Document Type : Original Article
Authors
1 Plastic Surgery, Al-Azhar University, Cairo, Egypt
2 Department of Platic and burn surgery, Faculty of Medicine- Al-Azhar University
3 Plastic and burn surgery, faculty of medicine, AL_Azher university, cairo, Egypt
Abstract
Keywords
Introduction
Abdominoplasty became the most common aesthetic surgical procedure with development of safe anaethesia and fast recovery.
In 1980s illoze1 introduced liposuction in addition to abdominoplasty in the same procedure this give more contour enhancement in the same procedure. Articles on combining liposuction and abdominoplasty have been published during the 1990’s; but, the literature at that point became not generally supportive of this combination, advising warning.1
In 2001, Saldanha et al.2 defined lipoabdominoplasty technique much like Illouz’z Suction Abdominoplasty.
Liposuction assisted abdominoplasty became first executed in October 1996 by means of detaching an belly flap from the deep fascia with liposuction.2
Abdomioplasty procedure has developed for all patients and asking for contouring and reshaping of this body areas.3
Surgical abdominoplasty on my own is also insufficient within the obese affected person because the thickness of the belly panniculus isn't always reduced; in addition, secondary to tissue tension with wound closure, a few necrosis of pores and skin above the pubis isn't uncommon.4
The introduction of liposuction strategies has allowed surgeons to limit scar duration in positive applicants, remodeling abdominoplasty right into a minimally invasive manner.5
Using liposuction in addition with abdominoplasty has been controversial. The combination of techniques has been related to increased incidence of venous thromboembolism and wound-recovery complications. With using of thromboembolism prophylaxis, the risk of thromboembolism was decreased and so on increased rate of liposuction assisted abdominoplasty.6
So in our study we study the use of liposuction assisted abdominoplasty and monitoring its results.
Patient and Methods
This was a prospective study case series that included a total a total of 30 patients have been passed through assisted liposuction abdominoplasty.
All patients indicated for this technique were chosen from the plastic surgical treatment outpatient clinic; having belly lipodystrophy, and skin redundancy, and musculoaponeurotic divarication.
The patients classified according to Mattarasso classification to 3 groups, group (A) ten patients indicated to liposuction assisted extended abdominoplasty, group (B) ten patients indicated to liposuction assisted fullabdominoplasty, group (C) ten patients indicated to liposuction assisted mini abdominoplasty.
The study was performed into in al-Azhar university Hospitals (Al-Hussin and Sayed Galal) from October 2019 to April2020.
The assessment which include operative time, hospitasl stay, general drain output, time of drain removal, aspirate volumet, weight of excised tissue, scar length, complications, return to work, and patient satisfaction.
All patients were consented about the operation, anesthesia, viable complications, dangers, photographing, and inclusion on this study. All patients have belly deformities marked skin excess, lipodystrophy without or with muscle laxity (Matarasso type 2, 3 and 4).All Patients have BMI
Preoperative exam, planning and marking:
Full investigations, radiology including u/s ,CBC, SGPT /CREAT, INR must be done, and then we cautiously have a examine the stomach for hernias and previous operation scars, mainly subcostal cholecystectomy scar. Images are normally taken in 6 cardinal views .
We mark the incision line while patient standing , it must be 7 cm above superior vulvar commissure This mark is prolonged laterally, along skin crease while patient manually elevate her belly. The length and region of this proposed incision is then measured to make certain symmetry, figure (1).
Figure (1) Preoperative markings are made with the patient standing.
Figure (2) All areas for liposuction are marked this includes the entire central abdomen, flanks, and hip rolls.
Lateral part of the incision is marked and agreed by the patient then the proposed upper incision is identified and marked by pinch test.
Operative procedures:
The patient lies supine, compression stockings iwrapped around both legs, sterilization, towling, , anesthesia is administered. Tumescent solution is infiltrated in the abdominal flap and liposuction areas (epigastric region, central abdomen, lateral abdomen, hip rolls and flanks), tumescent consists of lidocaine 2% 10cm and epinephrine solution (1/200,000). 1cm put on 500 ringers or saline. We infiltrate the loose areolar tissue between abdominal wall and skin flap to make easier dissection with 3mm infiltration cannula till achieving tissue turgor, 20miniutes are left ,then liposuction of deep plane with 4 mm cannula then final refining with 3mm cannula
Figure (3) Traditional liposuction with 4 mm diameter cannulas
We assess the equality of flap thickness by pinch test,lipo suction begins in the central abdomen between the 2 outer borders of recti, we leave athiccker flap(4cm) in the central abdomen and thinner flap(2cm) in the lateral abdomen and flanks , so as to simulate the youthfull abdomen, additional canula entry sites can be done in the excisional abdominal flap,, direction of cannulu should be inferosuperior to preserve much perforators, after completion of liposuction we made the incision with 15 blade, incision is better to be made 2 centimeters below the marked line to overcome the later upward scar migration, don’t forget fluid compensation of liposuction aspirate and blood loss.
