The Benefits of Liposuction Assisted Abdominoplasty (LAA) as An Enhanced Abdominoplasty Technique

Eman Eltokhy, Loay M Gertallah, Walid A Mawla and Ibrahim A Heggy

Published on: 2019-02-28

Abstract

Background: Liposuction assisted abdominoplasty (LAA), was done in through detaching the abdominal flap from the deeper fascia by performing liposuction first. Due to the clinically verified safety and efficacy of this approach, mainly in minimizing the incidence of seromas and pain more additional cases were done since 2009. Most of the published studies of liposuction and abdominoplasty are retrospective and there are few prospective studies which are evaluating large number of patients. In the current clinical study we aimed to assess the benefits of performing liposuction assisted abdominoplasty (LAA) in patients that are in need for lipoabdominoplasty and compare the results of performing such combined procedures with performing abdominoplasty alone without prior liposuction.

Methods: We included 20 patients which needed lipoabdominoplasty that were divided into 2 groups; group 1 includes 10 patients where LAA were performed and group 2 includes 10 patients where abdominoplasty alone without prior liposuction. Then we have followed our patients to detect post-operative results and long term recovery and complication.

Results: The incidence of wound infection, seroma and skin flaps ischemia is less in group 1 than group 2 (p= 0.026, 0.046 and 0.039 respectively). Patients’ satisfaction, cosmetic results, body contouring was higher in group 1 than group 2 (p= 0.006, 0.009 and 0.029 respectively).

Conclusions: LAA is a safe and effective abdominoplasty technique, which suggests longer flap excursion and improved flap perfusion with lower incidence of complication.

Keywords

Liposuction Assisted Abdominoplasty (LAA); Seroma; Recovery; Satisfaction

Introduction

Abdominoplasty is a surgical technique that gains popularity worldwide as an easily performed procedure with low incidence of complication, due to the growth of performing surgery in the outpatient clinics and advances in anesthesia which allowed safer and faster recoveries [1]. The discovery of liposuction by Illouz YG has markedly improves body contouring and cosmetic results, moreover performing liposuction before abdominoplasty was found to be complementary and gives promising results [2]. Articles discussing the benefits of combining both liposuction and abdominoplasty were published since the 1990’s; but results during that period were not encouraging and advising caution [3,4]. In 2001, Saldanha described their group’s experience by performing a lipoabdominoplasty technique which was similar to Illouz’z Abdominoplasty (1992) [5,6]. Since that time lipoabdominoplasty has become named, Saldanha technique. Liposuction assisted abdominoplasty (LAA), which was previously named lipo-abdominoplasty, was first done in October 1996 through detaching the abdominal flap from the deeper fascia by performing liposuction first. This experience which includes 43 patients was done in 2002 and was published in 2003. It offered an enhanced perfusion and better recovery [7-9]. Due to the clinically verified safety and efficacy of this approach, mainly in minimizing the incidence of seromas and pain [10], more additional cases were done since 2009, and their results are published in Brauman. Most of the published studies of liposuction and abdominoplasty are retrospective and they might include either liposuction or abdominoplasty alone and there are few prospective studies which are evaluating large number of patients [1]. In the current clinical study we aimed to assess the benefits of performing liposuction assisted abdominoplasty (LAA) in patients that are in need for lipoabdominoplasty and compare the results of performing such combined procedures with performing abdominoplasty alone without prior liposuction.

Patients and Methods

This prospective study was undertaken in General Surgery Department, Zagazig University Hospitals, Faculty of Medicine, in the period from December 2016 to December 2018. We included 20 patients which needed lipoabdominoplasty that were divided into 2 groups; group 1 includes 10 patients where LAA were performed and group 2 includes 10 patients where abdominoplasty alone without prior liposuction were done. Surgery was performed under general anesthesia. The usual length of the operation was 4-4.5 hours. Patients were discharged home after about 2-3 hours in the recovery room. All patients were allowed to walk, showered, and returned to normal activity the morning after surgery. Strong abdominal exercises were avoided for 3 months after operation.

