The three key elements to consider when evaluating abdominal contour patients are skin quality, musculoaponeutic laxity and degree of lipodystrophy. With rapid weight gain or pregnancy, significant abdominal wall stretching can occur, leaving persistent skin excess and loss of elasticity. In addition, striae or stretch marks are visible where the dermis has been disrupted. Diastasis recti are often present: a weakness of the fascia is almost always identifiable in multiparous females. Moderate lipodystrophy typically results from hypertrophy of the existing adipocytes; however, with weight gain, adipocyte hyperplasia will occur. This results not only in undesirable adiposity, but also in the formation of cellulite as the fibrous septae within the subcutaneous adipose cause changes in the reticular dermis indentations on the skin surface. Patients seeking abdominoplasty can be classified on the basis of the physical examination and the plan for operative management. Type 1 patients are usually younger, with good skin elasticity and minimal lipodystrophy and good muscle tone. Good results can be obtained with suction-assisted lipectomy alone. A type 2 patient has mild skin excess, a normal musculoaponeurotic layer and mild to moderate lipodystrophy, particularly inferior to the umbilicus. Minimal lower abdominal skin resection in combination with liposuction is effective for these patients.
A type 3 patient has mild skin excess, lower abdominal laxity with diastasis of the recti and mild to moderate lipodystrophy inferior to the umbilicus. In addition to the skin resection and liposuction placation of the rectus sheath from the pubis to the umbilicus is required. A type 4 patient has skin excess, significant laxity of the musculoaponeurotic layer and lipodystrophy. Skin resection, liposuction and plication along the entire rectus sheath offers improvement but may require transaction of the umbilical stalk. A type 5 patient presents with severe upper and lower abdominal skin excess and laxity. Diastasis of the recti is severe and the patient is often moderately obese. Traditional standard abdominoplasty with placation of the rectus sheath and defatting is necessary.
Aesthetic improvement of the abdomen is achieved with a continuum of procedures ranging from liposuction alone to multistage belt lipectomy with repair of musculo-fascial defects. Modern abdominoplasty is a concept-oriented procedure to address lipodystrophy, musculoaponeurotic laxity and redundant skin. It combines aggressive liposuction of the abdomen and flanks with dermolipectomy in the suprapubic region. Undermining is limited to the midline to allow placation of the fascia. Preoperative evaluation and markings are made with the patient in the standing position. The anticipated area for skin resection is marked as are the areas for liposuction. Prior to induction of general anesthesia, lower extremity compression devices are placed and preoperative antibiotics are given. Once the patient is asleep and the Foley catheter has been placed, several small access incisions are made. Usually these are placed at the umbilicus, the top of the pubic hairline and laterally within the bikini or underwear line to minimize visible scaring; however, additional incisions are often used. Liberal placement of access incisions permits infusion of Klein’s solution and facilitates fat aspiration with the greatest control to improve the contour while limiting irregularities and asymmetries. Standard Klein solution is infused into the areas of planned suction-assisted lipectomy and dermolipectomy. The infusion volume is 1:1 with the anticipated aspiration volume.
After allowing the epinephrine to take affect, liposuction is performed deep to Scarpa’s fascia beneath the planned skin resection. Major contouring of the remainder of the abdomen is performed by suctioning in both the deep and the superficial fat layers. A 4-mm cannula is typically used, with either the Luerlock syringe system or vacuum aspiration. Aspiration volumes for the abdomen are usually between 2 and 4 l. If more than 4 l of fat is aspirated, in-patient observation is recommended. Once the result of the liposuction has been checked for irregularities and asymmetries and has been found to satisfactory, resection of the redundant skin is performed.
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