Traditional Abdominoplasty

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    TraditionalA b d o m in o p las ty

    Alan Matarasso, MD*

    The modern history of abdominoplasty can be

    traced to the late 1960s and 1970s, and was

    marked by acceptance of abdominoplasty as

    a bona fide aesthetic procedure with excision ofthe pannus, tightening of the underlying muscula-

    ture, numerous incision designs, recognition of

    complications, and performing it in conjunction

    with other cosmetic (eg, breast reduction, breast

    augmentation, and so forth) and noncosmetic

    procedures (eg, hysterectomy, cholecystectomy,

    and so forth).

    The introduction of liposuction in the 1980s

    dramatically and permanently altered the

    landscape of body contour surgery. Liposuction

    as a sole contouring procedure or in combinationwith excisional procedures represented the

    greatest advance in body contour surgery, even

    to date. In many instances incisions were short-

    ened and patients heretofore not considered

    feasible as candidates were able to be treated.

    Indeed the abdomen became a group of

    contour procedures that were referred to as the

    abdominolipoplasty system of classification and

    treatment. This group included liposuction alone

    (type I), mini abdominoplasty (type II), modified

    abdominoplasty (type III) (type II and III are consid-

    ered limited abdominoplasties), and a full standardabdominoplasty (type IV) with or without liposuc-

    tion (Fig. 1).

    Extensive abdominal liposuction in conjunction

    with a full (type IV) abdominoplasty is known as lip-

    oabdominoplasty, and is currently receiving re-

    newed interest. Lipoabdominoplasty has also

    been referred to by various other nomenclatures

    such as suction-assisted abdominoplasty, ab-

    dominolipoplasty or marriage abdominoplasty.

    This article describes a standard abdominoplasty

    without or with liposuction (lipoabdominoplasty).In the 1990s, with the increase in popularity of

    laparoscopic and arthroscopic procedures,

    attempts were made to perform abdominoplasty

    endoscopically. These procedures met with tech-

    nical difficulties, a lack of refinement in instrumen-

    tation and, more significantly, the inability to

    address remaining excess skin, which often

    appears greater than anticipated after the rectus

    muscle is plicated. If applicable these techniques

    are most likely to be useful in males. It is this

    excess skin that must be excised that is ultimatelythe rate-limiting factor in the surgeons ability to

    shorten any abdominal incision. Unlike, for

    example, the face, where incisions can success-

    fully be shortened while still removing the amount

    of skin necessary, in the abdomen as more skin

    needs to be removed the incision must be made

    longer.

    The turn of the twenty-first century heralded the

    increase in bariatric surgery and subsequently an

    emerging field of bariatric plastic surgery. Abdom-

    inal contour surgery is the cornerstone of the

    numerous extensive excisional procedures under-gone by patients with massive weight loss. It is

    interesting, then, that plastic surgery has gone

    full circle in less than a generation, from small inci-

    sional stab wounds for liposuction-dominated

    procedures to extensive lengthy incisions now

    deemed necessary for these large excisional

    procedures. In terms of abdominal liposuction,

    Department of Surgery (Plastic Surgery), Albert Einstein College of Medicine, 1009 Park Avenue, New York,NY 10028, USA* 1009 Park Avenue, New York, NY 10028.E-mail address:matarasso@aol.com

    KEYWORDS

    Lipoabdominoplasty Liposuction Abdominoplasty Body contour surgery Mini abdominoplasty Secondary abdominoplasty Massive weight loss

    Clin Plastic Surg 37 (2010) 415437doi:10.1016/j.cps.2010.03.0060094-1298/10/$ see front matter 2010 Elsevier Inc. All rights reserved. p

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    recent interest is now focusing on the benefits of

    laser-assisted liposuction (and the various wave-

    lengths), and its role in facilitating fat removal

    and the unknown potential for skin tightening.

    This article focuses on the most commonly

    encountered abdominoplasty scenario of the post-

    partum abdomen that manifests itself as loose,damaged, excess skin; widening (bony) pelvic

    girth; rectus muscle diastasis and stretching; alter-

    ation in the location of fatty deposits, umbilical

    hernias, and altered appearance of the mons pubis

    (with distortion, widening, and ptosis) (Fig. 2).

    Emphasis is on technique. In addition 10 special

    situations encountered in the abdominoplasty

    population (eg, the scarred abdomen) are dis-

    cussed. These often inevitable and irreversible

    changes of pregnancy continue to plague the

    physically fit, health-conscious baby-boomergeneration accustomed to obtaining optimal goals,

    personally, professionally, and physically. Main-

    taining their youthful physique, fashions, and

    appeal, particularly in an environment that more

    Fig. 1. The abdominolipoplasty system of classification and treatment. This system includes liposuction alone(type I), mini abdominoplasty (type II), modified abdominoplasty (type III) (types II and III are considered limited

    abdominoplasties), and a full standard abdominoplasty (type IV) with or without liposuction. SAL, suction-assis-ted lipectomy. Pink arrows, liposuction; yellow, undermining; green, excision; cross-hatching, fascial plication.

    Matarasso416

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    than ever idealizes slimness, youthfulness, and

    vitality, along with the current trend of low-cut

    clothing (creating the ubiquitous muffin top

    appearance in pants) is a priority for these patients.

    Indeed people have a tendency to perceive theirlevel of fitness or ideal weight (and the necessity

    to diet or exercise) by the appearance of their

    abdomen and flanks. In some it even acts as

    a surrogate marker for the aging process.

    MARKINGS

    The patient is marked wearing preferred undergar-

    ments to confine the incision to within the bound-

    aries of her clothing, and the undergarments alsoserve as a useful guide to symmetry when planning

    the incision. An ellipse (undermining wound

    contraction, healing, and so forth can alter the final

    location of the scar) of tissue to be excised is

    Fig. 2. (AD) A 43-year-old gravida 5 para 5 woman complaining of a large diastasis of the rectus muscle and hy-pomastia. Pre- and postoperative lateral and frontal views following breast augmentation and abdominoplasty.

    Traditional Abdominoplasty 417

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    fashioned by determining the ease in which the

    lower abdominal skin (from umbilicus to hairline)

    can be excised after grasping the pannus with

    both hands in an attempt for the fingers to touch

    the thumbs. While holding the pannus slightly

    upward, the lower incision is designed to traverse

    the natural lower skin crease, slightly below itsnormal position extending in length to just beyond

    the lateral skin folds (noted in a sitting position) and

    approximately 5 to 7 cm above the vulva cleft. The

    upper incision is demarcated passing over the

    umbilicus to encompass the old umbilical site

    and only higher if there is extensive loose skin,

    thereby forming an ellipse when joining the upper

    and lower incisions. The elliptical excision is

    drawn. Bisecting perpendicular lines are marked

    through it (Fig. 3) to line up the skin edges for

    subsequent closure. The incision for umbilical

    circumscription and 4 quadrants on it are marked,

    and the abdomen is infiltrated with approximately

    1 liter of superwet anesthesia (1 L Ringer lactate,

    1 mL 1:1000 epinephrine, 20 mL 1% lidocaine).

    This action is desirable because it allows addi-

    tional local anesthesia to safely be used in adja-

    cent liposuction areas without concerns about

    excess lidocaine or epinephrine; moreover, addi-

    tional superwet fluid only interferes with

    subsequent electrocoagulation. Liposuction is

    then performed in the aesthetic units of the

    abdomen as indicated (Fig. 4) in the suction areas

    and on the enti