Abdominoplasty

Patients seeking abdominoplasty most often complain of excess skin and subcutaneous tissue in the abdomen and abdominal protrusion due to laxity of abdominal wall caused by previous pregnancy, weight fluctuations and/or aging. A traditional abdominoplasty is indicated when the deformities involve both the supra and infraumbilical regions whereas a mini-abdominoplasty is usually indicated if the problems are limited to the infraumbilical region.

The ideal candidate for abdominoplasty is a young healthy woman who is a nonsmoker and whose weight is within, or slightly above, the normal range.

Indications are; skin and subcutaneous tissue excess and laxity limited to the anterior abdomen and abdominal wall musculoaponeurotic laxity.

Contraindications are generalized obesity with excessive intra-abdominal content. Also circumferential lower truncal excess, patients with unrealistic expectations, medical or psychiatric instability and smoking (considered to be a contraindication by most plastic surgeons). Planned pregnancy in the near future is also another contraindication.

A subcostal, open cholecystectomy scar is a relative contraindication for traditional abdominoplasty. History of diabetes mellitus, chronic obstructive pulmonary disease, cardiovascular disease, thromboembolic events are too.

In many cases, especially in middle-aged and older women, patients present with concomitant lipodystrophy of the hips and lateral thighs, as well as the abdominal deformities. These patients are still amenable to abdominoplasty in combination with liposuction of the areas of lipodystrophy.

Obese patients are not good candidates for abdominoplasty because they have excess intra-abdominal or visceral fat. Thus it will maintain a convex profile and will lead to a convex appearance for the entire abdomen.

The risk in Diabetes Mellitus patients are posed by the decreased ability to fight infection, potential vascular compromise, and decreased wound healing ability.

Smoking has been implicated in occlusive microvascular thrombosis and delayed wound healing and when associated with a procedure that already compromises the blood supply of the abdominal skin flap, can result in tissue necrosis and jeopardize the outcome.

Abdominal wall plication can increase intra-abdominal cavity pressure and this can potentiate certain problems. The increased intra-abdominal pressure may elevate the diaphragm and compromise pulmonary function, especially in patients who have chronic obstructive pulmonary disease. Second, increased intra-abdominal pressure after abdominoplasty results in decreased venous blood flow through the common iliac vessels, which predisposes patients to deep venous thrombosis (DVT) and pulmonary embolus (PE). Therefore surgery may be contraindicated.

It is always best for women to undergo abdominoplasty after they have had children and when they do not plan any more, many patients do become pregnant and have children after the procedure. It is wise to postpone the procedure if a pregnancy is anticipated in the near future.

Mini-abdominoplasty;

Indications for mini-abdominoplasty are limited to patients who present with abdominal laxity restricted to the infraumbilical region. The laxity has to be minimal and may be of the abdominal wall and skin/fat envelope. When the patient is flexed at the waist the lower abdominal musculature is relaxed enough to demonstrate laxity in the infraumbilical region. These patients are usually young women who have had one or two pregnancies, have good skin elasticity, and are not overweight.

High lateral tension abdominoplasty;

An HLTA is fundamentally different from the traditional abdominoplasty in the following ways: Maximum tension is created laterally, rather than centrally as in traditional abdominoplasty; HLTA attempts to not only improve abdominal contour, but also enhance the appearance of the anterior thighs by lifting that area and creating a narrowing at the waist as a result of the lateral emphasis. The procedure allows for extensive liposuction of the abdominal flap. because of the emphasis on lateral tension. HLTA often requires an extension of the scar laterally.

Preoperative considerations;

Special attention should be paid to weight fluctuations, any history of pregnancy, diet and exercise regimens and previous abdominal surgery and/or hernias. A careful medical history should be obtained along with a smoking history.

Physical examination;

On physical examination the patient’s weight and height should be determined. The body mass index (BMI), should be calculated. The patient is initially examined circumferentially in the standing position to evaluate the abdominal contour, surrounding contours of the posterior trunk, thoracic region, and thighs. Also the skin, the subcutaneous fat and the abdominal wall should be checked.

The overall quality of skin, vertical excess and the extent of its laxity, including scars and stretch marks should be noted. The patient needs to understand that infraumbilical skin will most often be removed, but supraumbilical stretch marks will not. These remaining stretch marks are often less unattractive when stretched by the procedure and can be hidden by some bikini patterns because of their transference to the lower abdomen.

