Comprehensive Body Contouring: Theory and Practice

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Hurwitz are getting closer and closer to being true sculptors of both the feminine and male form. It is both an instructional manual and surgical atlas. It's a wonderful part of my experience to see people truly change their perspective on life. It's not just about looking good to others; it's the psychology of your well-being. Pre-market AM. Related Images image1. Find News. During their work in Rome, Italy, they managed to develop a blunt hollow cannula, with additional function of suction.

Some of the previous cannula designs contained a cutting blade also. They made their results public in [ 61 ].

Fischers also started the crisscross tunnel formation method, from several incision sites. The new instruments have brought very promising results. The abovementioned complications were avoided using these instruments. Kesselring and Meyer [ 62 ] published their surgery results of sharp curettage aided by a suction device in , but their method did not receive a wide acceptance. Fournier would become a world leader in liposuction and fat transplantation, eventually insisting on the benefits of tumescent anesthesia and making a great contribution in opening new horizons and ideas to surgeons from different parts of the world.

The first US surgeon to visit France to learn the new area of liposuction was Lawrence Field in , a Californian dermatology surgeon [ 64 ]. Other surgeons from the States, coming to conferences and educating themselves about new methods in the literature, also showed an interest in the area. One of them was Norman Martin, an otolaryngologist. He visited to Illouz in and quickly started with liposuction surgeries in Los Angeles in [ 65 ]. It was when a group of physicians from various specialty disciplines received lectures from Illouz and Fournier.

Among them, dermatologists Claude Caver and Arthur Sumrall attended these classes. Rhoda Narins, a dermatologist from New York, also visited France in to learn the techniques. At the same time, a task group formed by the American Society of Plastic and Reconstructive Surgeons visit to Europe to learn and form opinions about this new procedure. Recognizing its potential, the abovementioned attempted to monopolize the whole field by having lllouz sign a contract with them to exclusively teach plastic surgeons worldwide. Fournier in turn refused to sign that kind of contract, and in spite continued to teach physicians from various fields [ 65 ].

Julius Newman, otolaryngologist and cosmetic surgeon, together with his associate Richard Dolsky, who was a plastic surgeon, together taught the first American course on liposuction, held in Philadelphia in There were altogether 10 dermatologists in attendance. Interest in liposuction has been on the upward spiral since and continued to expand in the United States. In and , several interspecialty courses were sponsored by the American Academy of Cosmetic Surgery. Some of the first publications about liposuction were noted in the dermatological literature, back in July [ 66 , 67 ].

Already in , liposuction training was ongoing in some residency programs. For instance, the dermatology section at the Tulane University School of Medicine was one of the first ones to teach residents about liposuction on a regular basis. Dermatologic surgeons also had a greater role in postgraduate education in liposuction, and established special training courses. The dermatological literature of the s is filled with numerous interesting and important articles describing liposuction methods [ 67 — 71 ].

Klein designed the tumescent technique, showcasing almost entirely bloodless session of liposuction with application of just local anesthesia [ 72 ]. This creative innovation was a turning point and dramatically altered the future of liposuction. The first dermatological textbook to contain a chapter on liposuction was Cosmetic Dermatologic Surgery, published by Year Book in , authored by Samuel Stegman and Theodore Tromovitch. Coleman and Fournier were guest editors of a special liposuction issue in Journal of Dermatologic Surgery and Oncology in Lillis and Coleman were guest editors for a special issue of Dermatology Clinics on liposuction in and again in William Coleman and Naomi Lawrence were guest editors for a special issue of Dermatologic Surgery in The first detailed instructions on care [ 73 ] for liposuction procedures have been approved by the American Academy of Dermatology in and published in The Tumescent Liposuction Council has been formed in , with the aim of increasing level of awareness about the advancing tumescent method for liposuction treatment.

Their newsletter was first published in Many postgraduate courses were organized to help teaching dermatologists how to master this method. During the s, dermatologists were major contributors to this field. In the beginning, large cannulas were employed for liposuction, some up to 1 cm in diameter. These large instruments may have caused damage to neurovascular bundles and occasionally may have led to uneven contours and seromas or hematomas in some patients.

Gentle touch was needed for use of local anesthesia, which was favored by dermatological surgeons.