Figure (4) Transverse incision of formerly marked is made with 15 blade
we use diathermy to open the dermis and cogulate blood vessles tissue (figure 5).
(figure 5).bevel dissection through the fat of the skin flap
We bevel dissection through the fat of the skin flap till reaching the rectus sheath at appoint midway between theumbilicus and the symphysis, this preserves more lymphatics and decreases seroma formation . meticulous homostasis should be done along the course of dissection. We incise THE UMBILICUS vertically with 11 blade and dissection scissors , we mark its upper and lower poles by threads , dissection is continued up to costal margins and xiphoid, then we plicate rectus abdominis muscle sheath by marking its medial border by methylene blue. This defines the diastasis, blication is don from xiphoid process superiorly and sumphusis inferiorly, and laterally from medial border of recti , plication is done by zero or 1 nilon looped suture, in one or two layers according to situation,at the level of the pubic symphysis, the knot tied and buried. Now it is time for flap resection, the patient is put in semisetting position by breaking operation table. The table is broken in forty five tiers to release tension off of the wound closure and allow excision of maximum skin excess (figure8).
Fugure (8) Towel clips are placed at the tips of the flaps to apply gentle suture before flap excision
Figure (6) umblicus seperation
Figure (7) Wide rectus abdominis muscle placation
it is forbidden to detach the the flap beyond costal margin to preserve its vascularity, but gentle cannula dissection is allowed to get more flap mobility and eliminate tissue ridge without affecting blood supply. This makes fibrous septa which contain vascular perforators, then we simulates linea alba of the youthful abdomen by traction sutures with vicryl 2/0 in the midline Figure (9) (figure9).Supraumbilical central portion adhesion sutures
this makes amidline deprssion like an athletic abdomen (linea alba). We apply gentle traction on the flaps by towel clips, mark the excision mark while counter pushing of the inferior edge, assess symmetry between both excision marks, then cutting. (figure 8).
We vertically incise the new umbilicus at the position midway between symphysis and xiphoid, thin pulling the umbilical stalk and suturing it.
Then we finally revise our hemostasisis before puttin stay sutures to distribute tension, we put 2 drains laterally then we begin skin closur by suturing of scarpa′s fascia, it is th most important layer and must be closed under maximum tension so as to reliefe the overlying layers, it is closed with 0 vicryl suture , We advance upper flap medially to eliminate any dog ears then deep dermal 2/0 vicryl sutures is put before final sub cuticular4/0 prolene sutures. Then we dress the wound and dress the pressure bandage.
Fig(10) Immediate post-operative
Results
Patients are classified to 3 groups according to Mattarasso classification, each of 10 patiens ,1st group did extended abdominoplasty,2nd did full abdominoplasty,3rd did miniabdiominoplasty. All with liposuction we evaluated resultant contour, aspirate volume, excised tissue weight, drain output, drain removal ,hospital stay complications and patient satisfaction in each group.
(group A)
The weight of excised skin and subcutaneous fat in the 10 cases under group (A) ranged from 2500 to 4000gm. with a mean of 3.070 kg. Operative time was ranged from 3.5 to 5 hours with a mean of 4 hours. The volume of Aspirate in 10 cases ranged from 3000 to 4000 cm with mean of 3.6 liters each case. The total drain output in the 10 cases under group (A) ranged from600 to1500 ml. with a mean of 885 ml per case. The days needed for drains removal in the 10 cases under this group ranged from 3 to 7 days with a mean of 4.8 days per case. The days of hospital stays in the 10 cases under this group ranged from 2 to7days with a mean of 3.8 days per case. Bad patient satisfaction occurred in one post bariatric patient showed recurrent protrusion of ant. abdominal wall which needed revision.
