COSMETIC - LWW Journalsjournals.lww.com/plasreconsurg/Documents/Updates_in...surgery between...

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COSMETIC Complication Rates of Lipoabdominoplasty versus Traditional Abdominoplasty in High-Risk Patients Salem Samra, M.D. Rajendra Sawh-Martinez, B.S. Oliver Barry, B.A. John A. Persing, M.D. New Haven, Conn. Background: Concerns over the safety of combining extensive liposuction with abdominoplasty in a one-stage lipoabdominoplasty procedure persist. This study reports a comparison of the perfusion-related complication rates between li- poabdominoplasty and traditional abdominoplasty among high-risk patients, those more susceptible to complications secondary to a smoking history or previous significant supraumbilical abdominal scar. Methods: The authors conducted a chart review of 161 patients from the Yale University Cosmetic Clinic who had undergone either lipoabdominoplasty (n 93) or traditional abdominoplasty (n 68) between 2004 and 2009. Patients were classified as high-risk patients if they were active smokers or had undergone previous abdominal surgery resulting in a significant supraumbilical abdominal scarring. Specific vascularity-related complications were compared between the techniques. Results: Patients undergoing lipoabdominoplasty had a perfusion-related com- plication rate of 4.30 percent compared with 11.76 percent in those undergoing traditional abdominoplasty (p 0.126). Among high-risk patients (26 smokers and 19 patients with significant supraumbilical scars), there was no statistically significant difference for perfusion-related complications, including skin ne- crosis, wound infection, and wound dehiscence. The need for surgical revision was 10.75 percent in patients undergoing lipoabdominoplasty, whereas 20.58 percent of patients undergoing traditional abdominoplasty needed revision surgery (p 0.116). Conclusions: Lipoabdominoplasty is not associated with a statistically significant increase in perfusion-related complication rates as compared with traditional abdominoplasty, despite the fact that it involves potential trauma to the vascu- larity of the elevated abdominoplasty flap. This holds true even in patients who are at increased risk for perfusion-related complications secondary to a history of active smoking or a previous supraumbilical scar. (Plast. Reconstr. Surg. 125: 683, 2010.) A bdominoplasty, as first described by Kelly in 1899, has undergone various iterations over the years. 1–3 Changes in the methods of in- cision, fixation of abdominal skin and fat, exci- sional design, and the removal of excess fat by liposuction have led abdominoplasties to become one of the most commonly performed aesthetic procedures in the United States, with 148,410 pro- cedures performed in 2007. 3,4 The combination of liposuction with abdomi- noplasty, termed lipoabdominoplasty, has been a controversial topic because of reports of throm- botic or fat embolic complications, and the po- tential for liposuction-induced impingement on the vascular supply of the resulting abdominal wall flap. 3,5,6 Using Huger’s 7 description of the three From the Section of Plastic Surgery, Yale University School of Medicine. Received for publication March 15, 2009; accepted Septem- ber 2, 2009. Reprinted and reformatted from the original article published with the February 2010 issue (Plast Reconstr Surg. 2010; 125:683– 690). Copyright ©2012 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e318265b55e Disclosures: The authors have no financial or commercial conflicts of interest. www.PRSJournal.com 74S

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COSMETIC

Complication Rates of Lipoabdominoplastyversus Traditional Abdominoplasty inHigh-Risk Patients

Salem Samra, M.D.Rajendra Sawh-Martinez,

B.S.Oliver Barry, B.A.

John A. Persing, M.D.

New Haven, Conn.