Theory and Practice

The cannulas that are normally used at the present time are extremely small in diameter, some with an inner diameter of less than 0. The use of several side entry points opens the possibility for removal of adipocytes. Many surgeons chose the usage of these quiet, disposable instruments, so they became quite popular as backup items. The aspiration units that manufacturers designed in cooperation with dermatological surgeons gradually became more powerful but more quiet as well, making surgical environment pleasant and positive experience.

In , dermatologist Jeffery Klein, MD, presented his development in the field tumescent anesthesia [ 85 ]. His innovation consisted of infiltration of a dilute solution of lidocaine with epinephrine to allow for more extensive liposuction using only local anesthesia, significantly minimizing bleeding [ 72 ]. This revolutionized the field of liposuction for all specialties [ 86 , 87 ].

Klein [ 88 ] and Lillis [ 89 , 90 ] showed in presentation that the hematocrit of the aspirate fat was minimal. The expected complications of hematoma and seroma formation became rare. Complex calculations of fluid and blood loss or autologous transfusion were no longer needed. Klein showed that diluted combinations of lidocaine together with epinephrine are really not absorbed in the same way as normally used commercial lidocaine.

Klein [ 91 ] proved that when tumescent liposuction is performed in combination with previous application of 0. This pharmacological discovery made possible for large volumes of fat to be removed. This development of tumescent anesthesia eventually encouraged some surgeons to progressively explore the different options and limitation of lidocaine.

Ostad et al. The rate of application of the tumescent anesthesia was found not to be dependent of lidocaine levels in plasma [ 93 ].

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The tumescent procedure has been of utmost importance in the field and experts around the world recognize its importance. There were quite a low number of cases with complications, however with no fatalities, when the tumescent anesthesia method was implemented as a local anesthetic with no excess intravenous fluids or for instance general anesthesia [ 95 , 96 ].

Complications and even fatalities in some cases have been reported when liposuction was performed under total anesthesia and deep intravenous sedation, after implementation of tumescent fluids. The mentioned variations of the tumescent technique have been strongly criticized by most dermatological surgeons all over the world [ 97 ].

Dermatological surgeons have also proven without any doubt that limiting the amount of fat aspirated contributes in general to the safety of the procedure [ 94 ]. Documentation of safety in liposuction procedures that are performed by dermatological surgeons has been impeccable [ 95 , 96 ]. The number of lawsuits has been shown to be significantly decreased when liposuction is performed applying the tumescent technique, in an outpatient setting by a dermatological surgeon.

Liposuction, as a procedure, is practiced by several specialties, and interspecialty rivalries have formed and exist to this day. Competing personal economic interests by different branches have led to attempts to restrict who should be allowed to perform liposuction and in what setting [ 56 , 57 ]. Several states have accomplished introducing negative impact legislation in order to limit the physical location in which liposuction can be carried out. Without a doubt liposuction is safest as an outpatient procedure. Demanding by law the performance of liposuction in a hospital setting may increase the risks and complications and endanger patients.

At first, ultrasonic liposuction has been developed in Europe in the beginning of s by Zocchi [ 98 ]. Ultrasonic techniques may be cannula based internal and by external application. Although the American Society of Plastic and Reconstructive Surgeons promoted ultrasonic liposuction in the past, dermatological surgeons generally gave up on this technique. Use of internal ultrasound increases the risk for cutaneous burns and seroma formation, and has almost no benefits over regular liposuction.

Several studies by dermatologists who were studying external ultrasonic liposuction have found almost no benefit to it, when used before, during, or after a procedure. It has been the case that shaving instrument with suction to remove fat has been used in submental resection [ , ]. The medial third of the flap is advanced directly inferior, thus avoiding a medial fold. Suturing is done in layers; the subcutaneous tissue is approximated with nylon, and the dermis is closed with a subdermal Monocryl continuous suture. For intradermal suturing, the same Monocryl suture is used.

Penrose drains 1 cm are used through the lateral aspect of the incision. Gauze is placed in the incisions, transparent sterile adhesives are attached, and a very low- compression garment is used. These photos show the area of umbilical transposition, marked in the skin in a Y- shape after the abdominal flap excess is removed and attached to the pubic area. The abdominal flap is incised and three flaps are created that will be projected to the inside to reach the umbilicus, thus keeping the scar around the umbilicus in a hidden position. A cone-shaped section of fat is removed so that a slight depression is created around the umbilicus.

