Reoperative Aesthetic & Reconstructive Plastic Surgery

1626
PART V
R EOPERATIVE SURGERY OF THE TRUNK
CORRECTION OF CONTOUR IRREGULARITIES
AND DEPRESSIONS
This 44-year-old woman underwent liposuction of the thighs, knees, and buttocks
1 year before presentation. She was noted to have circular, linear, and irregular-
shaped depressions in the medial, lateral, and anterior thighs. Preoperative surgical
marking of areas of maximum indentation were made in solid red. Intermediate ar-
eas of indentation were marked with parallel red lines, and red circles indicated ar-
eas with lesser degrees of indentation. Areas of protuberance were indicated by
crosshatched lines or Xs. Anterior and medial thighs and the knees were aspirated
with the patient in the supine position under general anesthesia.

The aspirated fat was injected into the area of depression using 14- and 16-gauge
intravenous catheters. The patient was next placed in the prone position. The fat
was aspirated from the posterior aspect of the thighs. Of a total of 1400 cc of aspi-
rated fat, 200 cc was injected into various areas of indentation and depression.
1627
Chapter 41
Reoperative Liposuction
Fourteen months after the rst corrective procedure, several areas of the thighs ap-
peared full and out of balance with the rest of the thighs and body. Some areas of
the thighs had received less liposuction than others up to this point. The hips and
the abdomen also appeared full. Additional liposuction without fat grafting was
performed.

1628
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The postoperative results at 4 years 10 months after the rst corrective procedure
show good improvement in the anterior, medial, and lateral thighs and the knees.
A slight indentation persisted in the left lateral thigh.
The postoperative results remained stable at 13 years 4 months.

CORRECTION OF DIFFUSE IRREGULAR INDENTATIONS
AND PROTUBERANCES
1629
Chapter 41
Reoperative Liposuction
This 45-year-old woman had liposuction in multiple body areas using tumescent
technique;she underwent a second procedure for improvement. A total of 1500 cc
of aspirate was removed from the abdomen. At consultation she was noted to have
diffuse, irregular, circular, and oval indentations of the lower abdomen and redun-
dant skin in the upper abdomen.
Preoperative surgical markings identi ed areas of protuberance in the right lower
lateral abdomen, suprapubic area, supraumbilical area, and multiple areas of inden-
tation in the lower abdomen. Areas of protuberance were in ltrated with 0.25%
lidocaine with 1:800,000 epinephrine and treated with SAL. An internal ultra-
sound device was used to create space for fat grafting in densely brotic subcuta-
neous tissue of the lower abdomen.The Lysonic 2000 cannula at a power setting of
2 was introduced into the subcutaneous space of the lower abdomen caudal to the
umbilicus after wetting solution was in ltrated.

1630
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The use of the ultrasound device permitted breakthrough of the scar, which was
con rmed by passing a blunt 2.4 mm cannula without suction.
No fat was aspirated during the application of ultrasound. A total of 15 cc of fat was
transferred into the lower abdomen. The deeper level was injected using a blunt-
tipped cannula. Sharp circumscribed indentations were injected with an 18-gauge
needle at the super cial (subdermal) level. Postoperatively, the abdomen was cov-
ered with nonsticky foam and an elastic garment.
Twenty months postoperatively,some improvement in the contour was seen. (NOTE:
UAL is rarely used in corrective liposuction to maximize fat preservation.14)

TREATMENT OF FATTY DEPOSITS AT SECONDARY SITES
1631
Chapter 41
Reoperative Liposuction
This 71 kg (157-pound) nulliparous woman underwent SAL of the lateral, upper
posterior, and medial thighs, buttocks, and hips at the age of 37. A total of 1950 cc
of aspirate was removed. Improvement in the contour was noted in the posterior
view of the body.
Thirteen months later, she had additional SAL in the lower abdomen, anterior
thighs, and medial knees. Total aspirate was 790 cc. The upper abdomen was not
treated.

1632
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Fourteen years after the initial operation, at age 51, still nulliparous and 9 kg heav-
ier, the patient returned for liposuction in the upper abdomen, anks, waist, and the
back. UAL with Lysonic 2000 was used to remove 4475 cc of aspirate (2625 cc of
fat).
Postoperative results after 3 months show reduction in the size and improvement in
the contour of the trunk and lower back. However, possibly because of the initia-
tion of hormone replacement therapy 1 month earlier, she had gained 3.8 kg, and
her buttocks and thighs grew larger.

References—With Key Annotated References
1. Chang KN.The use of intraoperative grid pattern markings in lipoplasty. Plast Reconstr Surg
114:1292, 2004.
2. White DJ. Ultrasound-assisted liposuction: Operative techniques. Plast Reconstr Surg 8:133,
2002.
3. Barton F, Markman B. Anatomy of the subcutaneous tissue of the trunk and lower extremity.
Plast Reconstr Surg 80:248, 1987.
4. Lockwood TE. Super cial fascial system (SFS) of the trunk and extremities: A new concept.
Plast Reconst Surg 87:1009, 1991.
5. Rohrich RJ, Smith P, Marcantonio DR, et al. The zones of adherence: Role in minimizing
and preventing contour deformities in liposuction. Plast Reconstr Surg 107:1562, 2001.
This article identi es ve zones of adherence in the trunk and extremities to be avoided to prevent
contour deformities when performing circumferential liposuction: laterial gluteal depression, gluteal
crease, distal posterior thigh, midmedial thigh, and infralateral iliotibial tract.Two patients who un-
derwent fat grafting in the buttocks and posterior, lateral, and medial thighs are illustrated.
6. Chang KN. Correction of contour deformities after liposuction. In Nahai F, ed. The Art of
Aesthetic Surgery: Principles & Techniques. St Louis: Quality Medical Publishing, 2005, p
2248.
7. Chang KN. Surgical correction of postliposuction contour irregularities. Plast Reconstr Surg
94:126, 1994.
This article presents surgical treatment of postliposuction contour irregularities with secondary liposuc-
tion and fat grafting and the outcome in 43 areas of the body in 22 patients.The surgical results in-
volving the lateral, posterior, and medial thighs, abdomen, hips, and waist in ve patients are illus-
trated.
8. Chang KN. Long-term results of surgical correction of postliposuction contour irregularities.
Plast Reconstr Surg 109:2141, 2002.
Long-term surgical results are presented in ve patients, ranging from 5 years to 13 years 4 months.
The bene cial results of the procedures, which have been previously reported, continue to be observed
during the follow-up.
9. Illouz YG. The fat cell “graft”: A new technique to ll depressions. Plast Reconstr Surg 78:
122, 1986.
10. Teimourian B. Repair of soft tissue contour de cit by means of semiliquid fat graft. Plast Re-
constr Surg 78:123, 1986.
11. Fodor PB. Secondary lipoplasty. Aesthet Plast Surg 22:337, 2002.
The author presents clinical classi cation of candidates and indications for secondary lipoplasty.The
results of secondary liposuction, dermolipectomy, and fat grafting in the abdomen, lateral buttocks,
and thighs in three patients are illustrated.
12. Coleman SR. Structural fat grafting. In Nahai F, ed. The Art of Aesthetic Surgery: Principles
& Techniques. St Louis: Quality Medical Publishing, 2005, p 289.
13. Saylan Z. Liposhifting instead of lipo lling:Treatment of postlipoplasty irregularities. Aesthetic
Plast Surg 21:137, 2001.
The author presents a technique in which the subcutaneous fat adjacent to the area of depression is
loosened with a specially designed cannula and shifted to adjacent area of depression by external
pressure. No fat is removed from or reintroduced into the patient.
14. Beckenstein MS, Grotting JC. Ultrasound-assisted lipectomy using a solid probe:A retrospec-
tive review of 100 consecutive cases. Plast Reconstr Surg 105:2161, 2000.
1633
Chapter 41
Reoperative Liposuction

