth one, which was written by Dr. Perspect Plast Surg ; 7: The markings are rechecked, ensuring symmetry and the ability to safely reapproximate the two sides.
A very thin, even layer of residual subcutaneous fat should remain below the dermis to minimize the chance of irregularities and avoid skin adherence to the underlying abdominal wall fascia with healing. When the endpoint of liposuction has been achieved, muscle plication follows. This allows ample exposure up to the level of the umbilicus and heals with an essentially invisible scar. Use of a standard lighted retractor similar to that used in breast cases facilitates the infraumbilical dissection.
This completely encircles the umbilicus and frees it from the surrounding skin. The endoscope is then used for visualization superior to the umbilicus Fig. Great care must be taken to avoid dissection into or through the anterior rectus sheath between the umbilicus and xiphoid. Undermining is A usually performed laterally to the level of the lateral border of the anterior rectus sheath and superiorly to the xiphoid.
Meticulous hemostasis should be achieved under direct or endoscopic vision. Myofascial plication is performed next. This is performed with the use of the endoscope and a continuous size 0 double-stranded looped nylon suture and a large tapered needle Fig. A continuous loop suture obviates the need to tie a knot at the level of the xiphoid. The plication begins at the xiphoid and runs in a continuous fashion to the level B Fig. It is dissected free from the surrounding soft tissue to allow access to the abdomen superior to the umbilicus to the level of the xiphoid, in preparation for myofascial plication.
The initial supraumbilical dissection is performed under direct vision using a lighted retractor. Meticulous hemostasis is important for proper visualization while using the endoscope. Endoscopic Abdominoplasty A B Fig. Plication is performed in a running fashion with a size 0 double-stranded looped nylon suture that allows strong myofascial plication without the need for a knot at the xiphoid.
The suture is temporarily run on one side of the rectus sheath when the umbilicus is reached. Plication resumes below the umbilicus down to the pubic symphysis. The suture is then run along the lateral edge of the umbilicus until its inferior edge is reached.
At this point plication resumes and continues down to the level of the pubic symphysis. Only the plication superior to the umbilicus is performed under endoscopic control.
A suction drain is placed and brought out, usually through the mons area to minimize scar deformity. The umbilical and mons incisions are closed in layers with intracuticular absorbable sutures. Box 4. Endoscopic abdominoplasty patients are usually younger and healthier and often more eager to resume their normal activity and exercise regimen before their body has had a chance to heal properly. A suction drain should be maintained until less than 30—50 mL of drainage occurs during a hour period.
Resume medications as instructed No vigorous activity or heavy lifting for 4—6 weeks 6 weeks. The incisions should be protected from the sun until all redness is gone. Preoperative and postoperative photographs are shown in Figs 4. After evaluation and discussion, endoscopic abdominoplasty was performed concurrently with abdominal liposuction to correct the myofascial laxity that was present.
She underwent endoscopic abdominoplasty with concurrent abdominal liposuction as well as liposuction of her saddlebag areas. Preoperative and postoperative photographs demonstrate a thinner and tighter abdomen, with a better overall contour and silhouette.
It is ideal for the patient who presents with relatively normal weight, excess abdominal adiposity, muscular laxity and diastasis, and little or no soft-tissue laxity.
For these patients, endoscopic abdominoplasty can achieve very positive results. The ability to perform muscle plication with completely concealable scars is the highlight of this procedure. For this reason, patient satisfaction is often very high. Keeping the incision hidden in the hear-bearing mons and within the circumference of the umbilicus is very important, as these patients are in good shape and expect to wear twopiece swimsuits and revealing clothing.
This may be more important than for full abdominoplasty patients. Preoperative markings and photographs should be performed standing and are invaluable to achieve the best possible results. Injection of bupivacaine into the rectus sheath and peripherally will help reduce postoperative discomfort, which facilitates deep breathing and reduces the postoperative use of pain medication.
Early postoperative evaluation and regularly over the next week will allow proper intervention if postoperative care issues arise. Reference 1. Limited incisions in abdominoplasty. Subcutaneous endoscopic plastic surgery using a retractor-mounted endoscopic system. Perspect Plast Surg ; 7: Minimally invasive abdominoplasty: Surg Laparosc Endosc ; 5: Endoscopic balloon-assisted abdominoplasty. Such procedures usually encompass a shortened scar, a smaller skin excision, and no umbilical transposition as in a full abdominoplasty.
Thorough abdominal liposuction is usually an important component of this procedure, as well as strong myofascial plication. Introduction The mini or short scar abdominoplasty is an important procedure for patients with mild to moderate skin laxity, excess adiposity, and muscular diastasis. The option of a short scar is very appealing, especially to younger women. Even with a short scar, however, excellent myofascial plication and concurrent thorough liposuction can be performed to achieve a very desirable result.
The umbilical stalk may be released during undermining and secured or repositioned to the rectus fascia. With this procedure, no external umbilical scar is created and the vertical position of the umbilicus is minimally changed at the completion of the case.