Note this slight depression, with the suturing of the umbilicus hidden inside. On the posterior abdomen, regular liposuction is performed whenever necessary. A mons pubis lift is another procedure that can be easily performed in association with abdominoplasty. The correction of umbilical hernias and other defects of the abdominal wall is also done during an abdominoplasty. In some cases of large umbilical hernias, it is advisable to perform a neoumbilicoplasty, so that there is no risk of necrosis of the umbilical pedicle.

The low compressive garment is used for the first postoperative month. Rodrigues et al demonstrated in some recent studies that there is a significant increase in the intraabdominal pressure after the use of compressive garments. Moreover, Berjeaut et al demonstrated that compressive garments may decrease the femoral vein flow significantly.

The use of compressive garments is being reevaluated now and we may change our postoperative routine after this study. When quilting sutures are placed, Penrose drains are used and are removed within 48 hours after the surgery. In the few cases in which this technique is not used, a suction drain is placed and removed when the collected fluid is less than 30 ml in 24 hours. Patients are kept in the Fowler position when they are in bed for the first week postoperatively.

When they are standing, they are instructed to bend their trunk forward and slightly bend their knees for the first week. Over the next 3 days they may gradually stand straight. Patients are allowed to drive 3 weeks after the operation and to exercise after the first postoperative month. Carrying heavy loads or performing sit-ups or any exercise that includes contraction of the abdominal muscles is allowed 45 days after the operation when aponeurotic plications are performed. A day period free of abdominal exercises is required for patients with abdominal muscle advancements.

Sun exposure is allowed 3 months after the operation in the areas where there are no scars. An 8- month to 1-year period should be observed before sun exposure of the scars. Ten sessions of manual lymphatic drainage are indicated, beginning 7 to 10 days after surgery. The direction of the manual drainage should be toward the axillary area and to the flanks.

Although we have demonstrated with lymphangiography that the lymphatic drainage changes its flow mostly to the axillary chain, still some patients present drainage to the deep lymph nodes and even to the inguinal chain one month after the operation. Case 1: Type 0. This year-old nulliparous woman was displeased with the projection of her abdomen.

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Because she had no diastasis and very little excess skin, liposuction was performed, and cc of adipose tissue was removed. She is seen 6 months after the procedure. She refused to undergo liposuction. As she presented a high abdominal fold, a high- positioned incision was made. After the plication of the anterior rectus sheath, there was flaccidity in the lower abdomen and flanks.

An L-plication of the external oblique aponeurosis was performed. She is shown 6 months postoperatively with a natural-looking abdomen with reduced projection. This year-old man had lost 20 kg and complained of excess skin in his abdomen. During surgery, it was noted that he had a very lax myoaponeurotic layer; therefore, in addition to correction of the diastasis, a vertical plication of the external oblique muscle was performed type B vertical.

There was not enough supraumbilical skin to remove all the skin between the umbilicus and the pubic area, so a vertical incision was made, thus preserving some of the infraumbilical skin type II vertical. Liposuction of the flanks and anterior and lateral chest was also performed. He is shown 8 months postoperatively. Note the marked dimples along the semilunaris line, formed by the external oblique vertical plication, and the more masculine aspect of his torso.

An abdominoplasty was indicated, with liposuction on the lateral aspect of the thighs and the lateral aspect of the abdomen. During the abdominoplasty, after approximation of the medial edges of the recti muscles, there was still some laxity of the anterior abdominal wall. In such cases, an L-plication of the external oblique aponeurosis is indicated type B. However, there was not enough skin excess to bring the flap all the way down to the pubic area, therefore the high abdominal incision was indicated type II high. The scar was high, because it was in the proper transition between abdominal anatomic units.

Two years postoperatively, it can be seen that the scar is very discreet and faded. Note the more marked dimples along the semilunaris line, formed by the external oblique plication. This year-old woman had had a projecting abdomen since childhood that had been exacerbated by two pregnancies. On clinical examination it was possible to feel a lateral insertion of the recti muscles type C. There was not enough skin to bring the flap all the way toward the pubic area.

