ABDOMINOPLASTY & THIGH LIFT
Liposuction for localised fat deposits and thick subcutaneous fat layers
Excisional lifting for significant laxity of skin and soft tissues
Occasionally, combination of both techniques needed
Don’t forget body contouring is three-dimensional
Consider effect of altering one aesthetic unit on others
Indications for trunk and thigh lifts:
1) Skin laxity without significant fat deposits
2) Excessive skin laxity and cellulite
3) Patients where skin tightening is primary goal
4) Medial thigh deformities in over 35s
5) Buttock ptosis
Lifts can be used either at time of initial liposuction or deformities that appear after
SURGICAL OPTIONS FOR ABDOMINOPLASTY
1) LIPOSUCTION ONLY
Localised deformity
Satisfactory skin turgor – primary determinant of success
Potential for skin to contract after suctioning
2) TRADITIONAL ABDOMINOPLASTY
Deformity above and below umbilicus
3) MINI-ABDOMINOPLASTY
Deformity below umbilicus
4) FLANKPLASTY
5) ENDOSCOPIC ABDOMINOPLASTY
PATIENT SELECTION
Age no barrier – liposuction into 80s
Aspirin and anti-inflammatory agents- discontinue 2 weeks before surgery
Smoking – stop 2 weeks before surgery
Classfication (sugested by Glazer)
Group 1
Good skin turgor
Small amount fat deposit
Usually liposuction in one stage good result
Usually under 30 years
Group 2
Skin good to mild turgor
No eveidence flaccidity
Moderate to localised fat deposits
Liposuction in one or two stages
Usually 40s or under if weight loss
Group 3
Skin faccidity
Fat deposits in increased volumes
Usually surgery followed by liposuction
Group 4
Patients with skin laxity
No fat deposits
50 – 65 years or younger if massive weight loss
Surgery only solution
COMPLICATIONS
Grazer & Goldwyn 1977
1)Seroma
2)Wound infection
3)Wound separation
4)Haematoma
5)Nerve damage
Some is inevitable
Mostly transitory and sensory
Small areas of permanent anaesthesia around and below umbilicus
6)Pulmonary fat embolism
7)Thromboembolism – one in 100 patients develop serious thromboembolic problem
Approx 1 in1000 die
Grazer uses standard 5% dextrose & 5% alcohol IV solution
Contains 50g alcohol administered 30 mins – 3 hours
Prevents breakdown of free fat to fatty acids (which lodge in
lungs and produce fat embolism)
Stimulates formation of tPA prostacyclin (anti-platelet, antithrombolic)
8)Skin and subcutaneous tissue necrosis – keep patient well hydrated
9)Hypovolaemic shock
Floros & Davis 1991 (BJPS)
– 6 year retrospective 133 abdominoplasties; 34 followed up long term
2 groups :
Group A 34 patients who atended review
Group B – remaining patients surveyed through records only
Results
Type of Complication
Group A(%)
Group B(%)
Infection
Stitch abscess
Skin necrosis
Oedema
Wound dehiscence
Haematoma
Seroma
Nerve injury
Pulmonary emboli
Bronchopneumonia
DVT
Ileus
14.7
6
2.9
8.8
2.9
0
5.8
32
0
2.9
0
0
5
5
4
2
2
2
1
1
1
1
Long-standing post op pain
2.9
1
Commones in A is lateral cutaneous nerve of thigh damage (one third cases)
No evidence that specific surgical technique is to blame
In both groups, SMOKERS haad twice as many complications with skin necrosis,
wound dehiscence or infection
Two diabetics had infection and seromas
Overall complication rate 34.6%
Difference between groups really nerve injury and it may be that this is not detected
early in follow up
SURGICAL TECHNIQUES
ISOLATED FLANKPLASTY
Specific procedure to reduce flank volume, to lift or reduce buttock and to leave skin
in tightened or firm condition
Extended fusiform skin and subcutaneous fat resection along the flank long axis
Uses ant and post iliac spine as reference
Resection takes all skin and sc tissue down to muscular fascia
Pinch test with patient standing best way to estimate amount of resection
Skin and fat dissection limited to what should be resected – no undermining done
If limited resection, post suture may stop at different distances from post mid-line
If buttocks and thighs involved, include extensive undermining in affected regions
Buttocks and lateral femoral skin undermined at fascial layer to allow all of skin flaps
to lift
SUCTIONING ABDOMEN ONLY
Less than 750 mls can be done under local
Grazer uses “lipocrit” to determine blood loss and need for replacement
Stab incisions in groin, inguinal crease or periumbilical area
FULL ABDOMINOPLASTY
Basic principles:
1) Incision – standard transverse lower abdominal incision
2) Elevation of panniculus & decision whether to use liposuction