1634
PART V
R EOPERATIVE SURGERY OF THE TRUNK
1. Which of the following is not a contributing factor to poor aesthetic results fol-
lowing liposuction?
a. Cannula with a bore that is too large
b. Excessive tumescent in ltration
c. Suboptimal incision placement for cannula access
d. Feathering at the periphery of a liposuction site
e. Overresection of subdermal fat
2. Which of these is a useful secondary surgical option for the treatment of post-
liposuction contour irregularities (indentation, depression, protuberant areas fol-
lowing inadequate resection) and/or extensively altered or redundant skin?
a. Repeat liposuction
b. Autologous fat injections
c. Dermolipectomy
d. All of the above
e. None of the above
3. To correct contour irregularities from lipoplasty, which of the following is an
important detail involved in the preparation of fat for autologous grafting?
a. Minimizing tumescent solution in the area of fat harvest
b. Using strong vacuum suction (40 mm Hg) to ensure prompt, atraumatic
removal of lipocytes
c. Extensive, homogenous in ltration of tumescent solution into the area to
be corrected to mimimize the risk of hematoma following injection
d. Injecting the fat before the aspirate has had a chance to form separate layers
e. Rinsing the aspirated fat with dilute antibiotic and saline
4. Which of the following maneuvers are used to improve the precision in fat in-
jection when performing fat grafting to correct postliposuction contour irreg-
ularities in truncal areas containing dense subcutaneous scarring?
a. Use of a blunt-tipped cannula for pretunneling prior to injection
b. Placement of fat using a sharp needle
c. Placement of fat using a blunt needle
d. a and b
e. a and c
5. What procedure should be used to correct a noticeable depression caused by
overresection during a liposuction procedure in the lateral thighs?
a. Lateral thigh lift
b. Autologous fat injection
c. Thinning of the surrounding area to equal the thickness of the overre-
sected area
d. Purse-string suture around margin of overresected area
e. None of the above
R EVIEW QUESTIONS

1635
Reoperation After Liposuction
and Body Contour Surgery
Ricardo Baroudi
C ha pter 4 2
Reoperative Problems
Insuf cient or excessive fat removal
Bulging
Skin irregularities
Incorrect placement of umbilicus
Skin laxity
Scar malposition
Perhaps the single most important element
in mastering techniques and tactics is experience.
Once you have the fundamentals, acquiring
the experience is a matter of time.
Greg LeMond
Body contour surgery most frequently involves the breasts, abdomen, anks, but-
tocks, thighs, and arms. Although this surgery produces the necessary body con-
touring, the associated sequelae, particularly the long, unpredictable scars, are often
objectionable and a lingering problem for patient and surgeon.The results of body
contour surgery have improved signi cantly with the introduction of liposuction
for fat removal. This technique leaves inconspicuous scars and offers patients an
excellent option for body sculpturing. Liposuction and traditional aesthetic sur-
gery operations can be staged or performed in combined procedures to improve

1636
PART V
R EOPERATIVE SURGERY OF THE TRUNK
postoperative results and to accommodate anatomic and histologic characteristics
and aging changes encountered in each body region.
In body surgery the potential need for a minor or a major reoperative procedure al-
ways exists.The effect of aging on the human body is unpredictable. One might ask
why healthy people in the same decade of life, even at the same age, look so differ-
ent and have such diverse body con gurations. We know that genetics, lifestyle,
disease, and diet can in uence body appearance.We also know that body shape and
skin quality, musculoaponeurotic texture, and fat deposits can affect the appearance
of the body.When surgery is performed, these same factors will in uence the suc-
cess of the nal result. Even without the occurrence of complications (for example,
necrosis, hematoma, and infection), natural factors beyond the surgeon’s control
may compromise the nal surgical result and bring about the need for reopera-
tion. The need for reoperation can be attributed to improper surgical planning,
anatomic and tissue failure, poor patient selection, incorrect choice of procedure,
poor technique, and complications beyond the surgeon’s control. In some cases the
patient’s unique body structure can be responsible for poor results, even when a
well-quali ed expert has performed the operation. No surgeon achieves 100% suc-
cess; reoperation is always a possibility.
PATIENT-PHYSICIAN RELATIONSHIP IN THE
REOPERATIVE ENVIRONMENT
There are no speci c rules for treating an unsatisfactory result or for anticipating the
response of an unsatis ed patient. Each patient’s expectations and emotional behav-
ior will vary according to personality, education, or family involvements.
The surgeon should be careful to offer the patient the feeling of absolute under-
standing during the healing period. If the surgeon fails by overlooking a signi cant
detail or by tactless, negligent, or imprudent behavior, this patient-physician equi-
librium can be easily disrupted. Reoperative candidates are highly insecure. Most
likely their rst surgical experience was disappointing and has made them unhappy
and anxious.
Setting a deadline for the completion of projected corrections is rec-
ommended to encourage the patient to persevere with the surgery to
achieve a de nitive solution to the problem.
Patients who present with a still unresolved complication from a previous surgical
procedure are anxious to have the problem corrected as quickly as possible.Very of-
ten they do not understand the extent of the complication and its possible conse-
quences.Whatever the situation, the surgeon should present an optimistic outlook.
In dangerous situations or in those in which the surgeon recognizes that there are
limitations to solving the problem, providing accurate information and documen-
tation to the patient is important for ethical and legal reasons. The patient should