Note the marked improvement of the projection of the abdomen promoted by the advancement of the recti sheaths. This year-old man had no excess skin but did have a projecting upper abdomen. A lateral insertion of the recti muscles could be palpated in the supraumbilical area type C. In this case, only correction of the myoaponeurotic layer was performed by a direct access, advancing the recti sheaths. Note the marked improvement of the supraumbilical area. He is shown 8 months after the procedure.

She is shown 1 year postoperatively demonstrating improvement of the skin redundancy and better tension of the abdominal wall, obtained by the plication of the anterior rectus sheath. Her main complaint was the anterior projection of her abdomen. All the skin between the umbilicus and the pubic area was removed type III. The only myoaponeurotic procedure was plication of the anterior rectus sheath type A. She is shown 2 years postoperatively demonstrating improvement of the anterior projection of her abdomen and enhanced contours where liposuction was performed.

She had a 2 cm diastasis with a good muscular tonus and had a large amount of excess infraumbilical skin. The diastasis was corrected and the excess skin between the pubic area and the umbilicus was removed. Two years postoperatively, the improvement of the muscular tension of the abdominal wall and her abdominal contour is evident. This year-old woman was generally dissatisfied with her body contour, including a lack of waist definition and low projection of the gluteal region.

She underwent an abdominoplasty with correction of the rectus diastasis, plus liposuction of the upper thighs, flanks, lumbar and sacral region, and posterior abdomen. Fat grafting was performed in the gluteal area. Note the smooth dimple created by the plication of the recti muscles and the delicate contour created by liposculpture. Although she had a large amount of intraabdominal fat, the main adipose volume was located in the subcutaneous tissue.

She also had a rectus diastasis and a general laxity of the anterior abdominal wall. Plication of the anterior rectus sheath and of the external oblique aponeurosis were performed. She is shown 6 months postoperatively; note the significant reduction of the subcutaneous fat and the increase in tension of the myoaponeurotic layer.

She also had significant excess skin type III. She is shown 6 months postoperatively. Note her improved waistline and that the scar was positioned in the lower abdominal fold, between the abdominal anatomic units. However, this operation still has a considerable range of associated complications. Scar widening, scars that are hypertrophic and dyschromic, and dog-ears are common.

Specific treatments can be applied to control these conditions, such as the use of chemical peels for hyperchromic scars, intralesional steroid injections for hypertrophic scars, removal of excess skin in dog-ears, and scar excision to correct wide scars. The quality of the scar can be improved with good surgical planning by decreasing the tension on the abdominal flap.

The use of Micropore strips or a silicone sheath over the scar can also improve scar quality. Sitting the patient upright during the operation after skin closure enables the surgeon to identify and treat dog-ears. These are preventive measures that will not avoid all complications but can certainly decrease their incidence.

This patient has a hypertrophic and hyperchromic scar and umbilical stenosis 6 months after abdominoplasty. Loss of Sensitivity Flap undermining and traction after abdominoplasty may lead to decreased sensitivity of the abdominal skin.


The regions most likely to be affected are between the umbilicus and the pubis. The main modalities of sensitivity loss are to pressure and heat. Therefore, these patients are more exposed to contact burn accidents on hot surfaces such as hot ovens and barbecue grills. On the other hand, when lipoabdominoplasty is performed, the innervation of the abdominal flap is kept intact, thus preserving skin sensibility in these areas. This year-old woman sustained a burn as a result of a lack of sensitivity after an abdominoplasty was performed 10 years previously. The burn was caused by the use of a hot towel applied over the supraumbilical area to improve what she thought was an inflammatory lymph node, but it was actually a small epigastric hernia.

The burn was corrected, and then the hernia was corrected 1 year later. Umbilical Constriction Although it is not a common complication, umbilical constriction may be troublesome. When trying to obtain a more youthful and beautiful umbilicus, some plastic surgeons tend to decrease the amount of skin left in the umbilical pedicle.

However, if there is excessive tension at the edges of the skin to be sutured to the umbilicus, dehiscence may occur, and a circular scar will constrict the umbilical area. After the plication of the anterior rectus sheath, there is an expected shortening of the umbilical pedicle. The umbilical pedicle fixation to the anterior rectus fascia permits the surgeon to control the pedicle height and consequently the tension at the skin edges during the suture.