Wide undermining of abdominal flap to costal margins
3) Plication of diastasis recti
4) Closure
Resection of redundant abdominal flap
Skin closure with hips flexed
5) Tailoring of umbilicus
6) Suctioning of upper abdomen if indicated
7) Suctioning of adjacent deformities
8) Trimming of flaps and dog-ears
9) Drains and dressings
1) Incision selection
Patient body type
Bathing suits
If long waisted, may not be possible to obliterate umbilicus & inverted T is used
Historically, several different incisions used
Baroudi (1987) bicycle handlebar incision
Recent inverted W
2) Elevation of panniculus
Can suction either before or after panniculus is elevated
Elevate with electrodissection
Circumscript umbilicus
Elevate or xiphoid and costal margins
3) Plication of recti
Non-absorbable suture for first layer of closure
Then running layer of absorbable – avoids palpable knots
4) Closure
Patient in flexed position
Vertical cuts made to fit panniculus
Excess tissue resected
Panniculus pulled down and tacked into position
5) Tailoring umbilicus
Position about 15 to 17 cm from vulvular ant commissure
Beforehand, suction median raphe to give more youthful appearance
Vertical incision through skin to make opening for umbilicus
Can use this opening to suction through
Suture abdominal skin to rectus fascia at 3, 6 and 9 o’clock positions
(prevents umbilicus being pulled back into wound)
No 12 o’clock suture means no hooding – as a youthful umbilicus
Suture remainder
6) Suctioning of upper abdomen
Controversial issue, since possible compromise of upper skin flap
Smaller cannulas reduce risk
7) Suctioning of adjacent deformities
Esp hips and flanks
Can also suction medial thigh
6) Trimming of flaps and dog ears
If high umbilicus, which doesn’t extend beyond transverse pubic scar when flap
pulled down, then can compensate with small vertical scar
?use of quilting sutures for undermined regions
Makes a smoother more refined incision line
8) Drains and dressings
Two drains stab incision in mons pubis or through incision itself
Supportive garment – Velcro abdominal binder
MINI-ABDOMINOPLASTY
Less extensive operation
Indicated if deformity primarily below umbilicus
Choice of incision essentially same as for full abdominoplasty – lateral extent of
incision is not as long
Suction entire abdominal wall before elevation
After elevation to umbilicus, can determine if plication is necessary
Same suturing technique as for full abdominoplasty
Can extend dissection 3-4cm above umbilicus for putting plication sutures above
umbilicus
Final closure as before
Same aftercare
ENDOSCOPIC ABDOMINOPLASTY
Potential Benefits:
1) Decreased scarring
2) Extended reach
Allows entire abdo fascial surface to be exposed through single incision
3) Excellent visualisation
4) Surgeon positioning
5) Preservation of anatomical structures
Skin incisions and dissection limited eg. superficial inferior epigastric vessels
6) Augmented flap vascularity
Vessels preserved
No skin excision so no tension on wound
7) Decreased morbidity
Shown with other endoscopic abdo procedures
Patient Selection:
Little or no excess skin
Mild or moderate amounts of fat can be liposuctioned
Supraumbilical laxity can be corrected also by this technique
REVERSE ABDOMINOPLASTY
Deformity (including surgical scars) confined to upper abdomen
Incision in upper abdominal region under infra-mammary fold
Can be done with breast reduction as a combined procedure
COMBINED PROCEDURES
Combined procedures with abdominoplasty not resulted in increased morbidity if
patient selection appropriate and autologous blood available
MEN
Body deformities differ in men
Localised fat deposits commonly chest, abdomen, flanks, back, medial thighs
Skin and soft tissue laxity occur in lower abdomen, medial thighs, chest
Rarely have laxity problems in anterior or lateral thighs
POST-OPERATIVE MANAGEMENT
Flexed position on day of surgery
Mobile 24 hours following surgery
Semi-flexed position for 24 hours
Suctioned patients don’t have to be flexed
Removal of drain 24 – 48 hours
Velcro binder for 2 – 3 weeks after surgery
Prophylactic antibiotics
Ultrasound may help resolve lumps and eccymoses
Given a few days post surgery depending on patient’s level of comfort
Twice a week for 2 – 3 weeks
Resume normal activity in 3 – 4 weeks
For suction alone this is when eccymosis and oedema subsides
4-6 weeks before aerobics
REVISION PROCEDURES
Suction techniques not recommended earlier than 4 months post operatively