1637
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
be informed of the expected result, the number of surgical stages required, the
length of postoperative recovery, and the cost.
Patients without complications but with suboptimal results can also become frus-
trated with their surgeon. Refusing to tolerate another disappointment, they fre-
quently search for another surgeon who can improve the result. With these pa-
tients it is imperative to establish what improvements can be realistically achieved.
It is better to offer less than more. If the results exceed the patient’s expectations, the
patient will be happier.
In complex primary operative situations in which suboptimal or poor results could
occur, the patient should be informed of this possibility.
Dif cult cases often require second procedures at a later date. This
concept—that any secondary procedure is part of a surgical plan—
should be clearly indicated on the surgery consent form, and the pa-
tient should understand that to attain the desired effect, a second or
even a third stage may be necessary.
The patient is also informed that no fee will be charged for additional procedures;
he or she will be responsible only for hospital charges and in certain situations for
the anesthetist’s fee. The secondary procedure is usually performed 6 months to 1
year later.
Even with the best communication, there is a small group of patients who demand
results beyond those which can be attained surgically. Given the negligible im-
provement that can be achieved and the unreasonably high patient expectations, for
these dif cult patients reoperation should not be recommended.The surgeon must
be able to distinguish which patients will bene t from revisional surgery and which
chronically dissatis ed patients will never be pleased. For this latter group, it is bet-
ter to refuse reoperation.
LIPOSUCTION
With liposuction the nal result is a combination of fat removal and skin retraction.
Determining the correct amount of fat removal to obtain a perfect result is dif cult,
because liposuction is a blunt and inexact procedure that always results in some in-
jury to the subcutaneous fat. Furthermore, skin elasticity, scarring, and the extent of
injury to the subcutaneous fat are unpredictable at best.The patient’s age, skin tur-
gor, body shape, and the surgeon’s experience also in uence the nal result.
The following basic questions need to be addressed: How much fat should be re-
moved? Are one or two stages needed? When is liposuction not needed and skin
excision preferable? When should liposuction be used alone? When should liposuc-
tion be used in combination with traditional aesthetic surgery procedures?

1638
PART V
R EOPERATIVE SURGERY OF THE TRUNK
In an attempt to clarify the indications for speci c procedures, I have developed a
classi cation of liposuction candidates (above). Regardless of the classi cation, it is es-
sential for the surgeon to determine the type of procedure indicated and how it
should be performed.
Until recently, liposuction of the anterior abdominal wall has always been consid-
ered potentially dangerous because of reduced blood supply to the abdominal skin
ap and the potential for skin loss. Recently, Avelar1 and Saldanha2 have introduced
techniques that allow conventional skin resection and aggressive liposuction in the
same surgical stage.The following case demonstrates the Saldanha technique.
Patient Classi cation for Liposuction
Characteristics
Type
Treatment
Group 1
Good skin turgor,
Young patients
Liposuction in one stage
no accidity, moderate
fat deposit
Group 2
Moderate or voluminous
Patients over 35 years of age; young
Liposuction in one or two stages
fat deposit, no accidity,
patients with weight uctuation
(depends on degree of accidity
mild skin turgor
problems; patients with excessive
after rst procedure)
skin laxity
Group 3
Skin accidity, fat deposits
Patients in their forties or older;
Liposuction and surgery in one
young patients with structural or
operation or staged
metabolic problems
Group 4
Skin accidity
Traditional surgery alone (no lipo-
suction)
The procedure is begun with liposuction in the anterior and lateral abdominal
walls as necessary.The liposuction is designed to allow mobilization of the superior
skin ap without extensive undermining. Both deep and super cial liposuction is
performed and includes the ellipse of tissue that will be eventually removed in the
hypogastrium.This allows the ultimate scar to be a little shorter than the conven-
tional approach.
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1639
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
Using a specialized retractor that will allow access over the rectus muscles, under-
mining is accomplished only to the lateral borders of the rectus muscles. Standard
plication is performed from xyphoid to umbilicus. The skin ellipse is removed
above Scarpa’s fascia leaving the defatted subcutaneous tissues attached to the mus-
cles in the hypogastrium. Only a central segment of the subcutaneous tissues is re-
moved in order to complete the plication from umbilicus to pubis.With the supe-
rior abdominal ap fully mobilized by liposuction, it is generally possible to remove
the same amount of skin in the hypogastrium as with a conventional abdomino-
plasty.
The final closure is kept as low as possible with an ideal measurement of 7 cm from
the anterior vulvar commissure to the suture line.

1640
PART V
R EOPERATIVE SURGERY OF THE TRUNK
These illustrations demonstrate the variation in the degree of undermining in the
superior abdomen with conventional abdominoplasty, the Saldanha technique, and
my preferred method. As can be seen, the conventional technique requires the
greatest amount of undermining, and the Saldanha technique requires the least.
My preferred method allows diminished undermining, but I prefer to perform the
extensive defatting of the anterior and lateral abdominal wall in a second stage.
Nevertheless, the Avelar and Saldanha techniques are becoming more accepted in
Brazil and abroad. Our preferred technique is to do an open trimming of the fat be-
neath Scarpa’s fascia with scissors or knife leaving the additional liposuction for a
second-stage procedure 6 months after the initial abdominoplasty. With this ap-
proach, the abdomen retains good skin turgor and no accidity (see group 1 in the
table). Scar revision can be carried out at the second stage when necessary. Sal-
danha reports a revision rate of 12%.3 Our revision rate has been approximately
22%.
PROBLEMS FOLLOW ING LIPOSUCTION
Patient complaints after liposuction most commonly are related to insuf cient or
excessive fat removal, skin irregularities, and skin laxity resulting from poor skin
retraction. Following liposuction of the abdominal wall, even when indicated, these
problems can be compounded by body weight variations after the surgery.The un-
predictable capacity of the skin to shrink with more than 6 kg (13 pounds) of
weight loss may affect skin turgor. It is unclear why, in patients of similar age, the
skin reacts differently when suctioned.
Conventional abdominoplasty
technique
Saldanha’s technique
Baroudi’s technique

1641
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
The effect of weight uctuations after liposuction is
illustrated by this 37-year-old patient who had prior
liposuction in hypogastrium and thighs. Four years
later,she returned with abdominal skin accidity sub-
sequent to several episodes of weight loss and gain.
She is shown preoperatively and 8 months postoperatively after routine abdomino-
plasty. Because she was unhappy with scar quality and the residual ank and hy-
pogastrium fat deposits, scar revision and secondary liposuction were performed.
Four months after these reoperative procedures, a
handlebar-shaped scar remains. The scar is suffi-
ciently high at the inguinal regions and low at the
pubis to remain hidden under a bikini.