Therefore, in some cases, the skin pedicle should be advanced superficially using the aponeurosis as a step to obtain tension decrease of the skin suture between the umbilical skin and the abdominal flap. The umbilicus should always be designed with broken incisions. The umbilicus should fit in the gap created at the abdominal flap by skin incisions so that a broken line is formed when sutured, to avoid scar constriction.

This year-old woman developed umbilical stenosis 3 months after an abdominoplasty. She is shown after correction with transposition flaps. Seroma Seroma is the most frequent complication of abdominoplasty. It has been considered as an inevitable complication until Baroudi and Ferreira in described the use of quilting sutures to prevent a seroma. In , Nahas et al demonstrated that this technique was efficient in patients with risk factors to develop a seroma, such as those individuals who are overweight, those who have presented with massive weight loss, and those with supraumbilical scars.

Fibrin glue was also used to prevent a seroma, but it was not successful, because it does not promote a strong adhesion between the abdominal flap and the aponeurosis. Therefore a seroma can be prevented in most cases. However, when a seroma occurs, aspiration of the fluid should be done every 3 to 4 days until there is a decrease in volume to less than 20 to 40 ml.

If a seroma is not recognized or if it is not aspirated, its absorption can be delayed, and a capsule will form around it. A deformity of the abdomen will occur from the contraction of this capsule around the fluid collection, in the same way that it occurs around a breast prosthesis.

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To treat the so-called pseudobursa, it is necessary to remove the capsule and to use quilting sutures to reattach the subcutaneous to the aponeurosis. Extensive undermining is usually necessary to correct this secondary complication. This patient had undergone an abdominoplasty 1 year before and developed a deformity in the lower abdomen from fibrosis that occurred in the first 3 months after the primary surgery.

Note the pseudobursa, which is very similar to a capsule formed around an implant. The capsule was removed and the tissue was closed with quilting sutures to avoid recurrence. Flap Necrosis Although flap necrosis is a multifactorial complication, excessive tension and undermining are two common technical causes of necrosis after abdominoplasty. Abdominal flap necrosis can be a dramatic complication, depending on its extension. Making a good preoperative plan based on the type of skin and subcutaneous deformity can prevent excessive tension of the abdominal flap.

A conservative undermining should also be done at the upper abdomen to decrease the number of vessels severed. A narrow tunnel above the umbilicus can preserve some of the rectus perforator arteries, thus increasing the arterial flow of the flap. Mayr et al demonstrated that in extensive undermining, there is a decrease in blood flow in the inferior area of the abdominal flap to For this reason, surgeons should be careful when performing liposuction of the undermined flap.

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Lipectomy of the flap under direct vision can be a better choice when it is necessary to decrease flap thickness. Quilting sutures can also decrease flap tension. These sutures are progressively placed attaching the abdominal flap to the aponeurosis, advancing the flap, thus decreasing tension on the skin edge. The healing was achieved by secondary intention A. She is shown 15 days B and 45 days C after surgery. Hematoma Many factors can increase the incidence of hematoma after abdominoplasty. The surgeon must be aware that the space between the abdominal skin flap and the aponeurosis can expand when a hematoma occurs.

Therefore, to avoid this immense dead space, quilting sutures can be used when this complication occurs to limit a potentially large hematoma, and a small hematoma may be formed. A small hematoma is treated conservatively, whereas a large hematoma should be surgically removed to avoid secondary fibrosis. In such cases, a seroma may occur secondarily, which can be evaluated by ultrasonography. Seroma usually occurs 12 to 15 days after surgery. The secondary seroma should be sequentially aspirated.

This patient developed a hematoma on the third postoperative day. It was evacuated to prevent infection and the formation of a capsule. This patient had a chronic hematoma from an abdominoplasty performed 3 years before. After removal of the remains of the bloody content, it was possible to identify a thick capsule that was incised and removed. Quilting sutures were used, similar to the correction of a pseudobursa resulting from a seroma. Infection Infection is not a frequent complication of abdominoplasty.