Following abdominoplasty, preferable to wait 6 months to a year
Steroid injections for hypertrophic scars
EXCIONAL LIFTING (LOCKWOOD)
Aesthetic Abdominal Features (Lockwood)
1) Tight lateral trunk and inguinal tissues with deep waist concavity
2) Central tissues not tight with mild convexity of hypogastrium and mild concavity
of epigastrium
3) Midline epigastrium valley between rectus muscle bulges
4) Vertically orientated umbilicus
5) Vertical valley lateral to rectus muscle bulges below costal margins
6) Smooth, gentle, S-shaped outlines of anterior and lateral silhouette
Consider aesthetic relationship of hypogastrium and pubis
In women, vertical distance between umbilicus and exc vulvular commissure should
be 60% non-hair bearing (hypogastrium) and 40% hair bearing (mons pubis)
In addition to resection of lower abdominal tissue, the stretched vertical height of the
mons pubis may have to be shortened to meet these aesthetic goals.
In men, the vertical distance between umbilicus and base of penis should be 70%
hypogastric and 30% pubic tissue.
Classic abdominoplasty based on two theoretical principles which may be proved
inaccurate
1) wide direct undermining to costal cartilages is essential for abdominal flap
advancement
In fact, discontinuous undermining allows effective loosening of abdominal flap while
preserving vascular perforators/
2)assumed that with ageing and weight fluctuations (incl pregnancy
abdominal skin relaxation occurs primarily in the vertical direction from the
xiphoid to the pubis
This is true in lower abdomen, but in most people a strong superficial fascial system
(SFS) adherence to linea alba in epigastrium limits vertical descent
Epigastric laxity frequently results from a progressive horizontal loosening due to
relaxation of the tissues along the lateral trunk.
Standard abdominoplasty tightens centrally, thus increasing laxity laterally
Wide undermining prevents circumferential liposuction
High lateral tension abdominoplasty designed to produce more aesthetic body
contours
KEY TECHNICAL POINTS
(Plast Reconstr Surg 96: 603, 1995)
1) Direct undermining limited to the paramedian area
2) Discontinuous undermining to costal margins and flanks as needed
3) Skin resection pattern with significant lateral resection
4) Highest-tension wound closure placed laterally
5) Superficial fascial system repair with permanent sutures along the entire incision
2) Liberal use of adjunctive liposuction in upper abdomen and lateral and
posterior trunk
Thus only perforators cut when plicating rectus
Other perforators preserved thus allowing more liposuction
Advantages:
High tension laterally:
More natural abdominal contours
Strong lift of lax inguinal tissues
Mild lift of ant medial thigh tissues
Decreases tension on suprapubic wound closure
(reducing risk of skin necrosis and superior migration of pubic hair)
SFS suspension with permanent sutures:
More natural contour lines
Late suprapubic depression eliminated
Disadvantages of high tension laterally:
Tendency for dog-ear formation due to quick transition from high tension in
inguinal area to usual laxity of lateral trunk
May require minimal lengthening of abdominoplasty incision
Patient Selection:
Designed as alternative to standard abdominoplasty so same patient selection
Ie. where soft tissue laxity is a major component
Pre-op markings with patient standing
Short horizontal suprapubic line that angles towards ASIS then curves horizontally,
but maintained in bikini outline
Amount of inguinal laxity inferior to this is then marked (initial incision line)
When sutured, inguinal flap elevates only to proposed line of closure due to tethering
effect of SFS zone
Exact amount of resection determined at end of procedure, although can be estimated
Localised fat deposits marked for liposuction
Operative Technique
Inferior anchor resection line incised
Inferior abdomen undermined to umbilicus
If umbilicus not to be transposed, stalk is resected for better exposure and later
resutured to muscle fascia 1-2cm below original position
Direct undermining superior to umbilicus limited to medial rectus border to allow
muscle plication
Discontinuous undermining of remaining abdomen performed with vertical-spreading
scissor dissection
Table flexed to 30 degrees and redundant abdominal flap resected
Max tension placed along lateral incision limbs
Haemostasis