The thickness of the subcutaneous fat of the anterior abdomen and the surrounding lateral and posterior lower truncal regions should be determined.

Abdominal wall laxity is a reason for a protruding abdomen. It is essential to ascertain the integrity of the abdominal wall, whether there are any hernias present, and the extent of intra-abdominal or visceral fat.

Most patients presenting for abdominoplasty will demonstrate at least some degree of rectus diastasis. Men have a propensity toward a supraumbilical diastasis, whereas women most often present with infraumbilical muscle separation.

The abdominal physical exam should also include an evaluation of the mons pubis. The amount of excess fat should be determined.

Preoperative photographs are taken in the anterior, posterior, lateral and oblique views to demonstrate the full extent of deformities; they guide surgical planning and serve as an important tool in the postoperative assessment of the results.

Operative techniques;

Plastic surgeons vary in their approaches to any surgical procedure and abdominoplasty is no exception.

I prefer a ‘French Bikini’ pattern because it places the scar at the natural junction between the abdominal and thigh units.

In abdominoplasty the surgeon has to balance the needs of limiting the width of the scar, eliminating lateral standing cones or dog-ears, and appropriately positioning the mons pubis in the vertical dimenion. The inferior aspect of the elliptical excision is generally longer than the superior aspect can lead to the dog-ears. Patients who present in the lower BMI range generally do not cause as much difficulty with dog-ears as the patients who have a larger BMI. Patients who have relatively inferiorly positioned belly-button are also less troublesome with respect to dog-ears compared to those who have fairly high belly-button.

In the operating room, the patient is placed in the supine position, intermittent compression devices are applied to the lower extremities, and a dose of perioperative antibiotic is given. General anesthesia allows complete muscle relaxation, which is helpful during abdominal wall plication. Urinary bladder catheter is placed.

The operation begins by circumferentially incising around the umbilicus. than abdominal flap elevation is performed. I prefer not to do aggressive liposuction to extensively elevated abdominal flap in fear of injuring its remaining blood supply – the intercostal, subcostal, and lumbar vessels.

The tailoring process must be a balance between eliminating vertical abdominal excess, not elevating the mons pubis too high, and limiting scar width. The surgeon has to balance the needs of limiting the width of the scar, eliminating lateral standing cones or dog-ears, and appropriately positioning the mons pubis in the vertical dimension

To aggressively improve waist definition and elevate the anterior thighs, proponents of the HLTA technique (high lateral tension abdominoplasty) place a great deal of tension laterally. However, it often necessitate a lateral extension of the scar to eliminate the dog-ears created by the lateral tension.

The new umbilicus should be fairly small, vertically oriented, inverted, and its suture line should be buried within the cone shaped structure.

After closure of the abdominal wound, an abdominal courset is applied to the patient’s abdomen at the end of the surgical procedure and is utilized for a few weeks after surgery.

Complications,

Abdominoplasty is an extensive operation with potential risks and complications. Abdominoplasty, alone or in combination with other procedures, carries the highest risk among body contouring procedures. As a general rule complications are more common in higher BMI patients and because many patients that present for abdominoplasty may be in the overweight-to-obese range, they need to be approached with caution and full disclosure.

Wound dehiscence,

Wound dehiscence, described as separation of the wound at the level of the superficial fascial system, can occur after abdominoplasty. It can arise due to inadequate deep closure or inadvertent straightening up during the early postoperative period. It can usually be avoided by strong reapproximation and good preoperative patient education about staying flexed at the waist for 5–7 days after surgery and maintaining that position even during sleep.

 Hematoma,

Hematomas are potential complications of any surgery including abdominoplasty. They can be minimized by meticulous intraoperative hemostasis; and by avoiding bucking and coughing during extubation. They generally occur between the first and second postoperative day. Large hematomas present with swelling, pressure and pain, and require evacuation and drainage to avoid compromise of the abdominal flap. Some small hematomas can be managed expectantly, especially if they happen to be adequately drained by a drain. Often this will lead to prolonged periods of drainage from that area of the wound.

Wound infection,

Wound infections can occur after abdominoplasty, but tend to occur in patients with increased risk factors such as obesity, diabetes, and smoking. They can present in the form of wound cellulitis and/or an infected seroma. Infection is manifested by redness, heat, pain and then purulent collection. The treatment is appropriate antibiotics, evacuation and drainage of an abscess if present, debridement and dressing changes.