Surgical Technique

In the first group; LAA cases, the liposuction was performed first, followed by the abdominoplasty while in the second group abdominoplasty is done alone without prior liposuction. First, anesthetic fluid of the surgeon’s choosing is infiltrated between the deep fascia and the subcutaneous tissue with 3 mm infiltration cannulas attached to 60 cc Toomey syringes, to “separate” all the subcutaneous tissue from muscles of abdominal wall which is called hydro-dissection. Point of entry is from the right or the left sides, above the umbilicus. Initially infiltration and separation is done in the epigastrium then in the area below the umbilicus. The plane of dissection remains is deep to Scarpa’s fascia. The cannula slips under Scarpa’s fascia. Then, liposuction followed infiltration, removing the deep fat layer which is bordering the muscle and disrupting the skin which is retaining ligaments but preserving the blood vessels which is called “lipo-dissection”. Detachment of the subcutaneous tissue from the muscle by liposuction and removing the fat which is bordering the muscle creates a “safe zone,” which is a space that prevents perforations. The superficial surface of Scarpa’s fascia is separated from the infra-umbilical skin by liposuctioning the subcutaneous fat, which exposes Scarpa’s fascia and preserves branches of femoral artery which are coursing on the superficial surface of the fascia. Liposuction of the flap’s undersurface is used to detach and thin the flap. Then, a curvilinear incision is made to split Scarpa’s fascia in the midline to preserve its lymphatic and vessels and the abdominal flap is elevated from the deep fascia sharply and bluntly. Traction on the flap is applied to prevent flap downward movement. Panniculus excision is done and the flap is placed under tension during excision of the panniculus. Panniculus excision is done by superficial liposuction. Bleeding from the edge is expected. Subcutaneous suction drains are used. Tacking sutures are avoided for fear of flap’s vascular supporting tissue layer damage (Table 1).

Statistical Analysis

The data were analyzed using Statistical Package for Social Science for windows version 20.0 (SPSS Inc., Chicago, IL, USA). Mann Whitney U test was used to compare two groups of non-normally distributed data. Percent of categorical variables were compared using Chi-square test or Fisher's exact test when appropriate. P < 0.05 was considered statistically significant.

Results

The age sex and follow-up times for each patient who are included in both the 2 groups were similar. Our cases included 9 (90%) females and 1(10%) male patient in each group. Mean age of all patients was 39.73 ± 9.07 years (Figure 1).

Post-operative results

The overall complication rates of liposuction assisted abdominoplasty were 10% for patients in group 1 and 40% in patients in group 2 (p=0.049) (Table 2). There were no deaths. One patient from group 2 developed late complication; a deep venous thrombosis after lipoabdominoplasty and was hospitalized for anticoagulation (p=0.038). The incidence of wound infection, seroma and skin flaps ischemia is less in group 1 than group 2 (p=0.026, 0.046 and 0.039 respectively). The majority of patients reported experiencing a marked improvement in their appearance and function and patients in group 1 were more pleased with aesthetic results Patients’ satisfaction, cosmetic results, Body Contouring was higher in group 1 than group 2 (p=0.006, 0.009 and 0.029 respectively). No significant correlations were detected between the overall incidence of complications and patient age, smoking history, or body mass index. Men had fewer complications than women overall, but this finding was related to the fact that fewer men underwent an abdominoplasty (Figure 2,3).

Discussion

For over two many years liposuction and abdominoplasty have been done together, but there are few number of prospective studies which discuss benefits and drawbacks of such combined procedure with the individual procedures. This current prospective clinical study aimed to evaluate the safety of combined procedures (LAA) and compare the results between it and abdominoplasty alone. We found that the overall complication rates of LAA were 10% and 40% in patients with abdominoplasty alone (p=0.049).