A mini abdominoplasty involves the removal of a smaller amount of skin and subcutaneous tissue than a full abdominoplasty. The mini abdominoplasty represents a spectrum of surgical procedures depending on the deformity present.
These patients often have mild to moderate excess adiposity, mild to moderate skin laxity, and striae. They are generally relatively thin and their abdominal skin is usually in good condition.
Any striae present are usually located in the inferiormost portion of the infraumbilical skin. Myofascial laxity in this patient population is variable. Preoperative History and Considerations Box 5. In general, candidates for mini abdominoplasty are usually younger, healthier, and fitter than patients requiring more extensive procedures. Patients taking Box 5. Significant soft-tissue laxity Full abdominoplasty Extended abdominoplasty Circumferential abdominoplasty Circumferential abdominoplasty with an anterior vertical wedge.
Discontinuation of such medication 2 weeks before surgery will reduce or perhaps even eliminate this increased risk. Cessation of 6 or more weeks is probably ideal; however, patients with a long smoking history will still be at increased risk of ischemia. Those who do not stop smoking should be deferred, or the procedure should be performed in a more conservative fashion, for example a lipoabdominoplasty procedure see Chapter 6.
Oral and transdermal medications are suggested to help prevent postoperative nausea and vomiting. A Operative Approach Standard preoperative photographs in nine cardinal views are suggested with the patient standing Fig. The incision for a mini abdominoplasty should be kept as low as possible because there is no concern about removing all of the infraumbilical skin.
Whenever possible, the incision should be placed inferior to existing scars so as to eliminate them with the skin resection. The location and length of the incision are negotiable between the patient and surgeon and agreed upon prior to surgery. Normally the patient is asked to forcefully lift the lower abdominal skin and the inferior incision is marked at the level of the symphysis pubis Fig.
The primary variable for this procedure is the length of the incision. Patients almost always desire the shortest scar possible, yet their anatomy will often dictate the incision length.
Some patients request a short scar abdominoplasty but have moderate skin laxity. A short incision combined with removal of significant amounts of skin can easily be associated with lateral dog-ears, which are undesirable and should be avoided.
Seeing this demonstrated on their own skin is very educational and helps the patient understand the limitations of short scar B C Fig.
There may be variable amount of adiposity and myofascial laxity, but the skin at and above the umbilicus is usually good quality and free of striae.
The transverse incision is marked while the patient pulls up on the lower abdominal soft tissue. The center of the transverse incision is similarly marked by having the patient pull up on the lower abdominal soft tissue. If this option is properly presented, patients who could benefit from a full abdominoplasty may become more accepting of the scar, particularly if it can be placed low, where it can be hidden by swimwear or clothing.
This is an unusual scenario most commonly seen in younger patients who have never been significantly overweight. Concurrent Liposuction B Fig. The exact length is estimated based on the amount of soft-tissue laxity present and the amount of resection planned. Box 5. To accomplish this, the umbilical stalk should be released and dissection completed up to the xiphoid and costal margins Once the incision line is drawn, marking should be made for concurrent liposuction that will address all areas of excess adiposity and usually include the entire abdomen, lateral breasts, flanks, and mons area Fig.
For liposuction during the average mini abdominoplasty procedure, 3—5 L of infiltration of the subcutaneous fat using a epinephrine- and lidocaine-containing solution allows for thorough liposuction while minimizing bleeding see also Chapter 3, Liposuction in Abdominal Contouring. Entry sites are ideally placed within the skin to be resected and within the umbilicus.
The patient is brought to the operating room where sequential compression devices are placed on the lower 37 Chapter 5: It is then completed with the use of electrocautery to minimize bleeding from the skin edges. A Foley catheter may be beneficial to properly monitor fluid status and to ensure an empty bladder, which is helpful for muscle plication.
Nitrous oxide inhalation agents may cause visceral distension and should probably be avoided for most abdominoplasty procedures. IV antibiotics are administered routinely. Thorough infiltration of all subcutaneous tissue to be suctioned is then performed prior to full prepping and draping to allow time for maximal vasoconstriction see Chapter 3, Liposuction and Abdominal Contouring. Entry sites are placed within the planned surgical resection area and umbilicus Fig. The usual infiltration volume is between 3 and 5 L.
The lower transverse incision is made first using a number 10 scalpel partway through the dermis Fig. The electrocautery device is used to continue the dissection Fig.
Additional care should be taken to identify and control the superficial inferior epigastric and the superficial circumflex vessels, as these are likely to be encountered in most mini abdominoplasty patients and can be a source of postoperative Umbilical Considerations A Fig. To accomplish this, the umbilical stalk is usually released at its base from the abdominal wall fascia.
A more vertically oriented umbilicus with a deeper appearance is frequently achieved without any umbilical relocation as the stalk is pulled inwardly following muscle plication. Additional care is warranted in patients who have had lower abdominal surgery or a history of hernia, otherwise the dissection is straightforward.