The incidence ranges from 0. A white blood cell count can help to identify the presence of infection. A local swab can also help in the identification of the microorganism responsible for this condition; however, an isolated positive culture may indicate colonization only. A quantitative culture is a more reliable method for diagnosing infection. An effective way to monitor a cutaneous infection is to mark the boundaries of skin redness with a pen and follow its extension after the use of antibiotics.

This will give the plastic surgeon an idea of the efficacy of the antibiotics. The skin infection above is shown in the distal part of the flap on the sixth postoperative day, with the area of redness marked to serve as a parameter for evaluating the evolution of the infection.

Recurrence of Myoaponeurotic Deformity To correct the recurrence of a myoaponeurotic deformity requires an operation almost as extensive as the primary surgery; therefore the deformity should be prevented. It may occur for several reasons; the most common cause of recurrence of rectus diastasis is the use of plication of the anterior rectus sheath in patients with a lateral insertion of the recti muscles in the costal margins type C patients. Patients with a weak aponeurosis may also have a recurrence of the deformity, depending on the aponeurotic composition and predominant types of collagen.

This year-old type C patient had a recurrence of rectus diastasis. She was treated with plication of the anterior rectus sheath. The patient is seen 1 year after advancement of the recti sheaths. Atelectasis may occur as a result of limited postoperative ventilation and should be treated with respiratory pulmonary therapy. The most feared complication after abdominoplasty is deep venous thrombosis DVT ; the second most serious is pulmonary embolism.

Of cosmetic surgery procedures, abdominoplasty has the highest incidence of DVT, particularly when an intraabdominal procedure is performed. However, the incidence has decreased in recent decades since the initiation of administering low-molecular-weight heparin and the routine placement of mechanical calf compression devices.

Recently we published a paper on the high increase of intraabdominal pressure after the use of compressive garments, and another paper on the increase of common femoral vein stasis after the use of these garments. This may be a cause of DVT, and we are currently studying the effects of not using these external compression devices. Because DVT is a multifactorial condition, mechanical and pharmacologic prevention should be implemented in these patients, and early ambulation should be ordered. We have also evaluated the use of low-molecular- weight heparin 12 hours after the operation, comparing these patients with a group that had only mechanical preventive measures after abdominoplasty.

Apparently, there is no increase of bleeding when low-molecular-weight heparin is used for 7 days after surgery. Accurate diagnosis of the abdominal deformity will help to prevent complications. If plication is performed in these cases, there may be a recurrence, and a surgery as extensive as the original one must be performed to correct it. The only exception is when there is an indication that the operative time must be decreased. Quilting sutures should be used.

We are currently evaluating their indications. In such cases, a 2 cm incision in the posterior rectus sheath as well as in the peritoneum will prevent bowel injury during the plication of the posterior rectus sheath. This may decrease the aponeurotic resistance in the groin region, leading to a hernia. Benchmarking outcomes in plastic surgery: national complication rates for abdominoplasty and breast augmentation. Avelar J. Abdominoplasty—systematization of a technique without external umbilical scar. Aesthetic Plast Surg , Collagen fibers in linea alba and rectus sheaths.

General scheme and morphological aspects. J Surg Res , Improving tension decrease in components separation technique. A practical dressing to the umbilical stalk.

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J Plast Reconstr Aesthet Surg , Use of the anterior rectus sheath for abdominal wall reconstruction: a study in cadavers. A variation in the component separation technique that preserves linea semilunaris: a study in cadavers and a clinical case. Strategies in umbilical reconstruction. J Plast Reconstr Aesthet Surg e, Baroudi R, Ferreira C.

Seroma: how to avoid it and how to treat it. Aesthetic Surg , Does the use of compression garments increase venous stasis in the common femoral vein? Plast Reconstr Surg e, Biomechanical properties of skin in massive weight loss patients. Obes Surg , Scarpa fascia preservation during abdominoplasty: a prospective study. The increasing growth of plastic surgery lawsuits in Brazil. Body dysmorphic disorder should not be considered an exclusion criterion for cosmetic surgery.

Abdominoplasty and its effect on body image, self-esteem, and mental health. Effects of abdominoplasty on female sexuality: a pilot study. J Sex Med , Body dysmorphic disorder in patients seeking abdominoplasty, rhinoplasty, and rhytidectomy. Should plastic surgeons operate on patients diagnosed with body dysmorphic disorder? Reply: Should plastic surgeons operate on patients diagnosed with body dysmorphic disorders? Seroma in lipoabdominoplasty and abdominoplasty: a comparative study using ultrasound.

