Women and men of varying ages and backgrounds pursue abdominal contouring surgery. These are some common scenarios:
In non-obese young women and men, fullness in the abdomen is typically related to subcutaneous fatty tissue collections more than abdominal laxity. In these patients, abdominal liposuction is the treatment of choice
Morbidly obese patients may present with abdominal pannus overlying the pubis and the knees. These patients are challenging surgical patients, at risk for venous thromboembolism, blood loss, hypothermia, and wound healing problems.
The degree of obesity is calculated through the standard heigh and waist, the body mass index (BMI). The BMI should be determined as a routine part of the preoperative record, like blood pressure or hemoglobin content. Using the BMI, the surgeon can objectively classify a patient’s obesity as one of the following:
- Class I: Lean range (18.5–19.9)
- Class II: Optimal (average) (20–25)
- Class III: Overweight range (25.1–29.9)
- Class IV: Obese range (30–34.9)
- Class V: Morbidly obese range (35–39.9)
- Class VI: Extremely obese (40 or greater)
Importantly BMI estimates sedative or anesthetic risk. Morbid obesity (BMI > 35) imparts a threefold to fourfold create more significant respiratory depression from sedative drugs, perhaps because sleep apnea is more common in that group.
Male Body contouring
Men are pursuing body-contouring surgery in more significant numbers. Men benefit from liposuction of the abdomen, often in combination with liposuction of the flanks and back.
The male or android distribution is characterized by subcutaneous fat deposition in the upper body and central visceral fat deposits. These deposits are associated with androgen receptors on adipocytes. The typical adult obese man has disproportionate fat deposits in the subcutis of the abdomen, the waist, and the shoulders.
These fat cells are more metabolically active, i.e., change with dietary restrictions, and correlate with disease risk. With fasting, fat cell lipolytic activity appears centrally (visceral fat) and not in subcutaneous peripheral stores. Men lose visceral fat more than other body areas.
Abdominal obesity is a vital risk factor for diabetes mellitus, hypertension, and possibly some female cancers (endometrial, ovarian).
The visceral fat cells are critical because of their relationship to hepatic circulation. The breakdown fat cells drain directly into the portal circulation exposing the liver to high concentrations of free fatty acids; these, in turn, can cause hypertriglyceridemia. Therefore, obesity helps the development of type 2 diabetes, hypertension, dyslipidemia, and atherosclerotic cardiovascular disease.
The WHR accurately predicts intra-abdominal adipose collection and indicates the risk factors related to central obesity.
The female or gynecoid distribution refers to fat accumulation in peripheral stores, specifically those below the waist, like the thigh and buttocks. Peripheral fat deposits tend to be fixed and become active during lactation and pregnancy (more weight).
These deposits are associated with estrogen receptors on adipocytes. The fat cell lipolytic activity increases in the face with diminished food restriction (wasting face) but does not significantly affect the peripheral fatty deposit (arm, thighs, and buttocks).
The Postpartum Women (after childbirth)
Women after childbirth suffer scars, stretch marks, muscle, and skin laxity. Traditional abdominoplasty is typically the best procedure to address skin, muscle laxity, and contour deformity.
Massive Weight Loss
Weight loss may be achieved through diet and exercise or surgical means. The abdomen is the most common body region addressed in patients sustaining massive weight loss. Such patients demonstrate functional issues from abdominal wall laxity, excess skin, and fat deposits.
Abdominal Scars with Deformity
Patients with irregular abdominal contours due to scars from previous surgery often benefit from either direct scar excision or abdominoplasty.
Patients with a prior surgical history of pregnancy may present with hernias, incisional, ventral, and umbilical hernias. Patients may have incisional hernias in the lower abdomen as well. These hernia repairs are performed with abdominoplasty.
Abdomen Liposuction in Body Contouring
Most body contouring procedures aim to improve the contour and shape of the body to achieve a smooth, flowing, harmonious contour. Abdomen liposuction is the first step of abdominoplasty to achieve the best body contouring results.
Abdomen liposuction extends to adjacent areas such as the hips, flank, or the posterior trunk. Abdominal etching is a form of superficial liposuction performed to simulate the appearance of muscle definition.
The abdomen is an excellent donor source for fat grafts; fat is best harvested through traditional syringe aspiration techniques to minimize trauma and disruption to the adipocytes.
Abdomen Liposuction: Basic science and Anatomic Considerations
Abdomen liposuction will be performed between the costal margin up, the groin and the pubis down, and later flanks. The entire abdomen and flanks can be sculpted as one aesthetic unit.
The subcutaneous abdominal fat is amenable to all the various modalities of liposuction and continues to be one of the most popular and desired areas for liposuction. The subcutaneous fat is divided into a superficial and deep layer by the scarp’s fascia. These separate layers’ have relative consistency, and thickness varies for different anatomic areas. The sub-scarpal fat below the umbilicus is loose, while the area above the umbilicus tends to be more compact and fibrous.
