Before the advent of liposuction there was really little that could be done about shaping the upper part of the body. The trunk consists of the upper and lower abdomen, the flanks, the back, and the mammary region. All of these areas are very important when taking into consideration the silhouette of a person. With liposculpture, not only can large volumes of fat deposits be reduced in this area, but it can also give a new shape to the body. Cosmetic surgery of the abdomen started in the nineteenth century. Between 1890 and 1910 several cosmetic surgeons described the technique of dermolipectomy. In 1967, Pitanguy published his work on abdominal lipectomy. It was his experience that gave all of us the opportunity to understand the basic principles of abdominoplasty. Nevertheless, our patients hardly accept evident scars. It is for this reason that the concept of modeling the abdomen has radically changed since the introduction of liposuction techniques.
The anatomical characteristics of the abdomen are very important to take into consideration. The surface anatomy of the abdomen can de subdivided into the epigastrium or upper abdomen, the hypogastrium or lower abdomen, and the mesogastrium or midabdomen, which contains the periumbilical and waist areas. Some areas of the abdomen appear very difficult to defat and this is mostly because of the presence of numerous fibrous septa, especially in the waist area and in the upper abdomen. The upper abdomen is a very challenging area since the presence of this large amount of fibrous tissue can be responsible for unaesthetic postoperative wrinkles. Nevertheless, Scarpa’s fascia does not exist in the upper abdomen and if too much fat is taken away from this area there is no possibility that this fascia, existing only in the lower abdomen, may alleviate the adherences of the fibrous tissue to the skin. The back or dorsum is a very large area if we consider it from the scapular region down to the upper gluteal region. The muscular area of the back is vascular in the deep part near the fascia. There are two major areas where fat deposits occur in the dorsum. One is underneath the scapular region above the lower costal margin, in the bra area, and the other one is lower in the hip area.
According to my experience, with the introduction of liposuction, original abdominoplasty is rarely required. Liposuction should not be performed when little fat is present, with large skin aprons or extended stretch marks, and in the presence of muscle diastasis. To those patients who are not good candidates for liposuction I propose a two-stage operation. The first stage is liposuction and the second stage a mini tummy tuck if, after 6–8 months, skin retraction is not satisfactory. Most of my patients appear to be happy only with the first stage. The abdomen in fact has excellent retracting capacities, especially in young patients. Today 90% of surgical abdominoplasties are treated with liposculpture. The technique for the abdomen does not differ very much from that of other areas of the body. Liposculpture of this area can really change the silhouette of a person. There are areas in which care must be taken, such as the upper abdomen, where excessive defatting might result in rugosity after the postoperative edema has passed. This happens mainly in older patients with decreased skin elasticity. The preoperative evaluation of the patient is very important. The patient should lie down and then lift the legs up in order for the abdominal muscles to be evaluated. Liposuction alone is not done if there is significant diastasis of the rectus abdominal muscles. Preoperative photographs are taken and the patient is marked. In the operating theatre I explain to the patient how the orthostatic bed works and the anesthetist then starts sedating the patient. Liposculpture of the abdomen should never be made under general anesthesia. If muscle relaxation is present, intestinal perforation could occur. Moreover, the patient should be able to contract the abdominal muscles whenever asked to do so during the operation. A modified tumescent solution is used with the same amount infused as will be removed.
Real tumescent infiltration gives an excessive dislocation of the fat, making it very difficult to sculpt the body. After infiltrating, these areas are massaged energetically in order for the liquid to spread evenly. The orthostatic bed makes it possible to work in a natural everyday position on the body of the patients. As usual, the major debulking is made in a slight Trendelenberg position, then the patient is placed in an orthostatic position where the force of gravity can no longer give false effects. Tunneling is begun with my harpstring method. Generally four or five incisions are enough for the whole abdominal area. No importance should be given to the number of incisions made. The only important thing is to crisscross in the correct way. Tunneling should always be made in a vertical manner. Two incisions are suprapubic. From the left one I crisscross on the right side of the abdomen in a clockwise direction, and the opposite happens for the right incision. Another incision is placed over the umbilicus. From this incision I crisscross to the right and to the left. Other incisions can be placed under the breast so as to tunnel in the opposite direction. Of course different situations require different incisions. It is important to always work on a wet surface in order to allow the gloved hand to appreciate what it is touching. I work with my left hand flat on the surface of the abdomen until I am concerned about the diminishment of the volume.
Then I start pinching and rolling in order to evaluate the thickness of the remaining fat. A certain amount of subcutaneous fat should always be left. You should always feel unhappy at the end of your operation thinking that you could have taken away more. The important thing is what you leave not what you remove. Good and expert cosmetic surgeons are only able to imagine what will be. Because of the particular anatomy of the abdomen, I do heavier liposuction on certain areas of the abdomen in order to give a better silhouette to the patient. The midline between the costal margins contains a lot of fibrous tissue and fat can at times be difficult to remove, but when possible I take away more fat in that area than in the surrounding ones in order to give a depressed effect. I do this for patients that want an athletic abdomen similar to a culturist’s one. Also, I remove more fat in the triangle above the mons pubis and beneath the umbilicus. This gives more roundness on the left and right sides of the lower abdomen, which gives it a very feminine appearance. Sculpturing the waist is also a very important aspect of abdominal liposuction. This goes along with liposculpture of the higher hips. When the operation is completed, the operated areas are massaged with a steel tube. One of the tubes is smooth and the other is corrugated. The areas are in this way smoothened out. Later, 3M Reston foam is applied, which prevents bruising.
Over Reston foam the patients wear two pairs of garments. One is two sizes larger and is the one that has to go over the Reston foam. Another one is only one size larger because it will easily fit over the other one. After 4 days the patients begin massage sessions that will be for 2 months. Postoperative massages are very important for the abdomen because those fibrous areas will get very swollen after the operation and massage is fundamental in order for the postoperative edema to go away and to reduce the probability of permanent lumps. Patients are told that they should never sit at a 90° angle for at least 1 month. This would increase the probability of having wrinkles on the skin surface that would take a lot of time to resolve.
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