The incidence of wound infection, seroma and skin flaps ischemia is less in LAA than group 2 in which abdominoplasty alone was done. The majority of patients with LAA reported a marked improvement in their appearance and function and was more pleased with aesthetic results. Moreover, patients’ satisfaction, cosmetic results, body contouring was higher in LAA than abdominoplasty alone. Our results were near results of Brauman and Swanson [1,10]. Which proved the benefits of performing abdominoplasty which is preceded by liposuction which is better than abdominoplasty alone and they explained that; the main requirement for a safe and effective abdominoplasty is a well-perfused, healthy and mobile flap which is acquired in LAA. Complication rates after performing abdominoplasty operation vary widely, from 0% to 43%, which depends largely on the investigator’s definition of a complication [10-12]. Swanson reported nine patients (5.4%) developed a seroma after liposuction assisted abdominoplasty which is in line with our results and, lower than the rate reported in most previous studies (range,3.5-32%) [10,11,13-16] which performed abdominoplasty alone without preceded liposuction. Cases that are complicated with seroma were managed successfully with needle aspirations, without a need for reoperation. Flap mobility requires; detachment of the skin retaining ligaments which fixes the skin to the fascia mainly at the tendinous intersections and along the Linea Alba, additionally flap perfusion is maximal when it contains a well-perfused vascular network all these requirements are found during LAA. LAA was evolved gradually and it was previously named liposuction skin excision since [1,9-17]. The benefits of performing liposuction before the abdominoplasty are that; it loosened the subcutaneous tissue, the skin was stretched, umbilical transposition could be performed and avoid limited flap mobility. Additionally, performing liposuction, “disrupted - tore”, and the unyielding “skin retaining ligaments” and spared the (more flexible) blood vessels which are resulting in greater flap mobility than was possible with abdominoplasty alone. To clinically confirm the benefits of LAA flap compared with the Saldanha flap which was done by performing liposuction only, with tension on the liposuction flap, so as to disrupt the ligaments then carrying out a discontinuous dissection to mobilize the flap. Furthermore, the flap could be more thinned by open liposuction of its undersurface. And avoid performing liposuction through the full thickness of the subcutaneous tissue seemed safer, as no intrusion into the flap [6]. Results of previous researches stated that abdominoplasty techniques which are resecting the infra-umbilical panniculus also resect Scarpa’s fascia with its vessels, but LAA, could preserve some of these vessels because Scarpa’s Fascia’s superficial surface can be separated with liposuction and divided in the midline [1, 18-20]. Which strengthen our results. We are allowing patients to walk upright, which helps with respiration and venous return. Moreover, this leads to enhanced flap sensibility decreased infection rate because of the flap’s abundant perfusion [1]. Seroma formation remains a persistent complication of abdominoplasty [21,22]. The lymphatic drainage from the lower abdomen is superficial to Scarpa’s and it pierces the fascia 2-3 cm proximal to the inguinal ligament was incriminated in seroma formation [23]. Previously seromas can be effectively managed with local and systemic steroids before 2009 and Janis have confirmed the inflammatory pathogenesis of the seroma fluid [24,25]. Treatment with steroids might be beneficial in long-standing seromas; but, when steroids are used for prevention or treatment of fresh seromas, they might have harmful effects on the tensile strength of the healing tissues. Also preservation of a layer of areolar tissue above the abdominal wall is recommended to reduce rates of seroma [10,26]. Moreover, Saldanha describe a technique of performing abdominoplasty that limits tissue undermining and preserves the Scarpa fascia, as originally proposed by Le Louarn [27,28]. These authors report a greatly reduced rate of seromas [27]. Although most previous studies are in line with our results regarding the values of LAA in reducing the incidence of seroma but, different results were found by some investigators that there is an increased risk of seromas in patients treated with simultaneous liposuction others find no increased risk [13,16,29,30]. These discrepancies might be due to different number of patients different surgical technique used. It was found that electro-dissection leads to tissue destruction and seroma formation more than scalpel dissection which is not limited to abdominoplasty surgery; as fewer seromas are also documented after mammoplasty which may be a consequence of reduced tissue injury from electro-dissection rather an improved blood supply to the abdominal flap, limiting the degree of tissue undermining, flap mobilization and ultimately scar quality are compromised [10].