Abdomen Liposuction vs. Liposculpture (etching)
Superficial fat is present throughout almost the entire surface of the human figure, directly beneath the skin. It holds blood vessels and lymph vessels.
In 1982, the concept of superficial liposuction was introduced, and after the concept of subdermal liposuction. Suctioning fat from the superficial layer fat layer will result in skin draping and tightening, resulting in a more aesthetic result.
Ersek and Mentz used these new principles with their introduction of abdominal etching. It used differential liposuction to enhance the appearance of fatty tissue over the rectus abdominis muscle. We call it Liposculpture.
Liposculpture provided the surgeon allowing the surgeon to approach the entire body surface and influence skin tightening to a significant degree for the first time. However, since the superficial layer holds the vascular structure, which increases the risk for contour irregularities, an experienced surgeon should conduct it.
The deep fatty layer comprises fat cells positioned in an elongated horizontal layout and a large amount of connective tissue forming trabeculae through which blood vessels pass. When the deep layer is suctioned, this is called liposuction.
This deep fatty layer is present in the abdomen, flanks, trochanteric thigh, medial thigh, knees, and arms. Deep and superficial fat can be removed during abdomen liposuction, but we should leave at least 1 cm of superficial fat to support the dermis.
Twenty-five years of experience performing liposuction has convinced me that I need to be able to work superficially and in the deeper plane if I am to obtain the most significant results.
Patient Selection for Abdomen Liposuction
Patients often misunderstand the limitations and benefits of abdominal liposuction. Contouring the body in any area requires the physician to evaluate that area circumferentially. An excellent example is that the final abdomen depends on the area of the hips or flanks.
Furthermore, many patients seeking contouring of the abdomen may not be candidates for liposuction alone and require excisional techniques to allow them the best possible change in contour.
Some patients always fall into a “gray area” where there is no clear indication of which technique to apply. The decision usually depends on individual factors, such as age, the patient’s lifestyle, financial conditions, and ability to stay away from work for a short or long recovery period.
There is one rule to which the surgeon must adhere: the classification of the abdomen based on the degree of skin and muscle laxity and fat excess. The “gray area” occurs when the patient abdomen contouring deformity with a varying contribution of fat deposits skin and muscle laxity.
These patients are in grey areas; liposuction is combined with modifications of abdominoplasty depending on the degree of fat collection, muscle weakness, and skin laxity. Liposuction alone is performed when a fat collection is present with no skin laxity—Abdominoplasty alone when there is no excess fat to be aspirated.
Deciding whether a patient is suitable or not for the procedure involves a detailed discussion during a first consultation to determine the patient’s wishes, a complete history and examination, and appropriate body measurements such as weight and height.
Diabetes is not a contraindication for liposuction, as is speculated. These patients do well with careful blood sugar control using insulin/oral antidiabetic agents, light sedation, and medium to large liposuctions in one sitting.
Both parameters improve with liposuction. With careful blood pressure control, hypertension is not a contraindication for medium to large liposuction. Careful assessment and written agreement by the endocrinologist/cardiologist are needed.
An abdominal ultrasound/computed tomography scan is carried out in cases of suspected visceromegaly or mass in the abdomen. A careful check of hernial orifices is carried out, and suspected hernias are carefully excluded.
The patient should understand the extent and limitations of treatment and the costs involved, including the cost of a touch-up procedure if needed. If a large volume area is being treated or the patient wants to address multiple body areas, the possibility of staging the procedure should be discussed. If the patient is keen to continue, a second visit should be rescheduled for preoperative tests, photographs, and measurements.
Who is a Good Candidate for Abdomen Liposuction?
Abdomen liposuction is the most common office-based body contouring procedure. The ideal candidate has an average body mass index (BMI), good skin tone, protuberant areas of exercise- and diet-resistant fat, no comorbid disease, is a non-smoker, and has realistic expectations.
Requests for rejuvenation of the abdomens are increasing, particularly by young and middle-aged women, who are often well-educated and physically fit. They receive a psychological boost from the appearance of well-proportioned muscular abdomens.
There is evidence that early abdomen liposuction in one patient in these categories prevents progressive fatty tissue collection, resulting in ptosis of superficial fascia and skin ptosis and flaccidity.
The aging of the abdomen is highly variable. It depends on numerous factors, the most important of which is genetics. The net result is an unaesthetic appearance with various degrees of skin laxity and fatty tissue collections.
The increase in bariatric surgery for the morbidly obese has added to the group interested in the aesthetic improvement of their abdomens.
A successful Abdomen Liposuction patient must satisfy four key elements to achieve and keep optimal results:
- Lifestyle change
- Regular exercise
- Well-balanced diet
- Body contouring.