Figure (11) Pre and post operative view of liposuction assisted extended abdominoplasty
Group (B)
Operative time was ranged from 2.5 to 4 hours with a mean of 3.25 hours. The weight of excised skin and subcutaneous fat in the 10 cases under group (b) ranged from 2000 to3000g, with a mean of 2.37kg. The total aspirate volume in group B ranged from 3000 to 4000 ml, the mean was 3.65. The total drains output in the 10 cases under group (B) ranged from 3000 to 4000ml. with a mean of 676.5 per case. The total days needed for drain removal in the 10 cases under this group ranged from2 to 3 days with a mean of 2.9 days per case. The total days of hospital stays in the 10 cases under ranged from 2 to 3 days with a mean of 2.9 days per case. Fair patient satisfaction was achieved in single case (5%) due to asymmetric scar along the incision line. Others are fully satisfied.
Figure (12) Pre and post operative view of liposuction assisted full abdominoplasty
Group(C)
Operative time was ranged from 2 to 3hours with a mean of 2.6 hours. The weight of excised skin and subcutaneous fat in the 10 cases under group (C) ranged from950 t0 1300 kg. with a mean of 1.24kg. The aspirate volume ranged from2500 to3500 ml, the mean volume was 2.8l per case The drain output in the 10 cases under group (C) ranged from 250 t0 500 ml. with a mean of 445ml per case The days needed for drains removal in the 10 cases under this group ranged from 2 to 3 days with a mean of 2.5 days per case The days of hospital stays in the 10 cases under this group ranged from 1 to 2days with a mean of 1.7 days per case.
Complications
In group (A) there is wound dehiscence an recurrent protrusion of the ant. abdominal wall, in group (B) there is minimal dehiscence in one case and scar asymmetry in another case, in group(C) there is acase of dog ear. The reduced incidence of epitheliolysis to 0 percent, seroma to 0percent, and necrosis to 0 percent dehiscence 1.1percent, has statistical significance. Because the previous known worldwide percent with traditional abdominoplasty alone was 50, 3.8,5.1 for seroms epithiliolysis and dihescence respectively as published by saldanha2007 Although the incidence of hematoma was reduced to 0 compared to 0.6 percent and the incidence of deep venous thrombosis/pulmonary (0 percent compared to 0.2 ), we cannot consider these findings as statistically significant due to the small number of cases.
Figure (13) pre and post operative view of liposuction assisted miniabdominoplasty
N |
Total drains output volume |
Time to drains removal |
Hospital stays |
Aspirate volume |
Weight of excised tissue |
HB 2nd day postoperative |
Complications
|
Patient satisfaction |
||
early |
late |
|||||||||
1 |
600 |
3 |
3 |
3000 |
3500 |
7.5(2 units packed RBCs) |
NIL |
NIL |
Excellent |
|
2 |
650 |
3 |
4 |
3500 |
4000 |
11 |
NIL |
Wound dehiscence |
Fair |
|
3 |
700 |
4 |
4 |
3000 |
3000 |
11 |
NIL |
Recurrent protrusion |
Good |
|
4 |
810 |
5 |
3 |
4000 |
2800 |
11.6 |
NIL |
NIL |
Excellent |
|
5 |
930 |
5 |
3 |
3500 |
2500 |
11.3 |
NIL |
NIL |
Excellent |
|
6 |
1100 |
7 |
4 |
3500 |
2700 |
10.2 |
NIL |
NIL |
Excellent |
|
7 |
1050 |
4 |
3 |
4000 |
3200 |
11.4 |
NIL |
NIL |
Excellent |
|
8 |
1150 |
5 |
5 |
3500 |
2100 |
11.5 |
NIL |
NIL |
Excellent |
|
9 |
1500 |
7 |
7 |
4000 |
2900 |
11 |
NIL |
NIL |
Excellent |
|
10 |
1250 |
5 |
5 |
4000 |
3800 |
12 |
NIL |
NIL |
Excellent |
|
Table (1) Summary of postoperative results in group A
N |
Drain output volume 400-1000 |
Time to drain removal
|
Hospital stay |
Weight of excised tissue 2000-3000 |
Aspirate volume 3000-4000 |
HB 2nd day post-operative |
Complications |
Patient satisfaction |
|
|
|