1642
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Insuf cient fat removal occurs when the surgeon does not accurately estimate pre-
operatively the volume to be suctioned, when the patient has excessive fat volume,
or when liposuction has to be terminated before the desired amount of fat is re-
moved because of possible secondary laxity resulting from limited skin retraction.
In the case of insuf cient liposuction, a minimum of 6 months should elapse before
additional fat removal is attempted. When skin retraction is poor, as in patients in
group 2, secondary liposuction should not be attempted. Patients in group 1 have
excellent skin for suctioning.This is also true of patients in group 3, whose skin tur-
gor tends to improve after the surgery and becomes similar to that of patients in
group 1.
This 34-year-old woman had moderate fat deposit and skin flaccidity in the
supraumbilical regions, anks, and lateral trunk areas. Liposuction was performed.
Eight months postoperatively, the patient still complained of residual bulges in the
hypogastrium and anks. Reoperative liposuction was performed to complete the
treatment.

1643
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
No accidity or indentations were evident after the second liposuction. Natural
skin retraction occurred.The improvement in contour can be observed on compar-
ison of the preoperative and postoperative lateral views.
Excess fat removal causes localized skin irregularities, indentations, and skin accid-
ity which are dif cult to correct. The treatment for excessive fat removal is based
on a logical approach, i.e., fat injection to attempt to restore the turgor and to elim-
inate the problems of irregularity.There is no question that the technique of fat in-
jection has greatly improved to the point at which smaller irregularities and depres-
sions can be routinely handled with permanent and excellent results (see Chapter
41). Although one or more sessions may be required to achieve satisfactory results
even in small to moderate deformities, we have seen in increasing numbers prob-
lems related to liposuction that cannot be corrected by fat injection alone.The fol-
lowing three patients illustrate postliposuction deformities that cannot be com-
pletely corrected with fat injection, in our opinion.

1644
PART V
R EOPERATIVE SURGERY OF THE TRUNK
This patient was referred to us for consultation. As
can be seen in the posterior and lateral views, the
skin of the anks and the lateral aspect of the trunk
reveals almost complete fat removal to the level of
the dermis with indentations and irregularities pres-
ent in all regions. We did not feel that fat injection
alone even in multiple stages would successfully cor-
rect this problem.
In this patient the epigastrium reveals severe folding, indentations, and accidity as
a result of what appears to be a “miniabdominoplasty.” Perhaps periumbilical skin
was removed in an attempt to remove excess epigastric skin. Again, this is the type
of postliposuction deformity that cannot be corrected with fat injection alone and
will almost certainly require secondary abdominoplasty for revision.
This patient presented following liposuction with a similar problem to that of the
patient in the middle of this page. The epigastric skin appears to be disconnected
from the muscular fascia below, sliding in all directions with folds and depressions.
As demonstrated in the center photo, correction might be best accomplished
through a reverse type abdominoplasty to improve the accidity.

1645
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
This 23-year-old woman had extensive bilateral femoral fat deposits with evident
asymmetric volume. Despite good skin turgor, liposuction was performed in two
stages because of the difficulty in predicting the amount of skin retraction that
would occur postoperatively and in order to avoid causing skin laxity and or undu-
lations. This conservative approach obviated secondary problems. The volume re-
duction is evident, and body contour now appears normal.The patient is shown af-
ter the rst liposuction and 8 months later after the second liposuction.

1646
PART V
R EOPERATIVE SURGERY OF THE TRUNK
This 57-year-old patient represents a case of insuf cient liposuction with a subop-
timal nal result despite liposuction being performed in two successive stages. She
had bulging inner knee fat deposits combined with multiple small fat deposits
around the knee.
Postoperatively the patient still has residual fat collections. A second liposuction
procedure was performed. Six months after the second conservative liposuction
procedure the patient still demonstrates residual fat deposits.
Insuf cient liposuction is a dif cult problem to solve completely. Patients should be
advised about these possible limitations. A third localized liposuction procedure
may still be indicated for one or two speci c small bulges if the patient demands
further treatment.

1647
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
This 45-year-old patient had moderate fat deposits in the lower segment of the
upper arm and mild skin laxity. Routine liposuction was performed. Although there
was volume reduction, the patient complained of skin laxity.
A reduction brachioplasty near the axilla was performed. A fusiform skin resection
combined with a half triangle resection (with the base of the triangle at the axillary
line) removed the skin excess, leaving an L-shaped scar.

1648
PART V
R EOPERATIVE SURGERY OF THE TRUNK
This 45-year-old patient had fat bulges in the anks with good skin turgor.The pa-
tient’s main complaint related to the need for ank reduction. Liposuction was per-
formed speci cally in these areas.
Two years later the patient returned 6 kg (13 pounds) overweight, indicating that
she was trying to return to her normal weight.The anks did not show fat recur-
rence, whereas the hip regions and the posterior upper thighs were voluminous. All
of the demarcated regions were suctioned again, including the anks.The nal re-
sult is shown 4 months postoperatively. Since the second liposuction, the patient has
lost 4 kg (9 pounds). It is interesting to note the nonrecurrence of the previously
suctioned fat deposit after limited weight gain.

1649
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
This 37-year-old patient presented for consultation after liposuction of the abdom-
inal wall (epigastrium) with resilient depressions and two small necrotic skin spots
after triamcinolone injections for local indications.
The results are shown 6 months after two consecutive fat injections were per-
formed (with a 4-month interval between) and skin resection for the removal of the
necrotic sites. Limited but more acceptable results were obtained.

1650
PART V
R EOPERATIVE SURGERY OF THE TRUNK
This 39-year-old patient who had been operated on elsewhere presented with
lipodystrophy combined with a specific deformity in the femoral lateral region
near the lateral gluteal aspect after excessive liposuction. The preoperative pro le
view shows the skin apron with skin abbiness evident.
The patient underwent an upper inner thighplasty combined with ankplasty and
elliptic skin resection around the deformity. Despite the local skin resection, a resid-
ual dimple remains below the suture line. Secondary resection or fat injection could
possibly ll the deformity.

