Phẫu Thuật Tạo Hình Đường Nét Cơ Thể Và Hút Mỡ (Body Contouring and Liposuction)

288
PART | 5  Abdominal contouring procedures
the importance of “time efficiency” cannot be overempha­
sized in these types of cases.
Patients should be weight stable for several months and
nutritionally stable prior to surgery. While a normal BMI is
not always a realistic goal, an obese patient should be
counseled on further weight loss prior to surgery, as they
are not likely to derive optimal results from surgery.
Preoperative evaluation should focus on both personal
and family history of coagulopathy, including a history
of multiple miscarriages. Smokers should not undergo
combined procedures, due to high likelihoods of wound
complication and pulmonary compromise. Oral contracep­
tives and hormone replacement therapies can increase
thrombotic risk and should be stopped weeks prior to
surgery.
In the combined procedure population, the patient’s
dedication to total body transformation is extremely high,
and the expectation no less so. The outcome of the surgery
is expected to be transformative and staggering, given the
monetary and time commitment of the patient. It is impera­
tive that extensive preoperative discussions occur, using the
patient’s own photographs and outlining the realistic goals
of surgery. When sharing photographs from prior surgeries,
the representative photographs should be close in age and
body habitus to the patient. The limits of the patient’s own
anatomy due to natural body shape, age, skin quality, and
prior surgical scars should be carefully outlined. The patient
should also be informed that in any esthetic surgery, there
is always room for improvement and revision further down
the line.
SURGICAL TECHNIQUE
Many patients present to the plastic surgeon desiring
esthetic improvement of multiple regions. Among our
lipoabdominoplasty patients, the most frequent requests are
for breast esthetic surgery and for SAL of adjacent areas
including flanks, back, hips, and thighs.
In our practice, we routinely adjoin liposuction of back
and flank areas to our lipoabdominoplasties. Starting in the
prone position, the back and flank adiposities are addressed
first, prior to undertaking the anterior trunk. Circumferen­
tial reduction of excess adiposity produces a total torso
transformation and improves the visual esthetic from every
angle. Liposuction of back and flanks further assists in
creating a defined waist, where traditional abdominoplasty
can blunt the waistline. Residual adiposity in the flanks and
back can distract from an overall harmonious result from
a lipoabdominoplasty; when one area becomes smaller and
tighter, it can call attention to other problem areas that were
previously less noticeable.
Among the weight-loss and multiparous patients, ptotic,
involuted breasts can similarly detract from achieving a
harmonious result. The huge popularity of the so-called
“mommy makeovers” stems from the high incidence of
simultaneous deformities of the breasts and the abdomen.
Augmentation, mastopexy, and augmentation–mastopexies
are the most common procedures performed to rejuvenate
and restore felicitous dimensions to the breasts. When com­
bined with lipoabdominoplasty and suction-assisted lipec­
tomy of the lower torso, breast esthetic surgery can facilitate
a more complete transformation.
Facial esthetic surgery can be combined with lipoab­
dominoplasty, but with caution as to the length of the pro­
cedure. Patients often desire a combination procedure of the
face (a rhytidectomy and a brow lift, for example) that
would necessitate significant operative time and would
result in excessive operative time if combined with body
contouring procedures. If the patient also desires breast
surgery and/or extensive SAL, other esthetic surgeries may
be best performed on a separate date.
OPTIMIZING OUTCOMES
Promoting safe surgical practice and prevention of cata­
strophic events is the surest way to optimize outcomes (Box
28.1). Prior to the operating room, there should be a vigilant
investigation of both personal and family history of throm­
botic events.