Background: Concerns over the safety of combining extensive liposuction withabdominoplasty in a one-stage lipoabdominoplasty procedure persist. This studyreports a comparison of the perfusion-related complication rates between li-poabdominoplasty and traditional abdominoplasty among high-risk patients,those more susceptible to complications secondary to a smoking history orprevious significant supraumbilical abdominal scar.Methods: The authors conducted a chart review of 161 patients from the YaleUniversity Cosmetic Clinic who had undergone either lipoabdominoplasty (n �93) or traditional abdominoplasty (n � 68) between 2004 and 2009. Patientswere classified as high-risk patients if they were active smokers or had undergoneprevious abdominal surgery resulting in a significant supraumbilical abdominalscarring. Specific vascularity-related complications were compared between thetechniques.Results: Patients undergoing lipoabdominoplasty had a perfusion-related com-plication rate of 4.30 percent compared with 11.76 percent in those undergoingtraditional abdominoplasty (p � 0.126). Among high-risk patients (26 smokersand 19 patients with significant supraumbilical scars), there was no statisticallysignificant difference for perfusion-related complications, including skin ne-crosis, wound infection, and wound dehiscence. The need for surgical revisionwas 10.75 percent in patients undergoing lipoabdominoplasty, whereas 20.58percent of patients undergoing traditional abdominoplasty needed revisionsurgery (p � 0.116).Conclusions: Lipoabdominoplasty is not associated with a statistically significantincrease in perfusion-related complication rates as compared with traditionalabdominoplasty, despite the fact that it involves potential trauma to the vascu-larity of the elevated abdominoplasty flap. This holds true even in patients whoare at increased risk for perfusion-related complications secondary to a historyof active smoking or a previous supraumbilical scar. (Plast. Reconstr. Surg. 125:683, 2010.)

Abdominoplasty, as first described by Kelly in1899, has undergone various iterations overthe years.1–3 Changes in the methods of in-

cision, fixation of abdominal skin and fat, exci-sional design, and the removal of excess fat byliposuction have led abdominoplasties to become

one of the most commonly performed aestheticprocedures in the United States, with 148,410 pro-cedures performed in 2007.3,4

The combination of liposuction with abdomi-noplasty, termed lipoabdominoplasty, has been acontroversial topic because of reports of throm-botic or fat embolic complications, and the po-tential for liposuction-induced impingement onthe vascular supply of the resulting abdominal wallflap.3,5,6 Using Huger’s7 description of the three

From the Section of Plastic Surgery, Yale University School ofMedicine.Received for publication March 15, 2009; accepted Septem-ber 2, 2009.Reprinted and reformatted from the original article publishedwith the February 2010 issue (Plast Reconstr Surg. 2010;125:683–690).Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e318265b55e

Disclosures: The authors have no financial orcommercial conflicts of interest.

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vascular territories of the abdominal wall, studiesover the past 18 years have attempted to definewhat modifications in technique are necessary tomake lipoabdominoplasty a safe and effectiveprocedure.8–13 Matarasso first described four re-gions that could be safely treated by liposuctionwhen performing an abdominoplasty, recom-mending limited and cautious liposuction whencombined with a full abdominoplasty, and notedthat patients who had vertical scars and extensiveflap undermining and who were smokers had thehighest potential risk of flap necrosis with thecombined procedure.8,9 Liposuction was deemedsafest in the flanks (safe areas 1 and 2), whereasthe supraumbilical epigastric triangle (safe area 3)was most at risk for devascularization.8 Studies bySaldanha et al. and Lockwood have likewise dem-onstrated no increase in complications in patientswho underwent selective liposuction together witha full abdominoplasty.12,13 In the study by Heller etal.,11 the authors describe liposuction of the entireabdomen, including the epigastric and mesogas-tric areas, followed by abdominoplasty, and foundno increased complication rates in patients whounderwent the combined procedure.

Despite these advancements, concerns persistregarding increased complication rates in patientsundergoing lipoabdominoplasty versus tradi-tional abdominoplasty without liposuction, espe-cially for high-risk patients.11,14 A history of activesmoking or significant surgery in the abdomenabove the umbilicus, resulting in a large scar, arethought of as risk factors associated with postop-erative complications.15–20 Because smoking isknown to cause damage to the endothelium andbecause scarring could disrupt the vascular terri-tories that nourish the abdominal wall, such pa-tients would be at an increased risk for complica-tions such as skin necrosis, wound infection, andwound dehiscence caused by decreased perfusionto the abdominoplasty flap. Local complicationsincluding hematoma, seroma, wound dehiscence,and skin necrosis in patients undergoing lipoab-dominoplasty have been reported to occur in asmany as 52 percent of smokers compared with 32percent of nonsmokers.15 Among patients under-going abdominoplasty with a previous abdominalscar, local complications were found to increasefrom 26 percent to 32 percent.16