Dissection continues with electrocautery under direct vision to the level of the umbilicus. All perforators must be carefully controlled during this dissection Fig. Umbilical Considerations Mini or short scar abdominoplasty has significant challenges, particularly in relation to treatment of the umbilicus. An improved umbilical appearance can often be achieved with a mini abdominoplasty not requiring umbilical repositioning.
With smaller skin resections the umbilical location can be left unchanged, and this is usually desirable. Often in this scenario additional superior umbilical hooding is created With more significant skin resections, options of umbilical float or repositioning with a residual midline scar may be necessary. It is unusual in a mini abdominoplasty to be able to resect all of the skin between the lower incision and the umbilicus. This usually requires a longer scar and changes the nature of the procedure to a full abdominoplasty.
In patients with significant supraumbilical skin laxity a mini abdominoplasty procedure will probably not correct this deformity because of the umbilical tethering. Reverse abdominoplasty is a procedure that can be of benefit to this subgroup of patients as well see Chapter In our experience, a vertical closure as apposed to a transverse closure usually heals without a residual dog-ear deformity. Umbilical Float Umbilical float deserves special attention. Muscle plication is then performed and the umbilical stalk is reattached to the midline in a location 39 Chapter 5: Mini Abdominoplasty Short Scar Abdominoplasty inferior to its original site.
When increasing amounts of skin are excised, it becomes more difficult to reattach the umbilicus within a normal range, i. This must be avoided. Correction of this deformity is difficult and usually requires umbilical excision and the creation of a neoumbilicus at a more normal location see Chapter A much more desirable and commonly used approach is to detach the umbilical stalk, continue undermining to the xiphoid, perform xiphoid-to-symphysis pubis plication, and then reattach the stalk at its native or original level see Fig.
This will permit the umbilicus to be reattached at the correct level after muscle plication, which internalizes the previous stalk attachment point. This is a highly desirable technique because it avoids inferior umbilical displacement and allows for continuous muscle plication without suture interruption.
An inferior skin excision creates the most desirable umbilical appearance because the stalk remains at its normal location but the umbilicus is often deepened, made more vertical, and with greater superior hooding. Small umbilical hernias are frequently seen and are easily repaired with umbilical stalk division and reinforced with the muscle plication. This technique does not jeopardize umbilical perfusion Fig. Muscle Plication Box 5. Note the small amount of fat protruding from the divided umbilical stalk.
The small hernia is closed with interrupted absorbable suture. The umbilical stalk should never be in the way because it can be easily divided and reinserted in its native location, floated, or transposed. The best technique appears to be division of the umbilical stalk with continuous muscle plication from the xiphoid to the symphysis pubis, and reattachment of the umbilical stalk at its original level.
Because the umbilical stalk has been released there is no need to modify the plication process near the periumbilical area; instead, myofascial plication proceeds from xiphoid to pubic symphysis in a continuous running fashion. Failure to do so could lead to an undesirable inferior umbilical location. Muscle Plication 5.
The knot should be buried at the symphysis pubis to prevent postoperative palpability Fig.
A perfusion. Undermining of the ridge creates multiple septa within which neurovascular structures are intact Fig. Bupivacaine is injected into the sheath and throughout the entire area of undermining Fig. These undermining ridges are clearly seen and are brought medially by the strong muscle plication. The transverse mark made to identify the normal location of the umbilical stalk will facilitate placement. Additional care should be taken to make sure the umbilicus is re-secured in the midline.
Mini Abdominoplasty Short Scar Abdominoplasty Tissue Demarcation and Closure If a pain pump is going to be used, it should be placed and secured prior to reattachment of the umbilicus. The midline is demarcated and the tissue divided and temporarily closed.
If there is a significant thickness of subscarpal fat, it can be removed prior to umbilical replacement and closure Fig. This may thin the abdominal flap by an additional one-third Fig. Towel clips are then equally placed and tensioned as the demarcation is performed.
A B without compromising vascularity. A pain pump catheter and a drain are placed in the normal fashion Fig. Skin closure for this procedure is critical to avoid the occurrence of a dog-ear. The abdominal skin flaps must be very strongly advanced from the lateral aspects medially. If any dog-ear is left after the deep dermal Fig. We use lidocaine as a continuous drip to help reduce the discomfort associated with myofascial plication.
C Fig. This can be performed up to the level of the dissection if necessary. Frequently the layer of subscarpal fat in the mini abdominoplasty patient is fairly thin and resection is usually not necessary.
Following wound closure, skin adhesive is applied. The patient is placed in a compressive binder and taken to the recovery room. Postoperative Care Box 5. The caregivers should be instructed to release the binder if it feels too tight to the patient. It should also be released, smoothed and repositioned every few hours.
Arrangements for postoperative inspection should be made, usually within a few days of the procedure. Patients are allowed to shower from the second postoperative day. Vigorous activity and heavy lifting are restricted for the first 3 weeks. We find that most patients will slowly increase their activity at a reasonable pace as they recover.
The upper tissue is strongly advanced bilaterally toward the midline with each layer of closure to reduce the chance of lateral dog-ears. This greatly enhances the waistline achieved.