Who is Not a Good Candidate for Abdomen Liposuction?
Liposuction of the abdomen reduces subcutaneous fat and can result in conservative skin retraction, so it is a procedure that does not apply to patients with marked overhanging skin or a substantial proportion of intra-abdominal, visceral fat.
Abdomen liposuction is contraindicated in patients who are pregnant or in poor general medical health. Patients with morbid obesity, cardiopulmonary disease, body image belief issues, unrealistic expectations, wound healing difficulties, or who have extensive or poorly located scars should be excluded from consideration for abdomen liposuction.
Patients with any history of cardiac disease or arrhythmias should have an ECG. A chest X-ray is not performed routinely but should be considered in some older patients and heavy smokers, mainly when large volumes of tumescent fluid are needed, which may cause fluid overload.
During the initial and follow-up visits, calculating body mass index (BMI) is paramount to patient safety. BMI calculation is vital in follow-up visits to gauge long-term results. It is well known that morbid obesity (BMI > 35) imparts a threefold to fourfold risk from anesthesia.
Preoperative Preparation for Abdomen Liposuction
During this first interaction, the cosmetic surgeon must assess the patient’s goals of surgery and determine if the patient has realistic expectations regarding the outcome and postoperative body image. It is common for the patient to have unrealistic expectations. A dissatisfied patient is a failed procedure, so it is better to play down expectations and counsel the patient preoperatively that the goal of abdomen liposuction is improving contours and reducing fatty collection; of course, it is not perfect.
It is helpful to explain that efforts to remove all fat are likely to result in poor results, skin irregularities, or laxity and increase the risk of complications such as hematomas, seromas, and asymmetry.
Once the patient understands the concept of body contouring, instead of simply removing fat, and has realistic expectations, the likelihood of a successful outcome is higher
Patients with systemic diseases such as diabetes, hypertension, coagulopathies, and cardiovascular or respiratory disorders such as arrhythmias, angina, or asthma should be screened carefully or refused treatment in the office-based setting. Most patients should be ASA I or ASA II.
Category Preoperative health status
- ASA I Normal healthy patient, excluding very young and very old
- ASA II Patients with mild systemic disease but no functional limitations
- ASA III Patients with severe systemic disease
- ASA IV Patients with severe systemic disease that is a constant threat to life
Preoperative laboratory tests should include a complete blood count (white cell count, hemoglobin, platelets), coagulation tests (PT, PTT), renal function (urea, creatinine, potassium, sodium), and liver function (AST, ALT, bilirubin, alkaline phosphatase). Any abnormalities should prompt repeat tests and further investigation before the procedure.
Any concerns about a patient’s medical suitability to undergo anesthesia and an operative procedure should result in a referral for preoperative clearance with either an internist or cardiologist. This typically includes anyone with a significant medical history or patients older than 50 years of age.
Massive weight loss patients should undergo the same preoperative evaluation, and clearance for abdomen liposuction is the same as for any excisional-type body contouring procedure.
A detailed medical history should be obtained, including medications, allergies, and tobacco use. Critical are notations in the medical history of diabetes, massive weight loss, earlier surgery, previous liposuction, and a complete detailed list of medications and supplements.
- No aspirin or products holding aspirin (salicylic acid) should be taken for at least two weeks.
- Do not take a non-steroidal anti-inflammatory such as brufen, Voltaren
- Do not take any vitamins, especially vitamins C and E, for two weeks before surgery and for one week after surgery
- Discontinue all estrogens (check with your physician first) 4 weeks before surgery and two weeks after surgery
- Discontinue all benzodiazepines, such as Xanax, etc. These drugs slow lidocaine metabolism by inhibiting cytochrome P450 3A4. Lidocaine toxicity may ensue
Of course, if there is a medical indication and necessity for these drugs, consultation with the primary physician or appropriate specialist should be completed before discontinuing the medical therapy.
The physical exam is best performed before a full-length mirror, allowing an open dialogue between patient and physician. Attention must be paid to “gender ideal” muscular shape/ mass and fat distribution. Patients with round abdomens usually have fat deposits.
Poor skin contraction is likely if laxity is severe or if there are extensive striae from earlier weight gain or pregnancy. Abdominoplasty is sometimes righter than liposuction for these patients.
Scars should be noted and avoided during the procedure if they appear tethered to avoid inadvertent penetration of the abdominal wall.
Abdominal wall hernias must be checked carefully with the patient standing and supine, and if present, they should be repaired before liposuction.
For abdomen liposuction candidates, six key elements are documented
- Fatty tissue deposits and deformities
- Skin tone and quality
- Stretch marks
- Hernia’ orifices
- Superficial fat layers.