1651
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
SEROMA PREVENTION AND MANAGEMENT
FOLLOWING ABDOMINOPLASTY AND
MINIABDOMINOPLASTY
Seroma is a well known complication of body contouring, particularly of ab-
dominoplasty. In 1996 we published our rst 6-year experience using “adhesion
sutures” to prevent hematoma and seroma.4 We continue to feel that this simple
technique has virtually eliminated hematomas and seromas in abdominoplasty sur-
gery in our hands. Various other techniques to eliminate the “dead space” have
been reported, including the use of “tissue glue,” but the results have continued to
be unpredictable, with recurrent seromas, brotic reactions, and skin retraction still
reported.5
My technique of adhesion sutures is quite simple to perform, and we have used it
in any surgery that requires undermining, such as face lift, latissimus dorsi harvest
site, axillary dissection, mastopexy, and even traumatic skin avulsions. The tech-
nique is illustrated in the following gures.
This frontal view of a postoperative abdominoplasty patient illustrates where the ad-
hesion sutures were applied intraoperatively.We usually place 35 to 45 of these iso-
lated absorbable sutures in lines and columns from the xyphoid to the pubis (green
dots).The sutures are placed no more than 4 cm apart.The additional time required
to place the sutures is 20 to 25 minutes. Since 1998 we have completely eliminated
the use of suction drains, except in the axilla.We have seen a dramatic reduction in
the drainage in the axilla with placement of sutures.

1652
PART V
R EOPERATIVE SURGERY OF THE TRUNK
These intraoperative photos demonstrate the placement of the sutures approxi-
mately 4 cm apart. Since these photos were taken, the use of drains has been elim-
inated. As the sutures are being placed, signi cant “dimpling” of the overlying skin
should be avoided. Small surface irregularities disappear in the early postoperative
period.The sutures grasp the fat and sometimes portions of the super cial fascia but
should not approach the dermis. When placed correctly, the adhesion sutures sta-
bilize the ap over the underlying abdominal wall allowing the patients to sit com-
fortably even 48 hours after surgery.The ap does not slide over the muscular fas-
cia during normal postoperative activities. We always use a support garment to
improve the patient’s feeling of security.
We treated this patient who was referred after two recurrent seromas following ab-
dominoplasty by another surgeon. The pseudobursa of the seroma had been re-
sected, but the seroma returned.We drained 1.26 L of uid from this cavity.

1653
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Reoperation After Liposuction and Body Contour Surgery
When we opened the seroma cavity, the walls appeared granulomatous rather than
smooth, as might have been expected with a typical pseudobursa. Rather than re-
sect this tissue, we placed adhesion sutures and closed the wound simply.This suc-
cessfully eliminated this recurrent seroma without the necessity of placing addi-
tional drains.
PRIMARY OPERATIVE APPROACHES TO
ABDOMINAL CONTOURING
Candidates for primary abdominoplasty exhibit fat deposits localized in one or
more regions of the anterior abdominal wall, abdominal skin accidity, or both.
Liposuction, conventional abdominoplasty, or a combined procedure, performed
in stages or concurrently, is indicated.
Patients with abdominal fat deposits who have good skin turgor are good candi-
dates for liposuction performed in one stage. Satisfactory results are obtained with-
out scars or residual abby skin.When the fat volume is more signi cant and there
is a moderate degree of skin turgor, the capacity of the skin to retract is reduced. Al-
though volume reduction will be achieved, abby abdominal skin will result. The
extent of liposuction performed should be based on the amount of fat removal
possible, not on the surgeon’s desire.The skin should retract over the new fat frame
within the natural limits. A second liposuction procedure will be indicated if the
skin retracts properly; otherwise, a miniabdominoplasty or traditional abdomino-
plasty, perhaps combined with liposuction, is recommended.The determination of
future treatment is based on the nal result after the rst liposuction.

1654
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R EOPERATIVE SURGERY OF THE TRUNK
This 33-year-old woman had moderate fat deposits in the anterior abdominal wall
combined with mild skin accidity at the hypogastric regions; she also had a scar
from a cesarean section. Liposuction of the entire abdomen and a miniabdomino-
plasty without umbilical mobilization and an infraumbilical recti plication of the
rectus abdominis were performed.
Postoperatively the patient still complained of residual fat left in the hypogastrium
and some dog-ears at the end of the scar. The dog-ears had resulted because we
were trying not to extend the incision.

Patient satisfaction was achieved after reoperation with secondary liposuction and
resection of the skin excess, leaving a handlebar scar that is hidden under a bikini.
When the abdomen has fat deposits and abby skin, a miniabdominoplasty or tra-
ditional abdominoplasty is required.The extent of the problem determines which
technique is selected.The miniabdominoplasty, with or without liposuction, offers
a moderate resection of excess skin;liposuction can be performed in the same stage.
The extended miniabdominoplasty allows plication of the rectus abdominis mus-
cles, which requires umbilicus mobilization.
The umbilicus may be placed in the same position, moved 1 to 2 cm below its
original position, or even be amputated. In this last situation, when downward mi-
gration of the umbilicus would result in an unaesthetic appearance, neoumbili-
coplasty is performed in the ideal position.
Traditional abdominoplasty is indicated when an excessive amount of skin needs to
be resected to obtain good skin turgor. This surgery may be combined with lipo-
suction of the epigastrium and hypochondrium in the same surgical stage. Liposuc-
tion should be moderate to preserve the good condition of the skin ap’s blood
supply. Scar lengthening and the quality of the result should compensate for the
previous aesthetic appearance of the abdomen.
PROBLEMS FOLLOW ING ABDOMINAL CONTOURING
Despite the continuous refinements in the surgical treatment of the abdominal
wall, several secondary problems can occur that require reoperation.These problems
include scarring, residual fat deposits, umbilical distortions, and residual bulges.Very
often, liposuction, scar repositioning, and umbilicoplasty are required to remedy
these deformities.
1655
Chapter 42
Reoperation After Liposuction and Body Contour Surgery

1656
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Bulging Epigastrium, Hypogastrium, Periumbilicus, and Flanks
All of these regions, alone or combined, may exhibit residual bulges after miniab-
dominoplasty or traditional abdominoplasty with or without liposuction performed
in the same surgical setting. Although patients often report that no protrusion ex-
isted preoperatively, in fact the bulging epigastrium, hypogastrium, and anks were
always present.The abdominoplasty removes only the skin and fat from the umbili-
cus downward to the pubis in an elliptical resection. After plication of the rectus ab-
dominis muscle and the caudal slide of the skin ap, the upper abdominal region
(epigastrium) will retract backward mildly compared with the position of the in-
fraumbilicus segment. As a result, the epigastrium and the anks protrudes more,
and their contour becomes more obvious to the patient. In this situation ankplasty
and abdominoplasty are performed in the same stage, which offers the patient an
improved contour.
The epigastrium—even after moderate liposuction and before skin undermining
during abdominoplasty or after resection of fat excesses below Scarpa’s fascia—is
still thicker than the area below the incision at the pubis and the inguinal segments.
Residual moderate lymphedema of the skin ap can occur, causing the ap to re-
main swollen for several months postoperatively. This state manifests as an unaes-
thetic step over the scar line.
This 61-year-old patient with a thick, adipose panniculus and a protruding ab-
domen underwent routine abdominoplasty, having been informed about the neces-
sity of a complementary liposuction procedure at a minimum of 6 months postop-
eratively.