Heller et al. reported their modification oflipoabdominoplasty to be associated with a lowercomplication rate (9 percent compared with 42percent), a lower patient dissatisfaction rate (3percent compared with 42 percent), and a lowerrevision rate (3 percent compared with 39 per-

cent) than traditional abdominoplasty in 33patients.11 Our goal in this study was to determinewhether this modified one-stage lipoabdomino-plasty procedure performed on high-risk patientsinfluenced the complication rate compared withtraditional abdominoplasty.

PATIENTS AND METHODSThe charts of 161 patients who underwent ei-

ther lipoabdominoplasty or traditional abdomi-noplasty from 2004 to 2009 at the Yale UniversityCosmetic Clinic were reviewed. Ninety-three pa-tients had undergone lipoabdominoplasty and68 patients had undergone traditional abdomi-noplasty. High-risk patients were defined as ei-ther (1) patients who were current smokers,without active smoking up to 2 weeks or lessbefore surgery; or (2) patients with significantsupraumbilical scars, such as from open chole-cystectomies or midline xiphoid to umbilicusincision. Patients with scars from laparoscopicprocedures or infraumbilical scars such as fromcesarean section, hysterectomy, or appendec-tomy were excluded from classification as “signif-icant” abdominal scars.

Details of the surgical techniques used in thisstudy have been detailed in previous studies.7–13

Briefly, traditional lower abdominal abdominoplastyconsisted of an incision along the inferior border ofthe skin flap to be removed, with undermining of theskin flap superiorly, and rectus plication if indicated.Lipoabdominoplasty consisted of initial liposuctionfollowed by an inverted-V pattern abdominoplasty,with incision of the superior border of skin to beremoved and dissection carried superiorly to thexiphoid with limited lateral dissection to 7.5 cm fromthe midline.11 The superior skin flap was advancedinferiorly with the operating room bed flexed 30degrees. The degree of tissue removal is determinedby the endpoint of flap overlap inferiorly. All pa-tients were indistinguishable preoperatively (i.e.,they presented with excess abdominal fat, had excessskin laxity in the supraumbilical and infraumbilicalregions, and were typically found to have poor muscletone of the abdominal wall). Both procedures wereperformed during the study period; patients were sep-arated retrospectively for comparison (Fig. 1).

The mean age of the patients was 39.7 years inthe lipoabdominoplasty group and 38.2 years inthe traditional abdominoplasty group. The aver-age body mass index for patients undergoing li-poabdominoplasty was 28.95 (attained for 72 of 93patients). For patients who underwent traditionalabdominoplasty, the average body mass index was27.20 (attained for 56 of 68 patients). The patient

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complication rate was determined for the follow-ing complications: deep venous thrombosis, pul-monary embolism, hematoma, seroma, skin ne-crosis, wound infection, wound dehiscence, andneed for revisional surgery. Perfusion-relatedcomplications are defined as those involving skinnecrosis, wound infection, or wound dehiscence.Complication rates were compared between pa-tients undergoing lipoabdominoplasty versus tra-ditional abdominoplasty and between high-riskpatients undergoing the former versus the latter.Statistical analyses were performed using Fisher’sexact test on a 2 � 2 contingency table, and bodymass index comparison was carried out using anindependent samples t test. Values of p � 0.05were considered statistically significant. With smallsample sizes in subgroups, only very strong differ-ences between groups can be detected.