Planned ventral hernia. Staged management for acute abdominal wall defects. Ann Surg ; discussion , Skin sensibility of the abdomen after abdominoplasty. Patients with mild to moderate body dysmorphic disorder may benefit from rhinoplasty. Triangular mattress suture in abdominal diastasis to prevent epigastric bulging. Plast Reconstr Surg 4 Suppl :1, Hafezi F, Nouhi A. Safe abdominoplasty with extensive liposuctioning. Connective tissue alteration in abdominal wall hernia. Br J Surg , Abdominal-wall reconstruction with expanded musculofascial tissue in a posttraumatic defect.

Johnson D, Harrison DH. A technique for repairing massive ventral incisional hernias without the use of a mesh. Br J Plast Surg , Matarasso A. Abdominolipoplasty: a system of classification and treatment for combined abdominoplasty and suction-assisted lipectomy. Liposuction as an adjunct to a full abdominoplasty. Liposuction as an adjunct to a full abdominoplasty revisited. Effects of aesthetic abdominoplasty on abdominal wall perfusion: a quantitative evaluation.

Ultrasonography for measuring rectus abdominis muscles diastasis. Acta Cir Bras , Advancement of the external oblique muscle flap to improve waistline: a study in cadavers. An aesthetic classification for abdominoplasty based on the myoaponeurotic layer. Commentary on: Improvements in vertebral-column angles and psychological metrics after abdominoplasty with rectus plication.

Discussion: Evaluation of the long-term stability of sheath plication using absorbable sutures in 51 patients with diastasis of the recti muscles: an ultrasonographic study. How to deal with the umbilical stalk during abdominoplasty. A pragmatic way to treat abdominal deformities based on skin and subcutaneous excess. Pregnancy after abdominoplasty. Studies on the endoscopic correction of rectus diastasis. Wide abdominal rectus plication abdominoplasty for the treatment of chronic intractable low back pain. Nylon versus polydioxanone in the correction of rectus diastasis.

Should diastasis recti be corrected? Factors that may influence failure of the correction of the musculoaponeurotic deformities of the abdomen. Fibrin glue as a substitute for quilting suture in abdominoplasty. Skin sensibility to pressure measured with a system of loads. Concepts on correction of the musculoaponeurotic layer in abdominoplasty.

Rectus diastasis corrected with absorbable suture: a long-term evaluation. Aesthet Plastic Surg , Does quilting suture prevent seroma in abdominoplasty? Long-term follow-up of correction of rectus diastasis. An efficient way to correct recurrent rectus diastasis. Abdominal wall closure after selective aponeurotic incision and undermining.

Seroma after lipoabdominoplasty: fat thickness of the abdominal wall is probably a contributory factor. The use of tissue adhesive for skin closure on body contouring surgery.

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Collagen and elastic content of abdominal skin. Ventilatory function and intra-abdominal pressure in patients who underwent abdominoplasty with plication of the external oblique aponeurosis. Guidelines for pubic hair restoration. Is it possible to repair diastasis recti and shorten the aponeurosis at the same time? Factors influencing judicial decisions on medical disputes in plastic surgery. Tensioned Reverse Abdominoplasty Mauro F.

Deos Ricardo Arnt Eduardo Gus. Traditional abdominoplasty and mini-abdominoplasty procedures, with or without liposuction, usually address most of these problems. However, abdominal skin with or without fat excess—especially in the supraumbilical abdominal region—still remains a challenge for most plastic surgeons. Mini- abdominoplasties produce insufficient results, and conventional abdominoplasties result in a cephalad-positioned scar or in an additional infraumbilical vertical scar.

Resection of skin and adipose tissue in the upper abdomen was first described by Thorek in In Rebello and Franco described and systematized the approach to abdominal plastic surgery through the inframammary sulcus. Originally the technique involved fixation of the flap exclusively to the mammary sulcus, which resulted in its inferior dislocation or even in hypertrophic scarring, because the weight of the flap constantly exerted tension on the sutures. The technique presented in this chapter, called tensioned reverse abdominoplasty TRA , differs from the previous procedures in two significant ways: 1.