Toxic shock syndrome has been reported after abdominoplasty. Any postoperative patient, who presents with signs of malaise, appears very ill, and complains of generalized discomfort, with or without fever, should always be evaluated to rule out toxic shock syndrome. Treatment involves expeditious return to the operating room, opening up the wound, and washing it out vigorously. A consultation with an infectious disease specialist and good intravenous staphylococcus coverage is also warranted.

Seroma,

Seromas can occur after any abdominoplasty technique. I believe that closed suction drainage is the best way to prevent seromas from occurring, along with compression. No matter which approach is used, should a seroma occur it is usually initially treated by repeat aspiration.

Tissue necrosis,

Tissue necrosis can occur after abdominoplasty due to vascular compromise of the abdominal flap which can be made worse by the tension at closure. Predisposing factors include: A history of smoking; the presence of transverse upper abdominal scars; excessive tension at wound closure; liposuction in particular zones; unrecognized and undrained postoperative hematomas. The patient initially presents with a bluish and ecchymotic area, cooler than the surrounding tissue and betweenthe third and fifth postoperative day skin slough will be noticed clinically. Postoperative skin necrosis should be treated with conservative debridement and dressing changes. Hyperbaric oxygen therapy may reduce the extent of necrosis. Most wounds will heal within 6 weeks and scar revision will improve aesthetic outcome. To help reduce the risk of tissue necrosis it is wise to avoid operating on high-risk patients such as diabetics and smokers if possible, though not all surgeons steer clear of them. As a general rule, it is wise to perform as little elevation of the abdominal fl ap as possible that will create the desired contour, no matter which technique is utilized

MINI ABDOMINOPLASTY (SHORT SCAR ABDOMINOPLASTY)

The mini or short scar abdominoplasty is an important procedure for patients with mild to moderate skin laxity, excess adiposity, and muscular diastasis.

The length of the transverse incision is smaller than that typically used in a full abdominoplasty, as well as avoiding the use of umbilical translocation. A mini abdominoplasty involves the removal of a smaller amount of skin and subcutaneous tissue than a full abdominoplasty.

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.

This procedure is much less commonly performed than full abdominoplasty because most patients presenting for abdominal contouring have gained significant weight and/or have had several pregnancies, resulting in significant excess skin laxity, striae, and muscular diastasis.

Patient selection

• The ideal mini abdominoplasty candidate has isolated soft- tissue laxity of the lower (infraumbilical) abdomen,
• These patients may have variable amount of excess adiposity and myofascial laxity, but the skin at and above the umbilicus is usually free of striae,
• Many mini abdominoplasty candidates may be reasonable candidates for other abdominal contouring procedures, such as abdominal liposuction, endoscopic abdominoplasty, or full abdominoplasty, depending on the degree of soft-tissue laxity and the presence of excess adiposity and myofascial laxity,

Preoperative considerations

• The preoperative evaluation for mini abdominoplasty is comparable to that performed for full abdominoplasty
• Although these patients are usually younger and relatively fit, standard preoperative tests are recommended, and additional tests and clearances should be obtained as appropriate
• Smoking cessation is important for all abdominoplasty procedures. If the mini abdominoplasty candidate cannot stop smoking preoperatively, omission of concurrent abdominal liposuction should be considered
• Any history of PE/DVT or other blood clotting disorders should be properly evaluated by a specialist prior to the abdominal contouring procedure,

Operative Approach

• Abdominal soft-tissue dissection and undermining for a mini abdominoplasty depends directly on the source of the abdominal contour irregularity and the desired aesthetic result
• Elevation of the abdominal soft tissue up to the level of the xiphoid is almost always appropriate for proper myofascial plication.
• Thorough concurrent liposuction,
• Myofascial plication is one of the most important components in achieving a desirable outcome for the mini abdominoplasty
• When there is significant abdominal wall laxity, full myofascial plication from xiphoid to pubic symphysis is performed.
• Final Closure

 Postoperative Care

• The postoperative care for mini abdominoplasty is comparable that of as for a full abdominoplasty.
• Care should be taken to minimize the risk of postoperative nausea and vomiting, as this will cause great anxiety to the patient, with significant abdominal wall discomfort, increased blood pressure, abdominal swelling, and possible hematoma formation.
• To ensure there is no kinking or folding of the binder, which could result in ischemia or necrosis. It should also be released, smoothed and repositioned every few hours.
• Patients are allowed to shower from the second postoperative day.
• Vigorous activity and lifting are restricted for the first 3 weeks.
• The drain(s) is removed when output decreases to 25–30 mL/24 h.