Classic Lipoabdominoplasty: Optimizing the Aesthetic Result and Reducing Complications

Seromas are a nuisance for plastic surgeons performing abdominoplasties.  In an effort to reduce risk, a more limited dissection has been advocated.  Some surgeons recommend preserving the Scarpa fascia.  Others use quilting sutures.  Each of these methods has drawbacks.

So how does one avoid seromas?  The author believes his relatively low seroma rate in abdominoplasties (5.4%) derives from avoidance of electrodissection, which causes an internal burn injury.¹  This is an old technique that originated before tumescence was used, when bleeding was substantial and electrocautery reduced blood loss.  Today, a superwet infusion (1:500,000 epinephrine) dramatically reduces bleeding and makes Bovie dissection unnecessary.¹  Jackknife positioning of the operating table (up to 90 degrees) and deep fascial anchoring sutures serve to keep the scar low, within the bikini line, with no tendency to migrate superiorly.¹

The author has recently investigated whether a more limited dissection improves circulation to the abdominal flap.  First, a limited dissection, preserving perforators, was performed and the patient imaged using laser fluorescence.  Next, the dissection was converted to a full abdominoplasty dissection and the patient was re-imaged (Fig. 1).  Surprisingly, there was no significant difference in flap perfusion.  Any advantage in preserving perforators seems to be compensated by reduced wound tension, and advancement of a thick fasciocutaneous flap.  There is no anatomic or physiologic basis for Scarpa fascia preservation, which adds bulk to the lower abdomen (Fig. 2).  The limited dissection technique can cause upward migration of the abdominoplasty scar and pubic hair, compromising the aesthetic result.¹  Quilting sutures add substantially to the operative time.

These practice tips can optimize the cosmetic result and reduce the risk of seroma or healing problems.  SAFE anesthesia further improves patient safety by reducing the risk of venous thromboembolism.  All patients undergo ultrasound scans of the abdomen to detect any possible hernias and ultrasound surveillance before and after surgery to detect deep venous thromboses, allowing early detection and treatment, and avoiding a need for chemoprophylaxis. 

Reference

1. Swanson E. Prospective clinical study of 551 cases of liposuction and abdominoplasty performed individually and in combination. Plast Reconstr Surg. – Glob Open. 2013;1:e32.

Fig. 1.  Intraoperative laser fluorescence images.  A limited dissection abdominoplasty and superficial fascial repair have been performed (above).  Relative perfusion percentages are indicated, with 100% assigned to the pubic perfusion, which serves as a reference.  Areas with greater perfusion appear red and areas with less perfusion appear blue. The dissection is converted to a full dissection plus removal of the Scarpa fascia from the lower abdominal wall (below).  The deep fascia has been anchored to reduce skin tension. Measurements indicate no reduction in perfusion.

Fig 2.  Lateral intraoperative photographs compare the limited (left) and full (right) dissections in the same patient.  The retained Scarpa fascia and fat (left) leave bulk on the abdominal wall, compromising the degree of flattening of the lower abdomen and creating a longer distance for the upper abdominal flap to travel.  After conversion to a full dissection (right), the abdominal wall is flat and the flap has greater mobility.