Eight months later the patient underwent liposuction as marked, and scar revision.
The nal result is shown 6 months after the second surgery.
Skin Laxity, Fat Deposits, Scars, and Umbilical Malposition
Secondary skin laxity in the anterior abdominal wall usually occurs after excessive
liposuction. Residual and localized fat deposits, as well as unacceptable scars and
unaesthetic umbilical position or shape, also may be present after primary ab-
dominoplasty.
Miniabdominoplasty or traditional abdominoplasty, alone or in combination with
other procedures, is indicated to solve these problems. The nonextended miniab-
dominoplasty is performed without umbilicus mobilization. It affects only the hy-
pogastrium where rectus abdominis muscle plication may or may not be per-
formed.With miniabdominoplasty the entire region is undermined to the umbilical
level for fascia plication. With traditional abdominoplasty undermining is per-
formed up to the xyphoid. In both procedures a transverse elliptic skin resection is
performed at the suprapubic level. Suturing is performed in a straight or arcuate
line 13 to 18 cm in length, depending on the amount of skin resection.
1657
Chapter 42
Reoperation After Liposuction and Body Contour Surgery

1658
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The nonextended miniabdominoplasty is performed in patients undergoing pri-
mary and secondary abdominoplasty in whom liposuction in one or more abdom-
inal wall regions is indicated. A small skin ellipse is resected transversely at the pu-
bis level. In some situations undermining up to the umbilicus with or without
rectus abdominis muscle plication can be combined.The nal scar (up to 20 cm in
length) is placed transversely in the pubis no more than 7 cm above the anterior
vulvar commissure.
Individual adhesion sutures using 2-0 or 3-0 absorbable sutures are applied in the
undermined area with no more than 4 cm between them. No drains have been
used in the last 8 years and no seromas have been detected.The nal scar (up to 20
cm in length) is placed transversely in the suprapubic area no more than 7 cm above
the anterior vulvar commissure.The larger the skin resection the longer is the scar.
Minimum distance
between umbilicus
and anterior
commissure of
vulva—15 cm
5-7 cm
Fascia plicated
up to umbilicus
Undermined
area
Final scar
up to 20 cm
Skin
resection
Nonextended miniabdominoplasty

The extended miniabdominoplasty is performed in patients undergoing primary
and secondary abdominoplasty. The skin incision is similar to that used in the
nonextended miniabdominoplasty. Indications for liposuction in the abdominal
wall regions are also similar to those that apply to the nonextended miniabdomino-
plasty. Undermining is performed in a triangular area and extends to the xyphoid
level.The umbilicus is sectioned from its pedicle to facilitate plication. A special re-
tractor with a long sheet is placed to expose the extended tunnel.With the tunnel
open, plication is performed in two planes. Isolated 2-0 nylon stitches are placed
from the xyphoid to the pubis. A second continuous suture line, also with 2-0 ny-
lon, is placed over the rst.The skin is stretched caudally;the excess skin is resected
and adhesion sutures as described above are placed.The umbilicus may be replaced
in its original position or 1 to 2 cm below it.Two trans xion stitches are made to
bite the umbilical skin and the fascia below and to emerge again through the um-
bilical skin.When the stitches are tightened, the umbilical depth is obtained again.
A gauze pad is placed over the stitches to aid in scar formation during the rst 2
postoperative days.
1659
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
Skin of umbilicus
remains with skin flap
Fascia plicated
up to umbilicus
Undermined
area
Final scar
up to 20 cm
Skin
resection
Umbilical stalk
5-7 cm
Plication
Extended miniabdominoplasty

1660
PART V
R EOPERATIVE SURGERY OF THE TRUNK
In patients in whom the umbilicus remains below the aesthetic level (less than 15
cm from the anterior vulvar commissure), reoperative umbilicoplasty is indicated.
The umbilicus is resected from the abdominal skin ap through an elliptic vertical
incision. The umbilical stalk is dissected, and a skin island 1 cm in diameter is left
in its free extremity. Fascia plication shortens the stalk and places the skin island at
the level of the umbilicus. The umbilical hole at the skin ap is sutured in three
planes, leaving a vertical suture 3 to 5 cm in length.The skin ap is stretched cau-
dally and the excesses are resected. Between 15 and 18 cm from the anterior vul-
var commissure, a 22 mm transverse skin incision is made at the xyphoid-pubic
line to place the umbilicus in its nal position. Below this incision, fat is resected in
a circular fashion. Four stitches are placed in the cardinal positions around the skin
incision. These sutures are isolated 2-0 nylon stitches that bite the skin edge, go
deep and bite the fascia and umbilicus skin island, and then emerge through the
skin incision. When the stitches are tightened, the wound closure becomes circu-
lar. Another eight isolated 4-0 nylon stitches are placed around the umbilicus to
complete the closure. A natural invagination is obtained with the skin island placed
below. A gauze bolster covered with ointment is placed on the umbilicus in a
Brown-type pad (tie-over dressing) and remains in place for the rst 2 postopera-
tive days.
Before the umbilicoplasty, the adhesion sutures are applied beneath the undermined
area. No suction drains are required. The pubic incision is closed in three suture
planes:subcutaneous plane with isolated 2-0 Vicryl sutures, dermal plane with iso-
Continuous
oversuture
Two mattress sutures hold
the flap in its definitive position
18 mm
transverse
incision to
replace
umbilicus
Skin flap
after resection
Skin island
Rectus
fascia
Umbilicus
skin island
placed at
fascia level
Rectus
abdominis
muscle
Midline fascia
plication with
isolated sutures
Skin island
(1 cm diameter)
Umbilicoplasty

