Preoperatively, patients should be evaluated for the presence of visceral fat, which cannot be lipoaspirated. If present, patients should be forewarned that the final postoperative contour may not be flat unless the visceral fat is addressed through diet and exercise. Additionally, skin tone and anticipated retraction must be assessed. Often, a significant amount of retraction is obtained through liposuction alone such that excision of redundant skin is not required. The presence of deeper fascia, such as Scarpa’s fascia in the abdominal region, promotes tissue retraction. Once healed, if excess skin is noted, abdominoplasty can be considered at that time. The abdomen should also be evaluated for the presence of hernias, which pose a risk for bowel perforation if present. The upper and lower abdomen are considered distinct areas but are often treated together. It is essential that the upper abdomen be evaluated in conjunction with the lower abdomen in the preoperative evaluation. If excess adiposity is noted, especially in the area of the epigastric and supracostal fat pads, the upper abdomen must also be treated or it may persist as overhanging fat which is aesthetically undesirable. The supracostal fat pads must be flattened. Extra attention should also be paid to the periumbilical region.
Thorough aspiration of the fat in the periumbilical region is essential to produce a flat abdomen. As this area may be more fibrous and tends to be more sensitive, thorough tumescent infiltration is essential. Incision sites are generally placed in the suprapubic region and the upper lateral abdomen. These sites should be placed with some degree of asymmetry to produce the most inconspicuous postoperative result. An additional entry site in the umbilicus is often helpful and is well hidden once completely healed. In patients with a pannus, the incision sites should be placed below the pannus so proper drainage during the postoperative period can occur. If the entire pannus is not flattened completely and the incisions are placed too high, fluid may collect in the pannus and develop into seromas. The abdominal area may be more fibrous especially in those individuals who exercise this area frequently. It is often advantageous to initiate lipoaspiration with a 14-gauge cannula, which passes more easily through fibrous bands and septa. Once tunnels are created, a 12- or 10-gauge cannula can be easily used. A gentle stroke must be used and the tip of the cannula should always be monitored to prevent passage of the cannula under the subcostal structures into the thoracic cavity. In male patients, the flanks or “love handles” can be treated in the same session as the abdomen.
To access this area, the patient is placed on his side and the fat pockets can be accessed by incisions placed at the posterior aspect. The incision in the suprapubic area utilized for abdominal liposuction can be utilized to approach the flank region from the anterior perspective in addition to any entrance point more posteriorly. Aggressive liposuction can be performed in this area to thoroughly remove the excess fat pockets utilizing larger cannulas such as the 12-gauge Capistrano or the 10-gauge Finesse cannula.
The suprapubic area is a site about which patients infrequently complain but is satisfying to patients once addressed. A suprapubic mound may make the penis appear less defined and suprapubic fat extending onto the labia majora may be problematic for women, causing disfiguration. Furthermore, this area may appear more pronounced after abdominal liposuction. The site is effective for microcannula liposuction because this area requires sculpting around the base of the genitals and extension frequently into the labia majora on women. Further, women prefer a “mound of Venus” and thus, careful sculpting of the suprapubic area is required. The procedure is carried out in the fashion as described earlier in this article with overlapping interdigitating lipoaspiration from multiple aspiration ports. Microcannulas are utilized to creatively sculpt the tissue to the desired end point rather than to achieve a simple debulking. Fourteengauge Finesse cannulas are recommended. Excessive liposuction should be avoided and a layer of fat should remain in place to avoid palpable pubic bones. Significant ecchymoses and edema are common postoperatively in this area after both suprapubic and abdominal liposuction.
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