She was not a candidate for endoscopic abdominoplasty because of the presence of appreciable lower abdominal softtissue laxity. Because of this, however, she was an ideal candidate for a mini abdominoplasty, and underwent this procedure with full myofascial plication from xiphoid to pubic symphysis.
She noted that this was worse when she bent over. A mini abdominoplasty was performed with full myofascial plication and resection of excess soft tissue from the infraumbilical area. Here, the lower abdominal laxity has been completely eliminated, achieving a more youthful attractive silhouette. Drains are removed when drainage is less than 30—50 mL over a hour period. The patient is instructed to maintain a flexed position, and can usually straighten up between 7 and 10 days postoperatively.
Preoperative and postoperative photos are shown in Figs 5. Thorough concurrent liposuction, strong myofascial plication, appropriate skin excision, and proper wound closure are all important elements for this procedure. When properly designed, with important patient input, a very pleasing and gratifying result can be obtained for both patient and surgeon. McDevitt NB. Deep vein thrombosis prophylaxis.
American Society of Plastic and Reconstructive Surgeons. Prevention of venous thromboembolism in the plastic surgery patient. Deep venous thrombosis prophylaxis practice and treatment strategies among plastic surgeons: Obstet Gynecol ; Suggested Reading 5.
Blickstein D, Blickstein I. Oral contraception and thrombophilia. Curr Opin Obstet Gynecol ; Oral contraceptives and the absolute risk of venous thromboembolism in women with single or multiple thrombophilic defects: Arch Intern Med ; Clearing the smoke: Wound healing problems in smokers and nonsmokers after abdominoplasties.
The vascular territories of the superior epigastric and deep inferior epigastric systems. Cooper MA. Greminger RF. The mini-abdominoplasty. Addressing difficult areas in body contouring with emphasis on combined tumescent and syringe techniques. Tumescent mini abdominoplasty. Peltier M. Musculoaponeurotic plication in abdominoplasty: How durable are its effects? Evaluation of body contouring surgery today: Shestak KC.
Decision making in abdominoplasty. Complications of consecutive abdominoplasties. J Plast Reconstruct Aesthet Surg ; Wilkinson TS. There were respondents, and a total of 20 procedures reported. Hunstad and Stevens6,7 and others have used liposuction in these areas without ischemic consequences.
This new approach offers some advantages and may reduce the most common complications of ischemia and seroma seen with classic abdominoplasty. Closure was facilitated with quilting sutures described by Baroudi,10 and no suction drains are used. Preoperative History and Considerations The preoperative considerations for lipoabdominoplasty are similar to those for full abdominoplasty see Chapter 7.
Preoperative history and physical examination are performed. Existing scars and the presence of any hernia should be evaluated. For a healthy patient taking no medications, basic preoperative laboratory analysis should be considered. The midline and the proposed suprapubic incision line are marked. Existing scars and natural creases are used to place the incisions.
Figs 6. The superior line is marked as a bicycle handlebar incision as described by Baroudi. Preoperative markings are performed with the patient standing. The low midline transverse incision is extended bilaterally into a natural skin groove to the level of the anterior superior iliac crest.
The Baroudi bicycle handle marks are then made from the ends of this incision to the umbilicus. The rectus muscles are outlined in red. The plication tunnel is marked with interrupted purple lines coursing 1.
The areas for concurrent liposuction are marked in blue. Liposuction in the central supraumbilical area is performed only in the deep layer Fig. For those with a thin layer of abdominal Fig. Dissection is performed superiorly to the level of the umbilicus with electrocautery.
Safe Innovations Figs 6. This is a neoumbilicoplasty without scars. Figure 6. Figures 6. The supraumbilical undermining is performed as a midline tunnel, releasing only 1.
This limited undermining allows for moderate rectus plication and preservation of the perforators. Traction is then placed on the abdominal tissue and the umbilicus is positioned and secured.
Additional quilting sutures are placed throughout the remaining area of undermining to the level of the incision Figs 6. This achieves a very natural shape with no scar. Operative Approach Figs 6. The plication begins at the xiphoid and runs continuously to the symphysis pubis. These sutures are used to obliterate the entire tunnel from the xiphoid to the umbilicus. Results following this procedure are pleasing. Conclusion Fig. No drains are placed. Postoperative Care Patients stay overnight in our facility, where they can be cared for by nursing staff, and begin walking the next day.
Our patients wear compressive stockings from 1 hour preoperatively until 1 week postoperatively. Following discharge they are seen again in the surgical center between 5 and 7 days postoperatively. An abdominal binder is placed following surgery — snugly not tightly — and released and readjusted every few hours to avoid a crease or fold. Diet is advanced as tolerated, and exercise is increased according to patient tolerance.
For the last 2 years we have not used any drainage system for this procedure. Good body contouring has been possible even in obese patients with this single and safe operation.
A no-scar neoumbilicoplasty was performed the previous umbilical scar was completely resected. A—C Preoperative photos. D—F Postoperative photos at 8 months. D, E Postoperative photos at 2 years. Safe Innovations Clinical Caveats: Available at www.