An outstanding postoperative appearance does not
guarantee that an outcome is satisfactory to the parties
involved. A postoperative period that is free of major
Box 28.1  Guidelines in Clinical Practice
●
Hematologic and/or appropriate specialist consultation
for patient or family history of coagulopathy including
miscarriages, early myocardial infarction, prior throm­
boembolic events
●
Cancellation of immediate preoperative trips via air­
plane or car
●
A baseline preoperative duplex scan with even a minor
clinical suspicion
●
Oral contraceptives and hormones stopped at least a
month prior to surgery
●
Sequential compression devices prior to induction of
anesthesia, in recovery room and during overnight stay
●
Adequate
temperature
management
to
avoid
hypothermia
●
Low-molecular-weight heparins (Lovenox) starting at
12 h after OR and to continue 3–5 days until fully
ambulatory
●
Aggressive early ambulation by recovery room and over­
night stay nurse personnel
●
Patient and family to be educated about the importance
of ambulation in the immediate postoperative period so
it continues at home after discharge from the surgical
facility.

289
Chapter | 28  Lipoabdominoplasty
clinical complications, delayed healing, and catastrophic
events can significantly enhance both patient and surgeon
satisfaction.
POSTOPERATIVE CARE
All patients should be placed in a semi-compressive dress­
ing after lipoabdominoplasty and other ancillary proce­
dures. Initial dressing with foam dressing such as Reston
over liposuctioned areas and abdominal binders are appro­
priate. In our practice, patients are instructed to purchase
compressive garments that encompass the abdomen and
hips and wear the garments continuously for 6 weeks after
surgery. Both medical grade and commercially available
compressive garments are appropriate as long as they are
worn with consistency. Surgical edema often persists for
several months and inconsistent use of garments can exac­
erbate the unflattering appearance.
Scar massage, lymphatic massage, and topical therapies
such as silicone sheets are frequently used among our
patients, with the understanding that the therapeutic out­
comes are highly variable. Frequent wound checks and
hygiene, and frequent and regular postoperative visits are
essential in impeding wound problems before they flare out
of proportion.
Postsurgery weight control is regularly discussed with
our patients, so that the surgical results are maintained. This
is especially crucial in the postoperative period, when the
patient may be more sedentary than usual, and activity
restrictions prevent them taking strenuous exercise.
COMPLICATIONS AND THEIR
MANAGEMENT
Performing lipoabdominoplasty in a combined body con­
touring procedure has the potential for increased postopera­
tive pain to limit early ambulation, as well as the theoretical
potential for increased incidence of thrombophilia owing to
the length of the procedure and prolonged immobilization.
With cautious preoperative workup and limiting the number
of hours under general anesthesia, combined procedures
parlay the potential benefits of single anesthesia, decreased
total recovery time, and decreased expense to the patient.
We aim to establish that combining lipoabdominoplasty
with other esthetic procedures can be safe to the patient and
result in a low rate of complications similar to lipoabdomi­
noplasty alone.
The risk of deep venous thrombosis (DVT) and pulmo­
nary embolism in this situation is likely multifactorial: pro­
longed operative time, increased pelvic vein compression
due to rectus muscle diastasis repair, which increases intra-
abdominal pressure, and a prolonged recovery period with
relative immobility.
With the implementation of safe clinical practices such
as preoperative screening, early ambulation and multiple
methods of anticoagulation, thromboembolic events do
not appear closely correlated with abdominoplasty in
combined procedures. Hester5 noted that it was obesity,
rather than length and complexity of the surgical procedure,
which increased the likelihood of thromboembolism.
Another study of 103 abdominoplasties combined with
intraabdominal surgeries reported no thromboembolic com­
plications with TED hose and early ambulation as the sole
interventions.6
More recently, a retrospective review of 268 patients
who underwent combined abdominoplasty and cosmetic
breast surgery over a 10-year period found a 34% overall
complication rate including minor seromas and wound
dehiscence, but no thromboembolic events or death. Com­
bining two procedures did not lead to an increase in compli­
cations when compared to individually staged procedures.7
Over a 2 year period, 175 patients underwent lipoab­
dominoplasties in the author’s (R.S.) practice (Box 28.2);
141 patients (80 %) underwent combination procedures.
● Only lipoabdominoplasty 34 (20%)
● Combined with SAL back/extremities 79 (46%)
● Combined with breast surgery 31 (17%)
● Combined with other surgeries 31 (17%).