RESULTSPatient Population Analysis

Among the 161 patients, 27 were active smok-ers and 19 presented with significant supraumbili-cal scars (as described previously). These patientswere all considered high-risk patients. The averagebody mass index (weight/height2) for patients un-dergoing lipoabdominoplasty (body mass index,28.95) was higher than for patients undergoingtraditional abdominoplasty (body mass index, 27.20)(p � 0.04). Patients undergoing lipoabdomino-

plasty had an average of 2100.60 � 736.8 cc oflipoaspirate removed, with an average tumescentinfiltrate of 2335.71 � 578.04 cc.

Complications among High-Risk PatientsScar InfluenceAmong patients with significant abdominal scars

(Fig. 2), there was no significant difference in skinnecrosis rate (lipoabdominoplasty, 0 percent; tradi-tional abdominoplasty, 12.5 percent; p � 0.421),wound infection (lipoabdominoplasty, 9.09 percent;traditional abdominoplasty, 0 percent; p � 1.00), orwound dehiscence (lipoabdominoplasty, 9.09 per-cent; traditional abdominoplasty, 0 percent; p �1.00). The revisional surgery rate for patients witha previous significant abdominal scar who under-went lipoabdominoplasty was 36.36 percent (fourof 11) and consisted of additional liposuction forall four patients; one patient underwent re-eleva-tion of the abdominal flap and contouring of ab-dominal (truncal) deformities and another pa-tient underwent umbilicoplasty. For patientsundergoing traditional abdominoplasty, the revi-sional surgery rate was 0 percent (zero of eight)(Fig. 3). For patients with a previous significantabdominal scar, however, there was no statisticallysignificant difference in the need for revisionalsurgery between patients undergoing lipoabdomi-noplasty versus traditional abdominoplasty (p �0.103) (Table 1).

Fig. 1. Schematic of zones of dissection and liposuction in abdominoplasty andlipoabdominoplasty. (Left) Standard liposuction. (Right) Extensive liposuction ofthe anterior abdomen is performed in a lipoabdominoplasty, whereas the area offlap elevation is limited to 7.5 cm from the midline bilaterally.

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Influence of SmokingThere were no statistically significant differences

in perfusion-associated complication rates betweenlipoabdominoplasty and traditional abdominoplastyin all subgroups, including among patients whosmoked and those with significant abdominal scars.Among smokers, there was no significant differencein skin necrosis rate (lipoabdominoplasty, 0 percent;traditional abdominoplasty, 0 percent), wound in-fection (lipoabdominoplasty, 5.88 percent; tradi-tional abdominoplasty 0 percent; p � 1.00), orwound dehiscence (lipoabdominoplasty, 5.88 per-cent; traditional abdominoplasty, 10 percent; p �1.00). The revisional surgery rate for patients whosmoked and underwent lipoabdominoplasty was17.65 percent (three of 17) and consisted of moreliposuction for all three; one patient received a mons

plasty, and a second patient underwent re-elevationof an abdominal flap and contouring of abdominal(truncal) deformities (Fig. 4). For patients under-going traditional abdominoplasty, the revisional sur-gery rate was 50 percent (five of 10) and consisted ofre-elevation and contouring for three of five pa-tients, one dog-ear excision, and an umbilicoplasty.For patients who were smokers, there was no statis-tically significant difference in the need for revi-sional surgery between patients undergoing lipoab-dominoplasty versus traditional abdominoplasty (p� 0.102) (Table 2).

Complications in Total Patient PopulationExamining all patients and comparing the

two techniques (lipoabdominoplasty and tradi-

Fig. 2. Preoperative and postoperative lipoabdominoplasty views of a patient with a previous open cho-lecystectomy. Anteroposterior views of the patient before surgery (above, left) and without complication6 weeks after surgery (above, right). Lateral views of the patient before surgery (below, left) and withoutcomplication 6 weeks after surgery (below, right).