Accessed May Abdominoplasty and abdominal contour surgery: Liposuction as an adjunct to full abdominoplasty. Perspect Plast Surg ; Does liposuction really add morbidity to abdominoplasty?
Revisiting the controversy with a series of cases. Aesthet Surg J ; Lipoabdominoplasty without undermining. Lipoabdominoplasty with selective and safe undermining.
A new technique without undermining and fat layer removal. Arq Catarin Med ; The vascular territories of the superior epigastric and the deep inferior epigastric systems. Baroudi RA. Bicycle handlebar type of incision for primary and secondary abdominoplasty. The vascular anatomy of the lower anterior abdominal wall: A micro dissection study on the deep inferior epigastric vessels and the perforator branches.
Suction-assisted lipectomy, lipolysis, and hypexeresis. Hakme F. Technical details in lipoaspiration associated with liposuction. Rev Bras Cir ; The vascular anatomy of the anterior abdominal wall: Perspect Plast Surg ; 5: This procedure addresses and corrects excess abdominal adiposity and soft-tissue laxity, rectus diastasis and abdominal wall laxity, and skin striae. Patients often have the desired goal of returning to their pre-pregnancy or pre-weight gain abdominal contour.
Introduction The full or complete abdominoplasty is the most commonly performed method of abdominoplasty. This length is necessary to achieve the best results by facilitating complete removal of the infraumbilical skin and soft-tissue laxity that bothers these patients. This procedure can offer a lifetime improvement, particularly for patients who maintains their weight following the procedure. Patient Selection Box 7. Healthy patients with infraumbilical striae, moderate excess adiposity, skin and Box 7.
Chapter 7: Full Abdominoplasty soft-tissue laxity, and rectus diastasis or myofascial laxity are ideal candidates for full abdominoplasty.
For these patients, muscle plication could be deferred and a more conservative approach to soft-tissue resection may also be considered. Active smokers are at increased risk of ischemia and necrosis, particularly midline in the infraumbilical area above the transverse incision. In our practice, we suggest complete smoking cessation for 6 weeks preoperatively for patients wishing to undergo the complete full abdominoplasty.
Possible future pregnancy should be discussed with the patient and, if this is anticipated, it is suggested that abdominoplasty be performed following the last pregnancy. Preoperative History and Considerations: Box 7. This may result in some residual laxity at the end of the procedure.
A vertical midline incision is not a contraindication to surgery and can often be improved with scar revision. This allows for transverse tightening during abdominoplasty, in addition to the vertical tightening associated with lower abdominal soft-tissue excision.
The vertical tissue excision also allows for removal of some of the most poorly perfused tissue in the midline following undermining.
The appendectomy scar is often included in the tissue resection. All scars, particularly a vertical midline scar, can be associated with an incisional hernia. The patient should be relaxed to eliminate tightening of the abdomen and rectus muscles and permit accurate evaluation of contour and shape.
All photographs should include the area from the inframammary folds to the mid-thigh, because some thigh elevation will occur with this procedure A. B and D Left and right oblique views demonstrating the waist, extent of abdominal laxity, and the anterior thighs and hips. C and E Left and right lateral views, which further demonstrate abdominal contour.
The posterior view F is helpful in evaluating the buttocks and hip rolls. A left and right posterior oblique view complete the nine cardinal views not pictured. Patients taking birth control medications or hormone replacement therapy are at an increased risk for DVT and PE, and this should be discussed preoperatively. Because of this, we recommend placing all abdominoplasty patients in a tight abdominal binder for 2 weeks preoperatively. Operative Approach Preoperative photographs are taken in nine cardinal views Fig.
Markings are made with the patient standing. We ask the patient to place their hands together and strongly lift the lower abdominal skin vertically Fig. The central portion of the initial transverse incision is then marked at the superior level of the pubic symphysis.
This normally removes the upper third of the hair-bearing mons Fig. The length and location of this 57 Chapter 7: This mark is placed approximately at the level of or slightly superior to the symphysis pubis, which corresponds to the junction of the upper and middle thirds of the hair-bearing mons B. The mark is then extended laterally in a natural skin fold to be placed at a level the surgeon and patient have agreed on C.
The lateral height and length of the incision are measured to ensure symmetry D. An outline of the garment is made, allowing the incision to be placed within its borders Fig. It is often helpful to ask the patient to bring in their most revealing swimwear or lingerie. This will allow the incision to be placed and concealed within the borders of the garment Fig.
The lateral extent of the incision is marked and agreed upon by the patient. The lower the initial transverse incision, the more likely an inverted T closure will be needed because of the longer vertical distance to the umbilicus.
For patients with greater skin and soft-tissue laxity, the full abdominoplasty incision can be extended to go posterior to the anterior axillary line to address this without creating lateral dog-ears. Doing so results in a technique more appropriately referred to as an extended abdominoplasty see Chapter 8, Extended Abdominoplasty. The true extent of tissue resection will be determined intraoperatively. All areas for liposuction are marked at this time. They are placed in the supine position and compression stockings are placed Fig.