1661
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
lated 3-0 Vicryl sutures, and intracuticular plane with running 4-0 Vicryl sutures.
Micropore material is placed over the suture, and ABD pads are placed on the ab-
dominal wall.The patient leaves the operating suite wearing an elastic girdle.
Resection
Handlebar
incision
B
X
X´
E
F
D
C
A
ACE BDF
Undermined area
Traditional abdominoplasty is indicated when skin accidity of the entire anterior
abdominal wall is evident and when skin resection involves the entire hypogas-
trium. For this procedure I have been using a new type of low transverse pubic-
inguinal incision rather than the handlebar incision used previously. The skin is
marked in the following manner:A vertical line from the xyphoid to the vertex of
the anterior vulvar commissure (X-X´) determines the abdominal midline for the
future position of the umbilicus.Two transverse and parallel lines are placed perpen-
dicular to this line, one at the upper level of the umbilicus (E-F) and the other 5 to
7 cm above the anterior vulvar commissure (A-B). According to the pubis volume
and limits, two reference points (A and B) are marked at the transverse pubic line
and are placed 5 to 7 cm from the central vertical line bilaterally. Similar reference
points (E and F) are bilaterally placed at the transverse line at the umbilical level.
The distance of A-E should equal that of B-E. The length of these lines is usually
10 to 14 cm and varies according to the shape of the pubis and the volume of the
patient’s hips. At this point the assistant stretches the lower abdominal skin upward
with both hands and with equal tension.This maneuver eliminates all skin abbi-
ness in the hypogastrium and inguinal regions. From points A and B a line is drawn
toward the anterior superior iliac spine on each side. These lines have a concave,
curved con guration. Small variations in this marking may be used and are accept-
able if this curved line extends only a few centimeters inside or outside the iliac spine.
Traditional abdominoplasty

1662
PART V
R EOPERATIVE SURGERY OF THE TRUNK
A concave, curved line is drawn from the extremities of the iliac spine on each side
and up to above the umbilicus.These lines intersect the lines A-E and B-F at points
C and D bilaterally.The distances A-C-E and D-B-F should be equal for symmetric
resections and for aesthetic scar positioning.Temporary key stitches during the sur-
gery are placed at points A, B, C, and D to serve as reference points in case the ink
markings become smeared.These stitches are removed at the end of the operation.
The demarcated ellipse represents the skin segment to be resected. The triangular
shadowed area from the xyphoid to the iliac spines represents the region to be un-
dermined.The iliac spines, A-B and C-D, represent the area to be resected.
After rectus abdominis muscle plication, the abdominal skin ap is stretched cau-
dally. The ap is divided in two parts along the central vertical line (X-X´), and a
mattress stitch is placed to xate the pubis to the upper umbilical hole after its dis-
section from the abdominal skin ap. Each half of the skin ap is incised along the
lines A-C-E and B-D-F equally.Two mattress stitches are placed, one at point A and
one at point B. The four aps are resected. Finally the wound is closed in three
planes as has been described earlier. Umbilicoplasty is performed according to the
previously described technique before the nal closure.
Minimum distance
between umbilicus
and scar—10 cm
Distance between
scar and commissure
of vulva—5-7 cm

1663
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
Reoperative abdominoplasty follows the routine procedure:skin undermining, rec-
tus abdominis muscle plication, excess skin resection, umbilicoplasty; and place-
ment of the nal sutures.
Skin ap undermining should be as conservative as possible to reduce
the extent of the resulting dead space.
The area of the ap that is undermined has a triangular con guration: the base is
positioned along the lower transverse incision and the vertex is at the xyphoid ap-
pendix.With this pattern of undermining, the skin ap blood supply remains bet-
ter preserved, decreasing the risk of postoperative ap necrosis.
The intraoperative dissections shown here illustrate a change in our technique af-
ter 1990. On the left one can see the wide undermining that was our custom be-
fore 1990. On the right one can see that the undermining represents a triangle,
with the transverse incision in the suprapubic area at the base of the triangle. The
apex of the triangle is at the xyphoid. Of note is the lateral femoral cutaneous
nerve, which emerges 2.5 cm below the anterior superior iliac spine, becoming
super cial at the inguinal line. This nerve supplies sensation to the anterior lateral
aspect of the thigh. Dissection in this region must be super cial to avoid injuring
this nerve.

1664
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The intraoperative photo on the left shows the width of the undermining over the
rectus abdominis muscles before plication. On the right, the same region is seen af-
ter the plication. One can appreciate the signi cant narrowing that occurs between
the lateral borders of the undermined area.
On redraping the skin, one can see the bulging (oval area) that results from the pli-
cation in the epigastrium. This problem can be ameliorated by vertical spreading
between the bers on either side of the undermined area. This releases the tissues
enough to allow the bulging to atten out suf ciently without additional under-
mining.
The excess skin ap resection and suturing are also performed routinely.The nal
closure resembles a handlebar.The pubic low transverse suture segment is 10 to 14
cm in length (or longer, depending on its volume), placed 5 to 7 cm above the an-
terior vulvar commissure. The two lateral segments that run above the inguinal
crest toward the iliac crest bilaterally can be of variable length depending on the
volume of the hips.

1665
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
Scar Malposition
Abdominoplasty through a traditional low transverse pubic-inguinal incision, as
was performed before liposuction was introduced, is now the third most popular
option for aesthetic abdominal treatment, with liposuction being the rst choice
and miniabdominoplasty the second.The presence of vertical scars in the abdom-
inal wall or transverse scars in the epigastrium or hypogastrium from previous sur-
gical procedures will in uence the type of procedure chosen: liposuction, surgery,
or both.
The most common secondary problems observed after routine abdominoplasty are
scar malposition and unacceptable scar quality (for example, broad, hypertrophic,
and keloid). Often the scar is too high in the hypogastrium, placed 10 to 14 cm
above the anterior vulvar commissure, and runs transversely to the root of the
thighs instead of toward the anterior superior iliac spine bilaterally.Very often the
scar appears as an open W and is exposed when the patient wears a bathing suit.
The pubic scar becomes exposed because it is too high, and the lateral scar segments
are also exposed because they are too low at the thigh root. It is the exact reverse
of the ideal scar, which is high laterally and low in the pubis so that it remains hid-
den by the V shape of a bikini.
Following abdominoplasty this 45-year-old patient was left with a scar that ex-
tended as a straight transverse line, very high at the pubis and running to the root
of the thighs. The tan lines reveal that the scar remains exposed. The umbilicus is
also dislocated laterally.

1666
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The scar was revised by a handlebar incision so that the scar is now completely
hidden by the bathing suit.The incision was extended toward the iliac spine to al-
low resection of skin abbiness near the anks.The umbilical pedicle was dissected
from the skin ap and a small skin island was left in its free extremity.
To correct the excessively low umbilical pedicle position (less than 10 cm from the
vulvar anterior commissure), the primitive umbilical skin hole was sutured and a
new opening a few centimeters above was made. Routine umbilicoplasty was per-
formed.The distance of the new position of the umbilicus remains 9 cm from the
pubic incision.Transversely it is not the ideal distance, but the position is acceptable
in this case.