The patient is marked in the standing position, and a contour map is drawn with concentric circles, the central circle showing the thickest subcutaneous fat layer. The larger outer circles define the geographic region in the abdomen, such as the left and right abdomen and the left and right lower abdomen, with lateral areas marked as well. The midline is marked in preparation for suctioning and defining the Linea alba.
The author uses different colors to map out the plan for the procedure: blue or black in concentric circles stand for areas for fat removal and sculpting, straight lines that radiate from these rings are areas for less aggressive fat removal or feathering, and red markings represent areas of caution such as scars or areas where fat removal is to be avoided, and green markings represent proposed incision sites.
Incision sites should be marked. It should allow easy access to all areas to be contoured while placing them in discrete areas, such as below the bikini line or in the inframammary crease.
Blood pressure and pulse rate are measured, and the patient is weighed. The patient’s weight calculates a maximum safe dose of lidocaine administered is tumescent. Careful circumferential measurements (in centimeters) of the areas to be operated upon are performed. Immediately before surgery, all are weighed in kilograms and measured in centimeters. Measurements are repeated after one month.
Each liter of liposuction aspirate weighs approximately 0.9 kg of fat. We supply a goal weight for each patient undergoing body-contouring: this is their preoperative weight minus the weight of the tissue removed during surgery.
Measurements of the waist, hips, and area of largest abdominal circumference should be taken to document treatment results later and to enable a suitably sized compression garment to be chosen for the postoperative period.
A detailed step-by-step explanation of the procedure is given to the patient during the preoperative consultation. The potential risks and complications associated with liposculpture of the abdomen are explained again to the patient. It prepares the patient for what to expect and alleviates patient anxiety on the day of the procedure.
High-quality medical images should be obtained with anterior, posterior, lateral, and oblique views, documenting the results and objective evaluation of outcomes by both patient and physician. Findings may be challenging to interpret in more prominent individuals, males, or patients with multiple scars.
Following the first consultation, once the patient has decided to go ahead with abdominal liposuction, a second visit is scheduled for further assessment and routine preoperative tests. The second visit allows further dialogue between the patient and physician so that all questions may be answered and issues addressed.
The patient has sufficient information about the procedure, postoperative course, and long-term results to make a truly informed decision. The patient and physician should discuss the procedure, alternative treatments, financial obligations (including further surgeries if required), and complications and risks.
Informed consent is vital in evaluating and managing abdomen liposuction patients to protect the surgeon and the patient from unexpected outcomes or patient dissatisfaction. The operative surgeon should perform this vital process (not a nurse or staff) and be documented in the medical record.
Finally, a prescription for antibiotics and analgesia is given to the patient, with instructions to take the first dose of antibiotics the night before the procedure.
Abdomen Liposuction preoperative instructions
- You do not gain weight before surgery
- If you have any doubt about the surgery, do not have it done
- If you have had problems with drug or alcohol abuse at any time, notify the surgeon before scheduling the surgery
- Absolutely no smoking for at least two weeks before and two weeks after surgery
- Report to the physician any history of excessive bleeding or bruising
- Report all prior mental disorders or psychological problems to your surgeon
- If you have high blood pressure, report this to your surgeon
- If anticoagulants (blood-thinning) medication is being taken, this must be stopped at least five days before surgery, and blood tests must be taken before surgery
- Try not to schedule surgery on a day close to your menstrual period. It is preferable not to do surgery during the first five days of menstrual bleeding
- Take a shower daily with Betadine for three days before surgery
Patient Core Temperature
The patient is placed in a warming blanket 30–60 min before the procedure. The wetting solutions should be warmed at 38C and not administered cold. Also, calf compression devices are applied to the lower legs as preoperative precautions to assist in DVT prophylaxis and prevent the patient from becoming cold during the procedure.
Patient positioning depends on the area or areas that need to be treated, other procedures the patient will be undergoing, the patient’s body habitus/BMI, and surgeon preference. It is better to have excellent and efficient positioning allowing better contouring of the areas from several access points and directions to achieve the most significant aesthetic.
With that said, we believe that the prone and supine positioning offers the best opportunity to achieve symmetry by simultaneously evaluating the left and right sides of all body areas and reducing the need for revision. A urine catheter is placed for expected liposuction volume greater than 4 liters.
The author considers the anterior abdomen as one aesthetic unit and rarely treats just the lower or upper abdomen in isolation. A patient will be in the supine position and then turned over to the prone position for further contouring and blending of treatment areas. Properly, hips and flanks are included during the same procedure.
We are keeping the patient well-padded at all pressure points. The knees are placed on a pillow to encourage flexion, and anti-embolism support stockings and sequential compression devices are started before anesthesia
It is up to the surgeon to determine the optimal surgical setting for each patient undergoing liposuction. Factors that influence this decision are the amount of expected lipoaspirate, length and extent of the procedure, patient positioning, operating surgeon preference, anesthesiologist preference, and overall health of the patient.