The patient is covered with warm blankets to prevent heat loss, and an intravenous line is established Fig. To minimize bleeding, all incision lines are injected with a solution of lidocaine and epinephrine Fig. The lower transverse incision has been marked, extending approximately from the left to the right anterosuperior iliac crest.
The upper line, which serves as an estimate of the amount of tissue to be resected, is then drawn with the lateral aspects curving strongly cephalad.
Warm blankets are used to cover the patient immediately upon entering the operating room, and then a forced warmed air heating blanket is utilized to maintain optimum core body temperature B, C.
C D Fig. The cannula is frequently cleansed with Betadine solution when it is withdrawn and a new entry site is used F. Suctioning of the lateral axilla and fullness above the breast is best performed through an axillary entry site Fig.
The umbilical entry site is ideal for access to the central abdomen Fig. All liposuction is performed on the areas 60 Fig. The hip rolls and mons are thoroughly suctioned using an entry site within the area of tissue to be resected E, F.
The low transverse incision, previously marked, is made with a number 10 blade into, but not entirely through the dermis Fig. Electrocautery is then used to complete the incision, sealing the blood vessels within the subdermal plexus Fig. This is important, because these vessels can bleed postoperatively and lead to a hematoma see Chapter 15, Complications. A scalpel or electrocautery is used to perform soft-tissue dissection superiorly to the level of the umbilicus.
Electrocautery is then used to deepen the incision through the dermis, controlling the vessels of the subdermal plexus. This allows controlled hemostasis, essentially eliminating incisional bleeding. These vessels need to be individually controlled, cauterized, or ligated to prevent bleeding, which can result in a postoperative hematoma D.
The lower abdominal tissue from the incision line to the umbilicus. These are particularly prominent and numerous in the periumbilical region. A number 11 blade is used in a pushing fashion to incise the umbilicus in a vertical ellipse shape as previously marked B. Metzenbaum scissors are used to carefully dissect the umbilical stalk, leaving attached a small amount of subcutaneous tissue to ensure viability C.
These vessels are the second most likely source for postoperative hematoma and should be properly controlled with either electrocautery or suture ligature. Throughout the course of the dissection, meticulous hemostasis should be maintained to minimize intraoperative blood loss.
Full Abdominoplasty A B Fig. Inferior dissection is also performed, elevating the soft tissue to the level of the symphysis pubis B. The umbilicus is vertically incised and dissected free with scissors Fig. Dissection continues superiorly to the costal margins and the xiphoid Fig. At this point the stage is set to perform myofascial plication. Wide rectus abdominis muscle placation WRAP is begun by outlining the medial borders of the rectus abdominis muscle.
The 62 most superior point of the plication marking is the xiphoid process and the most inferior is the pubic symphysis. Myofascial plication is performed with a looped number 1 or 0 nylon suture on a tapered needle Fig. Plication is performed as either a single line or two lines of closure. An additional set of marks are placed laterally as an estimate of the plication to be performed during the second plication layer B.
This eliminates the need to tie a knot at the xiphoid. Plication is performed in running fashion down to the level of the umbilicus. At the level of the umbilicus, the suture continues on one edge of the rectus sheath until the inferior edge of the umbilicus is reached.
At this point, the plication process is resumed. The plication continues to the symphysis pubis in a continuous fashion C, D. The knot at the end of the plication suture is buried beneath the edges of the rectus sheath plication E. The suture is brought between these two edges and then held upright F. The needle is then passed through one edge of the rectus sheath and immediately brought back, so that both strands of the suture are deep to the medial edges of the rectus plication.
The knot is then tied, which eliminates palpability. This can create a set of indentations or rolls that need to be addressed. These indentations can be addressed with discontinuous or blunt undermining. At the upper edge of the umbilicus, the nylon suture continues in a running fashion down one side of the rectus sheath only Fig. Continuous myofascial plication resumes at the inferior edge of the umbilicus Fig.
The knot tied at the point of the plication at the level of the pubic symphysis should be buried. At this point, a soft-tissue roll medial to the costal margin may be evident which represents the superolateral level of 64 Fig. This will take tension off of the abdominal closure and, in the majority of cases, allow all of the tissue between the low transverse incision and a point superior to the umbilicus to be resected. This occurs because the level of tissue undermining has been brought medially and inferiorly from the costal margin by the myofascial plication process Fig.
Discontinuous undermining is recommended and is very effective at eliminating the soft-tissue ridge, mobilizing the tissues, and preserving tissue vascularity Fig. The Lockwood dissector is effective in achieving discontinuous undermining. Tissue demarcation and resection is performed next. The lower the initial transverse incision is made, the more likely an inverted T closure will be needed because of the longer vertical distance to the umbilicus present. The Pitanguy tissue demarcator is an excellent device.
This should be measured to ensure the left and right areas for resection are identical D, E. A full-thickness resection is then performed using a number 21 scalpel F, G. A temporary staple is placed in the midline.