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tional abdominoplasty), the rates of skin necro-sis (0 percent and 2.94 percent, respectively; p �0.177), wound infection (2.15 percent and 2.94percent, respectively; p � 1.00), wound dehis-cence (2.15 percent and 5.88 percent, respective-ly; p � 0.242), and need for revisional surgery(10.75 percent and 20.59 percent, respectively;

p � 0.116) were consistently lower in the lipo-abdominoplasty group compared with the tra-ditional abdominoplasty group, but the differ-ence was not statistically significant. Putting allthe perfusion-associated complications together,and including the need for revisional surgery, thecomplication rate for lipoabdominoplasty was

Fig. 3. Preoperative and postoperative traditional abdominoplasty views. Anteroposterior views of patient before surgery(above, left) and 6 weeks after surgery (above, right). Lateral views of patient before surgery (below, left) and 6 weeks aftersurgery (below, right).

Table 1. Complication Rates for Patients with Abdominal Scars*

Lipoabdominoplasty (%)Traditional

Abdominoplasty (%) p

No. of patients 11 8Perfusion-related complications

Skin necrosis 0 (0) 1 (12.5) 0.421Wound infection 1 (9.09) 0 (0) 1.00Wound dehiscence 1 (9.09) 0 (0) 1.00

Revision surgery† 4 (36.36) 0 (0) 0.103*Number (%) of patients with a significant abdominal scar who had complications after surgery. Lipoabdominoplasty and traditionalabdominoplasty show no significant difference in complication rates or need for revisional surgery.†Lipoabdominoplasty revisional surgery consisted of additional liposuction for all four patients, re-elevation and contouring for one, and anumbilicoplasty for another patient.

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significantly lower when compared with tradi-tional abdominoplasty (lipoabdominoplasty, 15.05percent; traditional abdominoplasty, 30.88 per-cent; p � 0.02).

DISCUSSIONIn an effort to reduce the need for abdomi-

noplasty revision, the previous recommendationof separating liposuction and abdominoplasty was

Fig. 4. Example of complication after lipoabdominoplasty, an unsatisfactory result requiring additional liposuction and flapre-elevation and contouring. (Above) Preoperative anteroposterior and lateral views. (Center) First postoperative resultdemonstrating maintained skin laxity and abdominal girth. (Below) Second postoperative result with adequate reductionof redundant skin 6 weeks after additional liposuction and flap re-elevation.

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challenged. Initial results showed improved out-come and perhaps, surprisingly, fewer complica-tions. To further investigate the safety of this newapproach, we analyzed outcomes of lipoabdomi-noplasty in high-risk patients.

The literature has already established that smok-ing is associated with increased complications.17–20 Increating flaps, the random blood flow to skin andsubcutaneous tissue is decreased as vascular terri-tories are divided. When patients already havecompromised flow to their peripheral tissues sec-ondary to vessel endothelial damage from smok-ing, creating flaps is thought to increase the riskfor complication. The same holds true in patientswith large scars, such as from an open cholecys-tectomy or midline laparotomy, because of an in-terruption in the normal blood supply to the ab-dominal wall.

In previously unoperated, nonsmoking pa-tients, the thought of performing extensive lipo-suction to the abdominoplasty flap that is to beelevated was discouraged because of the potentialrisk of increasing perfusion-associated complica-tions. Careful anatomical studies by Huger led tothe description of safe zones for cautious liposuc-tion combined with full abdominoplasty.8,9 As thework by Saldanha et al. and Lockwood demon-strated no increased complications when liposuc-tion was added a to full abdominoplasty, this fearhas begun to dissipate, with liposuction plus ab-dominoplasty becoming a more commonplaceprocedure.12,13 The report by Heller et al. pre-sented results that demonstrated no increasedcomplication rates when extensive liposuctionthroughout the abdomen was used in conjunctionwith a reduced-tension midline closure.11 The datapresented in this report not only add support dem-onstrating that this combined procedure is safe innormal patients but are evidence of no increasedcomplication rate in a high-risk patient popula-

tion. It is important to note that, in addition toliposuction, the lipoabdominoplasty carries tech-nical modifications, including a limited under-mining of 7.5 cm from midline in the superiorabdomen, a high-tension lateral closure, and alow-tension midline closure with a slightly (�1cm) superior location of the new umbilicus posi-tion in the superior abdominal flap. The higherposition of the new umbilicus serves to minimizeskin tension between the umbilicus and mons pu-bis, with eventual straight posture postoperatively.In this report, our case series demonstrates thatthe lipoabdominoplasty can be performed in assafe a manner as traditional abdominoplasty, evenin patients with less-than-normal perfusion to theabdominal wall.