Small-volume abdomen liposuction cases can be performed with local anesthesia, with or without mild sedation. Complex, large-volume abdomen liposuction and combined cases should be performed under general anesthesia.
The three types of infiltration methods – wet, superwet, and tumescent – differ primarily according to the volume of fluid used and infiltration/aspiration ratios. All three methods involve infiltrating physiologic intravenous fluid (lactated Ringer’s solution is preferred) and holding lidocaine and epinephrine. All our liposuction solutions are kept at a temperature of 38°C., the epinephrine is added to the Lactated Ringer’s solution just before infiltration.
The ratio of infiltration to aspiration is approximately 2:1. -1:1 for large-volume suctioning. For more minor procedures, the ratios are higher up to 10:1, i.e., 1000 mL of infiltration to 100 mL of aspirate.
The composition of the infiltration fluid depends on the amount of liposuction anticipated. The amount of epinephrine stays the same at one ampule (1 mL) per liter (1: 1 000 000) of Lactated Ringer’s, and we modify the lidocaine concentration depending on the amount of proposed liposuction to keep the dosage below the accepted maximum of 35 mg/kg.
I believe that tumescent infiltration should be carried out until the tissue has firmness and a slight “orange peel” appearance, which will help stabilize the tissue during the abdomen liposuction phase. The strict application of tumescent anesthesia allows safely to do large volume abdomen liposuction at ambulatory facilities with no risk.
Infiltration is performed through the preoperatively appointed assess sites. Tumescent fluid is delivered through the tubing with a motor-driven pump at a slow infusion rate (<50 mL/min)—infiltration into the superficial subcutaneous fat close to the dermis in sensitive areas. Later deep infiltration using the blunt cannula is easily tolerated, even in challenging fibrous areas.
The operating hand should move forward slowly and deliberately to fill between fat lobules at every level. In contrast, the other hand palpates the tissue from the surface, constantly aware of the location of the tip of the cannula. After withdrawing the cannula, a band-aid is placed to stem the flow of fluid from the incision site to prevent a reduction in pressure in the fat compartment.
Since tumescence is a temporary state, a top-up at once before aspiration of fat might be necessary to reestablish the firmness and turgidity required to stabilize the tissues.
Blood loss is less than 1 % of the total extracted volume. Major aspirations of 8–10 L imply a blood loss of no more than 80–100 mL, which in no way compromises the patient’s safety.
Large abdomens with soft fat and loose or slightly lax skin require more volume to reach tumescence than smaller abdomens or those with no striae or laxity and good skin tone. If large-volume infiltration is used, it is safer to inject by sections, even procedure’s duration due is prolonged. This way, a specific area is injected and extracted, and the next area is treated.
Major aspirations of 8–10 L imply a blood loss of no more than 80–100 mL, which in no way compromises the patient’s safety. If extraction over 10 L is considered, it is preferred to do the liposuction in two sessions.
Since the blood loss is minimal, the surgical trauma is low, and the drugs used as sedatives and analgesics are quickly metabolized, the second procedure can be done 1–2 weeks later.
The authors consider liposuction to be “large” when over 5,000 mL. In large liposuction, the anesthetic solution is injected with two infusions, and the extraction procedure is performed using two suction machines simultaneously. In general, we try not to extract over 10,000 mL per session.
Regardless of the technique used, the infiltration should be allowed 30 – 60 min before suctioning because the anesthetic’s estimated onset of action and the solution’s vasoconstrictor effect reach maximum. Following a 30–60 min permeation of local anesthesia will result in the homogenization of the adipose tissue. This effect is essential to facilitate suction and get regular postoperative results.
While waiting for the real action of tumescent anesthesia, we use external ultrasound energy to liquefy fatty deposits. Transdermal ultrasound will help in superficial liposuction and final contouring of the abdomen. Using ultrasound energy is vital in male patients or secondary procedures.
External Ultrasound with no suction is the noninvasive treatment of localized fat deposits of volume smaller than 300 ml by increasing the intracellular volume and rupturing the cellular membrane. I note that if fat grafting is considered, either ultrasound is not used or, if used, fat extraction can be done elsewhere.
For volumes more significant than 300 mL, we can combine external Ultrasound with either syringe liposculpture in small cases or power-assisted in large ones. External Ultrasound produced significant physician and patient benefits both operatively and postoperatively. Now the anesthesia has reached its peak. The skin looks blanched and firm.
Ultrasound-Power assisted Liposuction (U-PAL)
The author employs external ultrasound to emulsify fat before it is gently aspirated. There are several advantages of external ultrasound synergistically with PAL.
While waiting for tumescent anesthesia to achieve its maximum effect, the author provides external transdermal ultrasound helping to melt fat, especially in the upper abdomen, to ease fat extraction.