Any restricting fibrous septae dimpling skin released deeply
Drains brought out through mons pubis
3-layer wound closure
Umbilicoplasty
MEDIAL THIGH LIFT (Lockwood)
Skin laxity in medial thigh is often earliest sign of ageing in thighs
Skin of medial thigh is thin and inelastic
By 35 years, skin laxity usually means disappointing results by liposuction alone
Classical medial thigh lift problems:
Inferior migration and widening of scars
Lateral traction deformity of vulva
Early recurrence of ptosis
Modifications:
Modified to allow anchoring of inferior skin flap to the tough, inelastic deep
layer of the superficial fascia of perineum
Using Colles fascia as central anchor for medial thigh lift has produced more
consistent, longer lasting results
Indication: significant actual or potential laxity of medial thigh tissues
Liposuction often leads to skin relaxation, esp after age 30 years
Majority of skin laxity occurs at junction of anterior and medial thighs
Modification has rotated the standard surgical resection pattern anteriorly, allowing
entire procedure to be performed in supine position
Incision should not extend to buttock fold posteriorly
Markings:
In standing position with knees apart
Extent of medial fat thigh deposits marked
Estimate amount of skin redundancy
Actual resection averages 5 – 7cm stretched skin at anteromedial corner of thigh
Anchoring of perineal-thigh crease into Colles fascia provides additional 3-5cm of lift
Operative Technique:
Patients supine with hips flexed to 20 – 30 degrees
Stockinettes placed to knees
Excision of redundant tissue and subsequent repair performed with knees shoulderwidth apart
Initial deep liposuction followed by skin-only incision along superior resection line
After skin incision, undermine inferior flap posterior to pubic tubercle
Undermining extends 3-4 cm beyond planned line of resection
Undermining is post to pubic tubercle and superficial to adductor muscle fascia
Cannulae undermining more distal may be helpful for laxity problems extending to
knee
Take care of soft tissue between mons pubis and femoral triangle
Superficial undermining here preserves ext. pudendal blood and lymphatic vessels
Blunt dissection through this bundle at mons exposes Scarpa’s fascia or muscular
fascia which can be used to anchor thigh flap in pubic region
Once flap undermining complete, identify Colles’ fascial roll
Permanent anchoring sutures used
Scarpa’s fascia is used as anchor anteriorly and buttock-fold SF post
Drains generally not used
Complications
Delayed wound healing (30%)
Scar widening and migration (due primarily to over-resection)
Wound infection
Transient perineal lymphoedema
Persistent deformity due to inadequate resection
Thigh paraesthesia/anaesthesia , which improves over 1 year
TRANSVERSE THIGH/BUTTOCK LIFT
Classic is Pitanguy lift (1964)
Allows direct excision of trochanteric fat deposits
Also used for laxity of lateral thigh and buttock
However problems of noticeable scars and early recurrence of deformities
Lockwood:
Transverse resection of redundant skin and fat of trunk with incisional scar within
high-cut bikini lines
Can be used alone or in combination
Operative Technique:
Markings made standing in high cut bikini line
Amount of soft tissue redundancy superior to planned line is iestimated (knees 6 in
apart)
Usually 4-5cm – about ¼ of vertical excess along lat body
Redundant tissue inferior to planned line is estimated
Usually 10-15cm vertically along lateral contour
Patient in lateral decubitus position
Hip flexed anteriorly to 30-45 degrees (overcorrection)
Thighs abducted with foam blocks to keep knees 15 in apart
Liposuction of trochanteric and post thigh deposits if needed
Incision through superior resection line
Undermining along lateral countour just superficial to muscle fascia, staying lateral to
femoral triangle lymphatics
Undermining then sweeps posteriorly over deep fat of buttocks
Direct undermining should extend beneath flap to be resected and into trochanteric
region, releasing SFS zone of adherence that extends from lateral gluteal recess
around to femoral triangle lymphatics
No direct or discontinous undermining performed over buttocks
Discontinous cannulae undermining is performed more distally if aesthetic deformit
extends into lower half of thigh
Redundant soft tissue now resected
Drains
Post op compression garment
Hips flexed post op 20-30 degrees and thighs abducted 1-2 weeks to reduce wound
tneison