The amount of tissue to be resected should be equivalent on both sides Fig. The full thickness of the tissue is then resected Fig. It must be precisely placed in the midline. The skin is removed with a cone of underlying subcutaneous fat C, D.
We recommend sharp dissection using a number 10 scalpel A. We recommend a more conservative sharp resection, leaving behind some subscarpal fat for later trimming with scissors C. A vertical ellipse of skin is marked corresponding to the shape of the released umbilicus. The skin is vertically excised along with the subcutaneous tissue beneath the surface surrounding the new umbilical site Fig.
At this point, the stage is set to perform subscarpal fat resection in appropriate patients. The clips are placed at the same distance from the midline to maintain comparable elevation and tension. This is important to ensure a smooth and even resection. Subscarpal fat is resected throughout the entire area of undermining. Electrocautery or sharp excision can be used. The most central and superior aspect of subscarpal fat resection requires additional elevation.
This will expose the subscarpal fat all the way to the xiphoid, which can be trimmed under direct vision D. A continuous infusing pain pump catheter is placed B , secured with Vicryl sutures along the rectus plication to ensure that the local anesthetic is infused over the strong muscle plication C. Usually a single 7-mm Jackson Pratt drain is used, and both the drain and catheter are secured with silk sutures D.
Marcaine is injected into the rectus sheath to aid with postoperative pain management Fig. Usually a single 7 mm Jackson Pratt drain is placed.
The drain is placed through a stab incision and brought out laterally. The midline is closed again with a temporary staple. If redundancy is created in the midline, it will disappear postoperatively. If redundancy is present 67 Chapter 7: The medial advancement of the upper abdominal tissue provides a dramatic improvement to the waistline and hip rolls and effectively eliminates the lateral dog-ears D. This second line of 68 Fig.
Postoperative Care A Fig. The incisions are all covered with tissue adhesive, which serves as a water impermeable dressing Fig. This is important because it promotes tissue adherence immediately and reduces the chance of subsequent seroma formation. Resume medications as instructed No vigorous activity or heavy lifting for 4—6 weeks 69 Chapter 7: This also allows the opportunity to make sure that the abdominal binder is properly positioned, and that it is not too tight.
Making sure that there are no folds in the binder and foam as well as the drain tubing is also important, as these can irritate or damage the underlying skin.
Most full abdominoplasty patients are kept in our overnight facility cared for by a trained nurse. Some patients wish to go home and then are seen usually the next day or so. Instructions regarding drain care are provided to the patient and their caregiver. Preoperative photographs demonstrate a moderate amount of abdominal excess adiposity and soft-tissue laxity.
There is visible abdominal wall laxity and poor skin quality secondary to striae. She underwent full abdominoplasty with myofascial plication and concurrent liposuction.
Postoperatively, she has much improved silhouette and contour. This patient demonstrates relatively good skin quality and body habitus for her age.
Preoperatively there was excess adiposity and moderate abdominal wall laxity. The postoperative photographs show the usefulness of concurrent liposuction with abdominoplasty to improve the contour of the entire midsection from the costal margins to the pubic symphysis.
She underwent a full abdominoplasty with myofascial plication and concurrent liposuction of the abdomen and the middle and lower back. She also desired increased volume and projection of her buttocks.
Buttocks augmentation with fat grafting was also performed. There was mild to moderate soft-tissue laxity and her skin quality was fair. Good skin quality would make abdominal liposuction a reasonable alternative, but the presence of abdominal wall laxity and questionable skin quality makes full abdominoplasty with myofascial plication and concurrent liposuction a more effective procedure.
Postoperatively, the patient demonstrates improved abdominal contour, waistline, and silhouette. She was a reasonable candidate for circumferential abdominoplasty, but her main concern was her abdominal contour. She underwent full abdominoplasty with myofascial plication and concurrent liposuction of the abdomen and lower back.
The concurrent use of thorough tumescent liposuction, subscarpal fat resection, and strong myofascial plication allows the surgeon to achieve excellent results. Kim J, Stevenson TR. Wound complications of abdominoplasty in obese patients. Ann Plast. Surg ; Guyuron B, Raszewski R. Undetected diabetes and the plastic surgeon. An outcomes analysis and satisfaction survey of consecutive abdominoplasties.
Full Abdominoplasty 7. Plast Reconstruct Surg ; 15; Borman H. Pregnancy in the early period after abdominoplasty. Increased intraabdominal pressure in abdominoplasty: Intraabdominal pressure after full abdominoplasty in obese multiparous patients. Suggested Reading Dillerud E. Abdominal dermolipectomy in an abdomen with pre-existing scars: Hester RT Jr. Abdomiinoplasty combined with other surgical procedures: Safe or sorry? Advanced concepts in abdominoplasty.
Body contouring in the obese patient. Awareness and avoidance of abdominoplasty complications. The male abdominoplasty. These patients have substantially more tissue redundancy and excess adiposity than are seen in the full abdominoplasty patient. The extent of the soft-tissue laxity may not extend circumferentially to merit a circumferential abdominoplasty, or the patient may simply not wish to have the additional posterior component performed.