We always combine power-assisted, suction-assisted, and syringe-reduction liposuction. At first, a 3 mm spatula or multi-hole reciprocating cannula is first applied without suction (pre-tunneling). The tunnels are made in a crisscross fashion. Refinement is carried out in the superficial plane using small 2.0-mm or smaller cannulas.
The entire lower abdomen can be treated through two small access incisions below the bikini line. Access incisions are placed at the inframammary crease in line with the lower abdominal incisions to access upper-fat deposits. No hesitation should be made to place extra incisions to ensure complete treatment. The incision may be made in the umbilicus. It is preferable that if the patient has a prior scar from an abdominoplasty, incisions are made within the old scar.
I always start with syringe fat extraction for later use. I usually collect more fat than I might need, an average of 100 ml of pure fat.
Liposuction starts with suction-assisted liposuction or SAL. Cannulas of varying lengths and calibers are chosen to address areas of concern. We start 4mm-5mm to debulk deep fat in large abdomen liposuction. The 3.7 mm Mercedes-style cannula is one of the more versatile cannulas for the abdomen.
Liposuction is performed constantly, sweeping the region, and working from deep to superficial. A crisscrossing maneuver uses a long cannula to remove the fat on the same or opposite sides. The operating hand moves forwards and backward radially like the spokes of a wheel while the other hand stabilizes the skin over the tip of the cannula. As suction continues, the pinch test is performed intermittently to assess symmetry and reduction in thickness of the fat layer.
When performing liposuction of the hips and flanks, consideration of the gender difference is crucial. Anteriorly, the flank blends with the tissue of the lower abdomen in men. In contrast, the female hip is inferior and typically centered over the posterior iliac crest. Access to the hip and flank can be achieved via two inferiorly placed lateral paraspinous incisions that are easily concealed by under bathing suits.
The most advantageous of power-assisted liposuction is its usage in superficial layers with or without suction for tunneling and promoting skin redraping and tightening. Superficial abdomen liposuction is frequently applied to lax skin and excess fat patients. The surgeon must smoothly transition between different treated areas of the abdomens. However, he should emphasize the differing aesthetic difference between males and females, particularly when applying liposculpture.
In addition, feathering should be done with less suction and a smaller cannula or using a syringe reduction technique to create a smooth transition between contours.
More concentrated liposculpture is performed in the midline to enhance or create the appearance of defined rectus abdominis muscles. The PAL cannulas have been used further to etch horizontal depressions on either side of the midline to create the appearance of rectus abdominis muscle fitness in men.
Cannula strokes without suctioning are used well beyond the operative area radially to help to prevent irregularities in the abdomen and hips/ flank areas.
The procedure utilizes 2–4-mm Mercedes cannulas when lipoaspirate trying to obtain parallel defatting tunnels without nodules or thickening skin. Usually, only one surgeon operates with a homogenous approach to the operative field.
It is helpful for an assistant to work on the other side in the deep planes. However, the primary operating surgeon refines the surface when lipoaspiration approaches the subdermal fat.
Surgical Endpoints of Abdomen Liposuction
The skin of the abdomen can be prone to contour irregularities. Constant feedback from the tissues by manual palpation, pinch, and symmetry assessment helps decrease the likelihood of contour irregularities.
The endpoint is reached when the desired amount of debulking and improvement in body contour has been achieved based on the pinch test and careful inspection from different vantage points in the operating room.
Measured volume aspirated is a good indicator for bilateral procedures to judge symmetry and contour, comparing each side to the opposite. Other indicators such as treatment time, blood in aspirate, and amount of aspiration are essential factors to consider.
Other Techniques that Can be used in Abdomen Liposuction
Ultrasound-assisted liposuction utilizes ultrasonic energy to break down fat and facilitate suction-assisted removal. This technique emulsifies fat, which allows removal through traditional liposuction cannulas. Its mechanism of action is also primarily mechanical, but cavitation and some thermal effects are alleged to occur. UAL comprises three stages: (1) infiltration, (2) emulsification, and (3) evacuation and contouring. Skin protection may be utilized to help protect the skin from thermal injury.
Laser-assisted liposuction has been at the forefront of marketing hype at present. The treatment involves the insertion of a laser fiber via a small skin incision. The most common available wavelengths in the United States are 924/975 nm, 1064 nm, 1319/1320 nm, and 1450 nm. These devices employ a four-stage technique: infiltration, application of energy to the subcutaneous tissues, evacuation, and finally, subdermal skin stimulation. The belief is that heating the subdermal tissue may provide a skin-tightening effect. Prof Moawad is not convinced it yields clinical differences.