This may have been accomplished for threemain reasons. The first is because of an under-standing of the vascular territories that supply theabdominal wall as described by Huger et al. Be-cause of the limited undermining performed(only 7.5 cm from midline), a larger zone 3, sup-plied by the segmental lumbar, subcostal, and in-tercostal arteries, is preserved. In the traditionalabdominoplasty approach with a low transverseincision and wide undermining to the costal mar-gin, zones 1, 2 and, to a limited extent, 3 aresacrificed.

The second reason has to do with reducingtension on the closure. In extensively liposuction-ing the abdominal wall, a more pliable sliding flapis developed. Furthermore, starting with the su-perior border incision line of the skin flap to beexcised, one never needs to pull the skin tighterthan what the surgeon judges to be safe, to closethe abdominal incision line.

Lastly, tumescent infiltration into the ab-dominal wall before liposuction plays an impor-tant role. The epinephrine in the tumescentsolution reduces blood vessel caliber and de-

Table 2. Complication Rates for Smokers*

Lipoabdominoplasty (%)Traditional

Abdominoplasty (%) p

No. of patients 17 10Perfusion-related complications

Skin necrosis 0 (0) 0 (0) N/AWound infection 1 (5.88) 0 (0) 1.00Wound dehiscence 1 (5.88) 1 (10) 1.00

Revision surgery† 3 (17.65) 5 (50) 0.102N/A, not applicable.*Number (%) of patients with an active smoking history with complications after surgery. Lipoabdominoplasty and traditional abdominoplastyprocedures show no significant difference in complication rates or need for revisional surgery.†Lipoabdominoplasty revisional surgery consisted of more liposuction for all three, a mons plasty for one, and re-elevation and contouringfor another. Traditional abdominoplasty revisional surgery consisted of re-elevation and contouring for three of five patients, one dog-earexcision, and an umbilicoplasty.

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creases vascular and lymphatic damage duringthe procedure.21,22

In considering the revisional surgery rate, ourcase series demonstrates that the majority of re-visions consisted of more liposuction and abdom-inal flap readvancement. High rates of revision arenoted in the previous studies and are seen in pa-tients with high body mass indexes.11,15,22 We havefound that massive weight loss patients tend tohave a greater potential for revision, probably be-cause of reduced skin elasticity. To reduce the rateof revision in lipoabdominoplasty patients, theseresults suggest that more liposuction at the time ofthe initial surgery may be appropriate for somepatients. The endpoint of liposuction is “pinchtest” to estimate approximately 1 cm of fat thick-ness in all sections of revision. As for re-elevationand contouring in traditional abdominoplasty, theaddition of liposuction in the combined lipoab-dominoplasty may prove to decrease the need forthis revision.

CONCLUSIONSIn sum, lipoabdominoplasty involves less un-

dermining, decreased suture line tension, andmaintained abdominal flap vasculature as com-pared with traditional abdominoplasty. Successfuland safe surgery can be performed in smokers andin scarred abdomens without increased risk andwith a high degree of effectiveness.

John A. Persing, M.D.Department of Surgery

Section of Plastic SurgeryYale University School of Medicine

P.O. Box 8041New Haven, Conn. 06520-8062

[email protected]

ACKNOWLEDGMENTSThis study was supported by the Section of Plastic

Surgery Research Funds, Yale University School of Med-icine (S.S., J.A.P.), and a National Institutes of HealthClinical and Translational Science Awards T-32 Pre-doctoral Research Fellowship (R.S.-M.).

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4. American Society of Plastic and Reconstructive Surgeons.National Clearinghouse of Plastic Surgery statistics. Availableat: http://www.plasticsurgery.org/media/statistics/. AccessedSeptember 1, 2008.

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