||||||||
1 |
430 |
3 |
3 |
2600 |
3000 |
11.5 |
NIL |
NIL |
Excellent |
2 |
400 |
2 |
2 |
3000 |
3500 |
11.6 |
NIL |
NIL |
Excellent |
3 |
490 |
3 |
3 |
2000 |
3000 |
11.7 |
NIL |
NIL |
Excellent |
4 |
600 |
3 |
3 |
2300 |
4000 |
11.6 |
NIL |
Scar assymetry |
Good |
5 |
1000 |
3 |
3 |
2200 |
3500 |
11.3 |
NIL |
NIL |
Excellent |
6 |
750 |
3 |
3 |
2500 |
3000 |
12.2 |
Minimal dehiscence |
NIL |
good |
7 |
620 |
3 |
3 |
2400 |
4000 |
11.3 |
NIL |
NIL |
Excellent |
8 |
730 |
3 |
3 |
2300 |
4000 |
11.8 |
NIL |
NIL |
Excellent |
9 |
820 |
3 |
3 |
2500 |
4000 |
10.3 |
NIL |
NIL |
Excellent |
10 |
965 |
3 |
3 |
2200 |
4000 |
13 |
NIL |
NIL |
Excellent |
Table (2) Summary of postoperative results in grop B
N |
Total drains output volume 250-500 mm |
Time to drains removal 2-3 days |
Hospital stays 2-3 days |
Aspirate volume 2500-4000 mm |
Weight of excised tissue 950-1300mm |
HB 2nd day post-operative 11.5-13 mm |
Complications |
Patient satisfaction |
||
early |
late |
|||||||||
1 |
500 |
3 |
3 |
2500 |
1100 |
11.2 |
NIL |
NIL |
Excellent |
|
2 |
400 |
3 |
3 |
3000 |
1300 |
11.6 |
NIL |
Dog ears |
fair |
|
3 |
330 |
3 |
3 |
3000 |
1250 |
11.7 |
NIL |
NIL |
Excellent |
|
4 |
250 |
2 |
2 |
3500 |
1270 |
11.6 |
NIL |
NIL |
Excellent |
|
5 |
360 |
3 |
3 |
4000 |
1100 |
11.3 |
NIL |
NIL
|
Excellent |
|
6 |
400 |
3 |
3 |
2500 |
1050 |
10.2 |
NIL |
NIL |
Excellent |
|
7 |
330 |
2 |
2 |
2500 |
1060 |
11.3 |
NIL |
NIL |
Excellent |
|
8 |
340 |
2 |
2 |
3000 |
950 |
11.8 |
NIL |
NIL |
Excellent |
|
9 |
290 |
2 |
2 |
4000 |
970 |
11.3 |
NIL |
NIL |
Excellent |
|
10 |
310 |
2 |
2 |
4000 |
1030 |
12 |
NIL |
NIL |
Excellent |
|
Table (3) Summary of postoperative results in group C
Discussion
The Liposuction assisted abdominoplasty method is not only using liposuction with abdominoplasty, but it is wider concept including enhancing abdominal contour with least complications. . Total results of liposuction assisted abdominoplasty obtained in this series were satisfactory, 90% of the patients showed excellent to good results, while 10% showed fair results and this is consistent with Daniel Brauman (2018)7 which noted that 92% are fully satisfying. As regard patient satisfaction 27 of the 30 pt. were fully satisfied and this is conductive with the study of Kim et al. (2006)8 with 87% of patients achieving satisfactory results. 2 of 3 unsatisfied patients became satisfied after revision. Hospital stay was maximum 1 week in group A, 3 days in group b, 2 days in group c, actually this is longer than prescribed methods but we needed this for strict follow up. As regard blood loss and needing blood transfusion, only on case of group needed this consistent with Espinosa-de-los-monteros 20069 which needed no blood transfusion in his 55 cases study. In this series, the timing for return to work or resumption of everyday life activities achieved by 84% these patients were 3 weeks in group A and B ,2weeks in group C consistent with the study of brauman 2018 where 89% of patients were able to resume working 3 weeks post-operative.We observed a decrease in the final scar extension when compared with the initial marking in10, 50, 50 percent of patients, in the mini, full, extended abdominoplasty respectively which is conducted with saldanha 200710 which reported 2cm decrease in scar in 30% of cases. Only 2 patients needed revision (6.6 %) which is superior to Saldanha 2007 which reported 10% needing revision. As regard complications one of the patients developed seroma which was discovered clinically and confirmed by ultrasonography, it was managed intraoperatively by aspiration after cannula dissection of fibrous septa and pressure garment and f