Water-Assisted Liposuction (WAL)
WAL burst onto the scene in 2007 for awake liposuction, allowing improved contouring facilitated by an awake patient. First, the standard wetting solution is injected in the form of a fan-shaped spray by a waterjet approximating the force of a strong shower. As anesthesia takes effect, a more dilute solution is substituted. This constant fluid flow increases adipose cell detachment and reduces the risk of adverse volume-related fluid-electrolyte shifts, circulatory overload, and postoperative edema. It also shortens the procedural time in large volume liposuction and has been shown to promote blood-sparing fat removal in lipedema.
Radiofrequency-Assisted Liposuction (RFAL)
radiofrequency-assisted liposuction (RFAL) utilizes diathermy-like bipolar radiofrequency energy to disrupt fatty cells. A beneficial secondary effect on skin contraction is also claimed, and much like LAL, it causes a thermal injury at the subdermal surface.
IMPORTANT NOTES FOR THOSE WHO ADVOCATE THE USAGE OF THERMAL INJURY TO REMOVE FAT
Various technologies have facilitated fat removal over the past three decades. Many of these have used thermal injury. Thermal energy is introduced with ultrasound, laser, and radiofrequency-assisted liposuction. However, the thermal load imparted the creation of additional fibrosis, scarring, and contour irregularities. Therefore, using thermal devices designed to eliminate fat increases liposuction complications.
Post Operative Notes of Abdomen Liposuction
At the end of the operation, we use a specially made roller to gently milk out the remaining tumescent solution and break down fat cells from the entry points. Sutures are not applied to the entry points for easy dripping of the fluids allowing for easy drainage of the fluids during the postoperative period.
When all tumescent solution is drained from the surgery site postoperatively, gradual adherence and shrinking of the subcutaneous wound are initiated, resulting in a global three-dimensional wound contraction and a horizontal subcutaneous scar.
Occasionally, when skin folds or creases are expected, the patient is dressed in a supine position, and the area is dressed while applying tension on the skin flap. The author uses the first layer of cotton pads next to the skin, followed by an elastic bandage. Elastoplast on top of uniform placed elastic bandage is applied for two-three days. It helps diminish bruising and edema in our hands. Compression is essential to achieve accurate redraping of the skin.
Immediately following the procedure, the patient rests in the office for an hour or two and is supplied with light nutrition. Once they feel well and are supplied with typical vital signs, they are allowed home accompanied by a friend or relative. Patients require hydration to flush their kidneys from fat that may enter their systemic bloodstream and embolize. Hydration is encouraged for the first week after liposuction.
The analgesic effects of the tumescent anesthesia last several hours, after which simple analgesia is usually sufficient. Antibiotics, such as cephalexin, are continued for five days, and more potent analgesia is prescribed for three days but is usually not needed.
Some pink drainage, not bright red, is expected and may be profuse the first night. The patient or caretaker should call the doctor if there is bright red bleeding through the dressings, drainage of pus, increasing pain, or other unusual symptoms (fainting, shortness of breath, abdominal pain, chest pain, mental confusion, etc.
The Elastic bandage, micropore, and sterilized cotton bandage are removed on the second postoperative day; for easy lymphatic drainage and quicker to reduce inflammation. The patient is instructed to take a shower after removing the dressing. Often, patients remove their dressing and shower at home.
A patient will wear the compression garment 24 h per day, removing it only to shower for the first week. The garment will then be worn for the second week, 18 h per day, and for the third week, 12 h per day. Patients were evaluated at 24 to 48 hours, one week, and then 1, 3, and 6 months and one year after surgery
Patients are asked to ambulate on the day of the surgery. Light activity is allowed two weeks after surgery. Heavy physical activity (including gym, jogging, and extreme physical exercise) is strongly recommended after one month.
The severity and duration of skin hardening were directly proportional to the subdermal release performed to obtain skin retraction. Stretching exercises were prescribed from 1 to 6 months postoperatively.
External Ultrasound is used starting the following week after the surgery to improve the abdomen contour further and provoke a quicker reduction of inflammation. Ultrasonic therapy will be continued for skin hardening, irregularity, and ecchymosis. Bruising should be minimal and dissipate by 7–10 days after surgery.
Patients should expect to initially gain weight after abdomen liposuction due to volume shifts and postoperative swelling. Edema tends to peak from 3 to 5 days after surgery.
Patients should begin to see contour changes in their abdomens by two weeks, and at six weeks should be able to appreciate significant changes in their shape.
Maximum shrinking is usually seen after four months. As patients’ activity levels improve and necessary lifestyle changes proceed, further changes may be noticed. Depending on the patient, the final aesthetic result can be seen 3–6 months after surgery. The total wound healing time continues for 18 months.
Complications of Abdomen Liposuction
In our experience, liposuction complications of the abdomen are rare when performed by experienced surgeons. The most common complication is under-correction of the deformities and the need for a secondary “revision” procedure.