1667
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
Eight months after reoperative surgery, the scar and overall abdominal appearance
are much improved.The scar is now hidden by the bikini.There is an inconspicu-
ous scar below the nal umbilicus.The disadvantage of this small scar is more than
offset by the advantage of a well-placed umbilicus.
Incorrect Placement of Umbilicus
The umbilicus is the only natural scar in the body that is acceptable aesthetically.
Distortions in its shape and position can draw negative attention. Several types of
surgical umbilicoplasty attempt to reproduce the natural aspect of the umbilicus.
The surgeon should select the technique that can offer the best result. Unfortu-
nately, aesthetic problems secondary to umbilical surgery are common. Stenosis,
resulting in a big umbilical hole, and malposition are the most common complaints
associated with the umbilicus and are usually due to keloid reaction, necrosis, infec-
tion, or dehiscence.

This 47-year-old patient exhibited a combined problem of unacceptable scar po-
sition and a stenotic umbilicus following a previous surgery. During reoperative
surgery the scar was revised to resemble a handlebar shape and umbilicoplasty was
performed in the same stage.The result is shown 1 year postoperatively.
1668
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Following an abdominal procedure, this patient was left with several scars located
in the hypogastrium after secondary healing of an infection in the abdominal wall.
The umbilicus had been completely lost.

1669
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
To correct this problem, routine abdominoplasty was performed with complete
skin resection of the hypogastrium. Neoumbilicoplasty was performed in the same
surgical stage.6 A transverse skin incision was made and a defatting maneuver was
performed. Several stitches fixed the skin incision edges to the deep fascia. A
Brown-type bandage was placed over the neoumbilicus and removed 2 days post-
operatively.The wound was allowed to heal by secondary intention.
The nal postoperative result is shown.
FLANK PROCEDURES
Well-proportioned anks contribute to an aesthetic body contour. Often these re-
gions have large fat deposits and skin accidity, causing unattractive bilateral bulges.
When too voluminous, these bulges disrupt the harmony of the female curves and
buttocks, creating square-appearing hips. Liposuction has become the elective treat-
ment of choice for large anks without skin accidity. In patients with large fat
deposits and accid skin in this area, ankplasty based on an extended fusiform skin
resection is still the only operative solution.This surgery leaves long bilateral scars
that run from the anterior superior to the posterior superior iliac spine and below
the iliac crest.When fat deposits and accid skin are present, lipoplasty is combined
with ankplasty in the same surgical stage.

1670
PART V
R EOPERATIVE SURGERY OF THE TRUNK
After traditional abdominoplasty, bulging anks may appear more prominent. Re-
moval of the hypogastrium skin makes the abdomen at, exposing the ank ex-
cesses.These fat deposits always existed but were less evident preoperatively. In this
situation ankplasty and abdominoplasty should be performed in the same stage,
which offers the patient a better contour.
Flankplasty is a fusiform skin and fat resection from the anterior superior to the
posterior superior iliac spine.7 The amount of resection necessary is estimated by
the pinch test.The surgery starts with the patient in a prone position.The skin el-
lipse is resected in its posterior and lateral segments. Closure is performed in three
planes: deep sutures with isolated 2-0 Vicryl stitches to eliminate the dead space,
dermal sutures with isolated 3-0 Vicryl stitches, and running intracuticular sutures
with 4-0 Vicryl.The residual skin redundancy above the sacral region requires that
the excess be resected and the suture lines be joined, leaving a V-shaped closure.The
skin excesses at the lateral aspect of the anks are protected by ABD pads while the
patient is turned to the supine position. The excesses are then resected. The nal
closure is performed in three planes as described earlier. The nal suture is placed
along or a few centimeters below the iliac posterior crest up to the anterior supe-
rior iliac spine. No drains are required.
PROBLEMS FOLLOW ING FLANK PROCEDURES
The most common secondary aesthetic problems after ankplasty are related to in-
suf cient fat removal and skin accidity. Insuf cient fat removal requires secondary
liposuction, whereas skin resection alone is indicated to treat accid skin.
A 55-year-old patient on whom we performed a routine abdominoplasty returned
1 year later complaining of bulges and irregularities in the anterior abdominal wall
and in the anks.

Scar revision combined with ankplasty and liposuction of the epigastrium and
hypogastrium were proposed. No undermining or umbilical mobilization was nec-
essary.
1671
Chapter 42
Reoperation After Liposuction and Body Contour Surgery
The result, seen 6 months postoperatively, shows the improved body contour.The
new scar, along the anks and the pubic-inguinal lines, can now be hidden by a
bathing suit.The ank bulge excesses have been eliminated.

1672
PART V
R EOPERATIVE SURGERY OF THE TRUNK
We performed abdominoplasty on this 50-year-old patient 8 years earlier. The -
nal scar remained too high and was placed transversely up to the root of the thighs.
The patient wanted the scar to be bidden by her bathing suit and she requested the
removal of the skin excesses at the iliac crest roll.
The distance from the pubic scar to the anterior vulvar commissure was 11 cm.To
correct this problem, the abdominal wall skin was dissected up to the xyphoid;the
umbilicus was also dissected from its position. The skin ap was slid caudally and
the original scar was resected.The nal suture line was 8 cm from the anterior vul-
var commissure and 16.5 cm from the umbilicus, placing the umbilicus in a normal
aesthetic position.The umbilicus was sutured in place to the abdominal skin ap.

Three months postoperatively, the patient now has a handlebar-shaped scar that
extends around the anks.The scar lines run along the ank regions and extend to
the anterior superior iliac spine and posterior iliac crest projection.The body con-
tour reveals a new shape; the ank bulges, skin accidity, excessive skin laxity over
the sacral region, and the buttocks ptosis have been eliminated. Although the resec-
tion was performed in a belt shape, the nal scar is V shaped.
1673
Chapter 42
Reoperation After Liposuction and Body Contour Surgery

1674
PART V
R EOPERATIVE SURGERY OF THE TRUNK
The patient’s underwear now completely hides the scar that encircles her body.
COMBINED FLANKPLASTY AND
ABDOMINOPLASTY
A number of different types of surgical procedures can be performed on the anks
and abdomen depending on the speci c secondary problems. Liposuction and sur-
gery, alone or in combination, are routinely performed on these regions.
When ankplasty and abdominoplasty are performed in the same stage, ankplasty
is performed rst with the patient in a prone position.8 An extensive fusiform skin
resection is undertaken as described earlier. The patient is then placed in a supine
position and abdominoplasty is performed.
With these combined procedures, some precautions are necessary. Skin undermin-
ing of the epigastrium and hypogastrium should be conservative to avoid severing
the skin ap blood supply. In addition, at the point at which the anks meet the ab-
domen, excess skin should be dissected as little as possible; any dissection that is
performed should be as symmetrical as possible.