The complications of combined procedures were com­
parable to rates after lipoabdominoplasty alone, and supe­
rior to rates associated with traditional abdominoplasty in
the author’s practice. Three patients required hospitaliza­
tion after a combined procedure: two admissions were for
postsurgical complications and one patient for inadvertent
narcotic overdose while at home. There was a single inci­
dence of pulmonary embolism that recovered well with
intravenous heparin therapy and hospitalization. This par­
ticular patient received both mechanical and chemical pro­
phylaxis. It was discovered afterwards that the patient had
driven 10 hours the day prior to surgery.
CONCLUSION
Ultimately, a combined procedure should be attempted with
a clean preoperative workup and by a surgical team who
can complete multiple procedures in an efficient and timely
fashion. Postoperative care should include instructions for
early ambulation and adequate analgesia. Overnight stay is
Box 28.2  Complications among 175 Patients
Seroma = 5
(2.85%)
Pulmonary embolism = 1
(0.5%)
Dehiscence = 1
(0.5%)
Narcotic overdose = 1
(0.5%)

290
PART | 5  Abdominal contouring procedures
mandatory in our practice for all patients who undergo
combined procedures in addition to lipoabdominoplasty or
traditional abdominoplasty. Also, overnight stays are rec­
ommended for patients with any prior medical conditions
or for significant blood loss, difficult pain control, or dif­
ficult recovery from anesthesia. The ASPS Patient Safety
Committee guidelines detail guidelines for appropriate pre­
operative workup, patient selection, and perioperative man­
agement of risk factors.9,10 Consistent application of safe
practices is paramount in maximizing positive outcomes
and minimizing negative events.
Lipoabdominoplasty is a powerful and safe body sculp­
turing tool. In combination with other body contouring
procedures, it can lead to a comprehensive body transfor­
mation, anatomical, physiological, and psychological. We
attained a significant series from a single surgeon’s office
demonstrating that we can safely combine other procedures
with lipoabdominoplasty without multiplying the number
of complications. With vigilant patient screening, preopera­
tive planning, and aggressive postoperative management,
we can safely and effectively perform lipoabdominoplasty
in combination with other procedures.
REFERENCES
1. Hughes CE 3rd. Reduction of lipoplasty risks and mortality: an
ASAPS survey. Aesth Surg J 2001;21(2):120–7.
2. Voss SC, Sharp HC, Scott JR. Abdominoplasty combined with
gynecological surgical procedures. Obstet Gynecol 1986;67(2):
181–5.
3. Simons S, Thaller SR, Nathan N. Abdominoplasty combined
with additional surgery: a safety issue. Aesth Surg J 2006;26(4):
413–6.
4. Stokes RB, William S. Does concomitant breast surgery add morbid­
ity to abdominoplasty? Aesth Surg J 2007;27(6):612–5.
5. Hester TR, Baird W, Bostwick J 3rd, et al. Abdominoplasty com­
bined with other major surgical procedures: safe or sorry? Plast
Reconstr Surg 1989;83(6):997–1004.
6. Gemperli R, Neves RI, Tuma P Jr, et al. Abdominoplasty combined
with other intraabdominal procedures. Ann Plast Surg 1992;29(1):
18–22.
7. Stevens WG, Repta R, Pacella SJ, et al. Safe and consistent outcomes
of successfully combining breast surgery and abdominoplasty: an
update. Aesth Surg J 2009;29(2):129–34.
8. Most D, Kozlow J, Heller, J, et al. Thromboembolism in plastic
surgery. Plast Reconstr Surg 2005;115(2):20e–30e.
9. Haeck PC, Swanson JA, Iverson RE, et al. The ASPS Patient Safety
Committee Evidence-Based Patient Safety Advisory: patient selec­
tion and procedures in ambulatory surgery. Plast Reconstr Surg
2009;124(4S):6S–27S.