Strengths of the Current Study

Its prospective nature, consecutive patients, and the consistency of 4 surgeons and a symmetrical technique, our study benefits from a higher degree of reliability and little opportunity for conflicting factors which might affect the conclusions.

Summary and Conclusions

Performing liposuction and abdominoplasty, separately and in combinations, might be performed safely with suitable measures so as to decrease complications by reducing tissue trauma. LAA is proved better than abdominoplasty alone in decreasing incidence of seroma, pain and improving cosmetic results with better patient satisfaction and body contouring after operation. Scalpel dissection is preferred more than electro-dissection. Flexed patient position during in surgery is essential. Deep venous thrombosis and other post-operative complications may be decreased using safe precautions without a need for anticoagulation. The LAA technique is a simple and safe procedure to perform which is advised by a 22-year experience gained by plethora of previous studies, the LAA technique is suggested to surgeons as a better alternative to other lipoabdominoplasty techniques.

References

  1. Brauman D, Rene RWJ, Hulst V, VanderLei B. Liposuction assisted abdominoplasty: An enhanced abdominoplasty technique. Plast Reconstr Surg Glob Open. 2018; 6: 1940.
  2. Illouz YG. Body contouring by lipolysis: A 5-year experience with over 3000 cases. Plast Reconstr Surg. 1983; 72: 591-597.
  3. Heppe HP. Combined liposuction with abdominoplasty. Plast Reconstr Surg. 2001; 108: 577-578.
  4. Avelar JM. Abdominoplasty without panniculus undermining and resection: Analysis and 3-year follow-up of 97 consecutive cases. Aesthet Surg J. 2002; 22: 16-25.
  5. Illouz YG. A new safe and aesthetic approach to suction abdominoplasty. Aesthetic Plast Surg. 1992; 16: 3.
  6. Saldanha OR, Pinto EB, Matos WN Jr. Lipoabdominoplasty without undermining. Aesthet Surg J. 2001; 21: 518-526.
  7. Brauman D. Lipoplasty: A case for a low-volume procedure. Aesth Surg J. 2000; 20: 373-379.
  8. Brauman D. Liposuction abdomminoplasty. An evolving concept. Presented at the ASPS/PSEF/ASMS 71st annual scientific meeting, San Antonio, Tex.
  9. Brauman D. Liposuction abdominoplasty: An evolving concept. Plast Reconstr Surg. 2003; 112: 288-298.
  10. Swanson E. Prospective clinical study of 551 cases of liposuction and abdominoplasty performed individually and in combination. Plast Reconstr Surg Glob Open. 2013; 1: 3.
  11. Weiler J, Taggart P, Khoobehi K. A case for the safety and efficacy of lipoabdominoplasty: A single surgeon retrospective review of 173 consecutive cases. Aesthet Surg J. 2010; 30: 702-713.
  12. Trussler AP, Kurkjian TJ, Hatef DA. Refinements in abdominoplasty: a critical outcomes analysis over a 20- year period. Plast Reconstr Surg. 2010; 126: 1063-1074.
  13. Najera RM, Asheld W, Sayeed SM. Comparison of seroma formation following abdominoplasty with or without liposuction. Plast Reconstr Surg. 2011; 127: 417-422.
  14. Spiegelman JI, Levine RH. Abdominoplasty: A comparison of outpatient and inpatient procedures shows that it is a safe and effective procedure for outpatients in an office- based surgery clinic. Plast Reconstr Surg. 2006; 118: 517-522.
  15. Stewart KJ, Stewart DA, Coghlan B. Complications of 278 consecutive abdominoplasties. J Plast Reconstr Aesthet Surg. 2006; 59: 1152-1155.
  16. Kim J, Stevenson TR. Abdominoplasty, liposuction of the flanks, and obesity analyzing risk factors for seroma formation. Plast Reconstr Surg. 2006; 117: 773-779.
  17. Pitman GH. Commentary. Aesthet Surg J. 2000; 20: 380.
  18. Romanes GJ. Cunnigham’s manual of practical anatomy. Thorax and abdomen. 13th ed. Volume 2. London, United Kingdom, Oxford University Press.1968: 93-111.
  19. Grant JCB. Grant’s Atlas of Anatomy. 6th Baltimore, Md. Williams & Wilkins; 1972: 105-112.
  20. Clemente CD. Anatomy, A Regional Atlas of the Human Body. 4th Williams and Wilkins; 1996; 246-270.
  21. Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development following body contouring surgery for massive weight loss: patient risk factors and treatment strategies. Plast Reconstr Surg. 2008; 122: 280-88.
  22. Gusenoff JA. Prevention and management of complications in body contouring surgery. Clin Plast Surg. 2014; 41: 805-818.
  23. Saam S, Tourani SS, Taylor I. Scarpa fascia preservation in abdominoplasty: Does it preserve the lymphatics?. Plast Reconstr Surg. 2015; 136: 258.
  24. Brauman D, Capocci J. Liposuction abdominoplasty: An advanced body contouring technique. Plast Reconstr Surg. 2009; 124: 1685-1695.
  25. Janis JE, Khansa L, KKhansa I. Strategies for postoperative seroma prevention: A systematic review. Plast Reconstr Surg. 2016; 138: 240-252.
  26. Fang RC, Lin SJ, Mustoe TA. Abdominoplasty flap elevation in a more superficial plane: Decreasing the need for drains. Plast Reconstr Surg. 2010; 125: 677-682.
  27. Saldanha OR, Federico R, Daher PF. Lipoabdominoplasty. Plast Reconstr Surg. 2009; 124: 934-942.
  28. Le Louarn C. Partial subfascial abdominoplasty. Aesthetic Plast Surg. 1996; 20: 123-127.
  29. Neaman KC, Armstrong SD, Baca ME. Outcomes of traditional cosmetic abdominoplasty in a community setting: Aretrospective analysis of 1008 patients. Plast Reconstr Surg. 2013; 131: 403-410.
  30. Samra S, Sawh-Martinez R, Barry O. Complication rates of lipoabdominoplasty versus traditional abdominoplasty in high-risk patients. Plast Reconstr Surg. 2010; 125: 683-690.