The extended abdominoplasty may involve all of the components of a full abdominoplasty. The transverse incision of an extended abdominoplasty is longer than that of the full abdominoplasty, usually extending up to or beyond the midaxillary line.
Introduction The majority of patients who present for abdominoplasty are well suited for full abdominoplasty. The amount of excess adiposity and soft-tissue laxity in most abdominal contouring patients requires anterior resection with a transverse scar that often spans from one anterior superior iliac spine to the other, in order to avoid lateral dog-ears. A smaller number of patients present with smaller, more localized laxity amenable to mini abdominoplasty see Chapter 5, Mini Abdominoplasty.
At the other end of the spectrum, patients with substantial weight loss are best treated with circumferential abdominoplasty see Chapter 9, Circumferential Abdominoplasty. Extended Abdominoplasty Box 8. Their reasons may be varied, but the point is that they wish for maximum correction of their abdominal softtissue laxity without having to undergo a circumferential abdominoplasty.
Patient Selection Box 8. Any excess adiposity in the posterior trunk can be treated with concurrent liposuction if the quality of the skin and the soft-tissue laxity are appropriate. Preoperative Considerations Box 8.
It may include CBC, Chem. Exposure to tobacco or any other nicotine products should be avoided for 6 weeks preoperatively and several weeks postoperatively in order to reduce the deleterious effects of nicotine and other smoking byproducts on the healing process. Postoperative Care Operative Approach The operative approach for extended abdominoplasty is almost identical to that for full abdominoplasty, which is discussed in great detail in Chapter 7. The same sequence of preoperative photographs and markings is used.
The obvious difference is the longer transverse incision used for extended abdominoplasty Fig. Postoperative Care Box 8. As there is a theoretical increase in the potential incidence of seroma following extended abdominoplasty, the proper use of an abdominal binder postoperatively is especially important. Before and after photographs are shown in Figs 8.
Box 8. B After the markings of the swimwear are made, the proposed incision line can then be drawn. C We request our patients strongly lift their abdominal soft-tissue superiorly and then the initial transverse mark is made at the level of the symphysis pubis. E The lateral extent of the incision is dependent upon the amount of soft-tissue laxity.
In this case, the laxity extended to the posterior axillary line. The areas for liposuction are marked as well. F The abdominoplasty resection is noted as well as the liposuction aspirate. The drain should exit inferiorly from beneath the binder. Resume medications as instructed No vigorous activity or heavy lifting for 4—6 weeks 77 Figs 8. She was very concerned about the laxity and fullness of her hips.
She underwent an extended abdominoplasty with concurrent liposuction of the abdomen, mons, and hip rolls. Extended Abdominoplasty Figs 8.
He presented with marked laxity and redundancy of the abdomen and hips. The large abdominal soft-tissue apron bothered him a great deal. He underwent an extended abdominoplasty with thorough liposuction of the abdomen, pubic area, and hip rolls, which dramatically enhanced his overall contour. Figs 8. Extended Abdominoplasty Fig.
She had a BMI of 39, was relatively healthy with a stable weight, and was not on any medications. She underwent an extended abdominoplasty with full liposuction of the abdomen, back, and mons.
During surgery, the skin and fat resected weighed g and the volume of fat liposuctioned was 5. If you are a seller for this product, would you like to suggest updates through seller support? Written by a leading authority on the subject, this heavily illustrated operative guide examines all of the aspects and variations of abdominoplasty.
Nearly full-color illustrations and photographs show you in clear, clinical detail the pre-, intra-, and postoperative steps for each procedure, and videos on DVD present these techniques in action. Examines the practice of liposuction in abdominoplasty procedures to show you how to combine both for the best results from each surgery. Offers coverage of endoscopic surgery techniques to equip you with the latest procedures. Uses nearly full-color illustrations and photographs that depict in clear, clinical detail the pre-, intra-, and postoperative steps for each procedure for superb visual guidance.
Addresses specific patient populations such as the massive weight loss patient and the obese, emphasizing the special operative considerations affecting these groups. Follows a consistent format throughout that makes reference quick and easy. Includes a bonus DVD containing videos of key procedures in action that show you how to proceed.
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Michele A. Product details Series: Techniques in Aesthetic Plastic Surgery Hardcover: Saunders; 1 edition December 17, Language: English ISBN Try the Kindle edition and experience these great reading features: Share your thoughts with other customers. Write a customer review. Top Reviews Most recent Top Reviews.
There was a problem filtering reviews right now. Please try again later. Hardcover Verified Purchase. As a physician who has performed more than 2, abdominoplasties, I am pleased to say that even an old dog such as myself has much to benefit from this text.
Well written, experienced commentary with detail the best detail of any surgical text and most clinically relavent I have found. This book is mandatory for the fellowship training we provide and I have personally reviewed in over and over again. Not for non-medical folks.