Traction and fixation of the flap: The flap is put under extensive traction toward the mammary sulcus and is strongly fixated to the muscular abdominal aponeurosis, thereby minimizing or even eliminating the tension on the scar and preventing the previously mentioned complications. Extension of the inframammary incision and the amplitude of the undermining area: Patients with larger amounts of skin to be resected require incision unification at the midline, which results in a single U- shaped flap.

Alternatively, patients who have little or moderate supraumbilical skin laxity and no diastasis of the abdominal wall may be treated with limited incisions in the inframammary regions, thereby resulting in two undermining tunnels without unification at or crossing of the midline.

This is a result of the rich anastomotic vascular supply of the abdominal wall. The anterolateral abdominal wall consists of skin, subcutaneous tissue, and a muscle layer. It is bounded superiorly by the xiphoid process and the costal margin, laterally by the iliac crest and the oblique muscles, and inferiorly by the pubis and the inguinal ligament.

It is of utmost important that surgeons understand the vascularization pattern of the abdominal wall. The anastomoses between the superior and inferior systems occur mainly in the midline between the costal margin and the umbilicus. There is a clear dominance of the inferior epigastric artery system. The anterolateral abdominal wall is also irrigated by segmental perforating branches of the intercostal and lumbar arteries Huger zone III.

There is a smaller contribution of the retrograde flow of perforating vessels from the deep circumflex iliac artery to the superficial system Huger zone II. Indications and Contraindications As for all other surgical procedures, the correct indications for the technique and appropriate patient selection are the cornerstones of successful results. The greatest benefit of the TRA technique is the ability to treat deformities of the supraumbilical abdomen through a direct approach. This results in a much smaller area of undermining compared with that associated with conventional abdominoplasty.

Conventional abdominoplasty and mini-abdominoplasty should always be considered first, because the scars tend to be covered by clothes and favor gravitational forces. The only contraindication to this technique is a history of hypertrophic and keloid scarring. Physical examination is initially done with the patient in the supine position.

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The patient is then asked to perform a Valsalva maneuver so that the surgeon may determine the presence of any muscle diastasis or hernias. Imaging studies may be necessary if a hernia is suspected. The degree of lipodystrophy and the need for additional liposuction should also be assessed at this time. In these positions, the patient should bend forward so the surgeon can better evaluate the amount of skin excess and the location in the abdomen where this excess predominates. Preoperative Planning and Preparation The inframammary scar extension and the dissection amplitude are determined by the intensity of the supraumbilical skin excess.

This should be evaluated with the patient in the orthostatic position by exerting upper traction on the flap toward the breasts and determining the amount of skin to be resected. This will result in patients being placed into one of two groups. Group 1 Group 1 patients have larger amounts of skin to be resected and require incision unification at the midline. For patients in this group, the flap is dissected toward the umbilical scar to form a single U-shaped tunnel. Most frequently, the inferior limit of the undermining area is the umbilical scar, which solves most cases of skin laxity in the supraumbilical abdomen and sometimes even in the infraumbilical portion.

In patients who require complete abdominal midline plication, the undermining area should be extended caudally toward the pubis. In such cases the navel can be transposed superiorly or treated as it is during a conventional abdominoplasty. Group 2 Group 2 patients have little or moderate supraumbilical skin laxity and no diastasis of the abdominal wall. The incisions will be limited to the inframammary regions without unification at or crossing of the midline. The flap dissection will produce two oblique tunnels toward the umbilical scar; the width of each tunnel will be determined by the breast width.

These cases frequently require associated mini-abdominoplasties to treat infraumbilical skin excesses. The caudal traction of the inferior abdominal flap compensates for the less intense cranial traction of the supraumbilical portion, which is adequate for the treatment of most patients. The preoperative markings used for groups 1 and 2 are shown.

Red is used to mark the undermining areas, black indicates the incisions to be made, and areas in which liposuction is to be performed are shown in green and blue. In most cases, 1 L of solution is needed for the entire abdominal surface, whereas about ml are used for just the superior half. When excessive fat is present, the procedure begins with liposuction; this can be limited to the flap region, or it may include the entire abdominal wall.