Figures

Figure 1A and B: Preoperative appearance of female patient with marking of liposuction before abdominoplasty.

Figure 2: Appearance of the patient one week after performing liposuction assisted abdominoplasty (LAA).

Figure 3: Appearance of the patient one month after performing liposuction assisted abdominoplasty (LAA).

Tables

Table 1: Operative and postoperative data.

Operative and postoperative data

Group 1 (N=10)

Group 2 (N=10)

p-value*

Duration of operation (minutes) (Mean ± SD)

4.23 ± 0.17

4.83 ± 0.40

0.312

Hospital stay (days)   (Mean ± SD)

1.93 ± 2.06

1.06 ± 1.98

0.782

N=Total number of patients in each group; Quantitative data were expressed as mean ± SD; Mann Whitney U test; ‡ Chi-square test; p-value< 0.05 is significant.

 

Table 2: Post-operative results.

Outcome of treatment

Group 1 (N=10)

Group 2 (N=10)

 

p-value*

 

No.

%

No.

%

 

Complication

 

 

 

 

 

Absent

9

90%

6

60%

0.049

Present

1

10%

4

40%

 

Complication

 

 

 

 

 

Absent

9

90%

6

50%

0.038

Early alone

1

10%

3

30%

 

Late alone

0

0%

1

10%

 

Wound infection

0

0%

1

10%

0.026

Seroma

1

10%

4

40%

0.046

Skin flaps ischemia

0

0%

2

20%

0.039

Patients satisfaction

9

90%

5

50%

0.006

Cosmetic results

8

80%

4

40%

0.009

Body Contour

7

70%

5

50%

0.029

N=Total number of patients in each group; Quantitative data were expressed as mean ± SD; Qualitative data were expressed as number (percentage); ‡ Chi-square test; p-value< 0.05 is significant.