Abdominal liposuction may lead to skin laxity where full subcutaneous fatty pockets exist, particularly above the umbilicus—skin folding results, especially when patients. Discussion with patients before surgery must inform them of this possibility, and the potential upside/downside of liposuction versus abdominoplasty, allowing for the staging of these two procedures as needed.
Hyperpigmentation at the incision site is common, especially in Hispanic and black patients. This pigmentation is often post-inflammatory hyperpigmentation and resolves over four to six months.
Postoperative complications occur in three different windows. These are the perioperative period (0–48 h), early postoperative period (days 1–7), and late postoperative period (1 week to 3 months).
Liposuction surgery, especially when it involves multiple areas, places the patient at risk for hypothermia. Preventative measures include; warming the wetting solutions, increasing room temperature, and using warming blankets.
Fluid imbalance as a complication might occur in large volume liposuction, whether volume loss from bleeding or overload from excess injected fluids. Preventative measures include preoperative medical clearance when patients are over 50 years of age or have any concomitant risk factors, such as cardiopulmonary disease. Careful management of fluids helps prevent volume-related complications from large volume liposuction.
Fat emboli are a valid concern with higher volumes of liposuction. These patients are treated as patients with pulmonary embolism with 100% oxygen supplement and hydration.
The incidence of DVT in liposuction has been reported at <1%. However, this percentage is markedly increased when liposuction is combined with other surgery. Other early postoperative complications include venous thromboembolism, infection, and skin necrosis.
Wound infections, including necrotizing fasciitis, are serious complications fortunately, are rare. Complaints of persistent postoperative fevers or cellulitis should be closely monitored and aggressively treated. As a preventative measure, one gram of first-generation cephalosporins is administered at the beginning of liposuction. The course of antibiotics started one day before the operation will be continued in the postoperative period.
Late liposuction complications
include delayed seroma formation, edema and ecchymosis, paresthesia, hyperpigmentation, and contour irregularities. A loose closure of cannula sites, postoperative compression garments, and expression of residual fluid over liposuction areas at the end of the procedure can reduce the incidence of seroma formation.
Postoperative edema and ecchymosis occur to a varying extent in all patients. Significant ecchymoses may result in hemosiderin deposition and hyperpigmentation. Prolonged edema can occur up to 3 months post-surgery and is best treated with supportive care and lymphatic massage.
Postoperative paresthesia/dysesthesia can occur in all forms of liposuction. The sensory changes are usually reversible and can take up to 10 weeks to recover.
Large Volume Abdomen Liposuction
As the prevalence of obesity continues to increase, so do the accompanying risks to health and lifespan from hypertension, diabetes, coronary artery disease, and increased surgical morbidity and mortality. It is worth emphasizing that liposuction is only one of the weapons to fight against being overweight. After surgery, patients are better motivated to start a program including a dietary regimen and physical exercise, or in other words, a complete change in their lifestyle
Large-volume liposuction offers weight loss in patients who need faster weight loss to get immediate compliance to lower caloric intake and higher physical, calorie-consuming activity. Liposuction is worthwhile to consider as a reasonable alternative to other medical and more invasive surgical slimming methods.
Large volume liposculpture can be performed safely on healthy overweight patients. It improves body contour and image and reduces cardiovascular risk factors such as obesity, systolic blood pressure, and plasma insulin. It may even prevent or delay the development of diabetes or impaired glucose tolerance if the previously mentioned beneficial effects are long-lasting. Therefore, the resultant morbidity and mortality decrease.
When fat is extracted simultaneously from various body sites in the same session, the waist, hips, flanks, and abdomen, it is possible to obtain increased patient satisfaction. If the patient is very obese, the procedure should be divided into several interventions rather than one. It is good to remember the saying, “In cases of liposuction, entry points are small, but the wound is large.”
High-Definition Abdomen Liposculpture
High-definition liposculpture elevated the concept of abdominal etching. It uses musculoskeletal anatomy as a topographic template. We do liposculpture according to musculoskeletal topography and emphasize the muscloskeletal topography by fat injection. The typical candidate works out regularly and may be at or near ideal body weight. Using fat injection in every instance of liposculpting gives sculpting surgeons a new and powerful tool for sculpting.
Abdomen liposuction with Mini abdominoplasty
Mini abdominoplasty is an excellent procedure that combines liposuction, skin tightening, and a short scar. The ideal candidate is someone who already has a suprapubic horizontal scar, such as for cesarean section, and is young and fit except for some lower abdominal muscle weakness.
Hi-Definition Liposculpture has turned the liposculpting surgeon’s operating room into an art studio. Sculpting the abdomen under tumescent local anesthesia is safe and satisfying for both surgeon and patient. Circumferential abdomen liposuction and the adjacent areas lead to maximal three-dimensional skin retraction.