10. Haeck PC, Swanson JA, Iverson RE, et al. The ASPS Patient Safety
Committee. Evidence-Based Patient Safety Advisory: patient assess­
ment and prevention of pulmonary side effects in surgery. Part 2
Patient and procedural risk factors. Plast Reconstr Surg 2009;
124(4S):57S–67S.
Fig. 28.21, Fig. 28.22 can be found online.
Bonus images for this chapter can be found online at

291
© 2013 Elsevier Inc
Chapter 29 
Key Points
●
Abdominoplasty is an important technique in
improving body contour.
●
Correct treatment of the umbilicus is important in the
final result for patient satisfaction.
●
The technique can also be used to correct umbilical
problems such as in hernia.
●
The technique of umbilicoplasty is described.
Umbilicoplasty
Juarez Avelar
INTRODUCTION
Abdominoplasty is a very important operation to improve
body contour. The first one is credited to Kelly1 in 1899. A
previous description of skin and subcutaneous fat tissue
resection was performed by Demars and Marx2 in 1890.
According to Sinder3 this information was referred to by
Voloir4 in his thesis in Paris in 1960. Over many years
several abdominoplasty techniques have been described5–7
through different incisions by using a simple procedure of
panniculus resection without transposition of the umbilicus.
In 1957 Vernon8 described transversal abdominal lipectomy
with navel transposition, which is a remarkable step in
abdominoplasty.
In his original publication Vernon performed a circular
incision around the umbilicus to separate it from the
abdominal panniculus flap. Consequently, the surface of the
umbilicus was a circle (Fig. 29.1). For its reimplantation,
another circular incision and resection was done on the
abdominal flap to locate the new navel.
FIG 29.1 APPEARS ONLINE ONLY
Concerning the creation of the new umbilical region
during abdominoplasty many authors have proposed various
types of incisions around the umbilicus itself as well as for
its reimplantation on the abdominal wall (Fig. 29.1). The
final scar around the transposed umbilicus may be circu­
lar.5,6,9–11 Independent of whether the incision on the abdom­
inal flap is vertical, horizontal, circular, or semicircular,
because the surface of the umbilicus is a circle the final
scars have a tendency to be circular. When my method is
adequately performed the final scar is not a circle, but star-
shaped around the new umbilical area.
Even with excellent surgical skills the final scar around
the umbilicus is not satisfactory for many patients. There­
fore creating a new umbilical region is a major point during
abdominoplasty.
According to a survey by Grazer and Goldwyn12 in
1977, regarding 10 540 abdominoplasties carried out by
plastic surgeons from the USA and other countries, umbil­
ical scar contractures may occur in 45% of surgeries. In
that survey, they mentioned that 2% of surgeons believe
that some sort of retraction or contraction of the umbilical
scar always occurs after abdominoplasty when transposi­
tion is done. Following my method, the final scar on the
umbilicus region after abdominoplasty is not a circle on
the surface of the abdominal wall as in the use of other
techniques, but a multiple and atypical Z plasty which
makes a natural depression of the umbilicus without an
external scar.
PREPARATION, DIAGNOSIS,
AND PATIENT PRESENTATION
When I developed and described my method13 in 1976, I
used to perform abdominoplasty following the conven­
tional techniques of Callia9 and Pitanguy,6 with wide under­
mining of the abdominal panniculus from the suprapubic
region up to the costal margin. Therefore, my previous
publications14–18 were described showing the raw area all
over the muscular abdominal structures. However, after the
presentations and publications19–22 of my new procedure of
abdominoplasty without panniculus undermining (lipoab­
dominoplasty), I used the same method of umbilicoplasty
as previously described. Therefore, since 1999 when I
described my technique19 where the abdominal panniculus
is not undermined during surgery, all perforator vessels are
preserved in order to maintain normal blood supply to the
abdominal panniculus. It is important to emphasize the
surgical principles of my technique of umbilicoplasty in
order to demonstrate the philosophy of the method when
the umbilical region is treated during abdominoplasty
Part 5  Abdominal contouring procedures

291.e1
Chapter | 29  Umbilicoplasty
FIG. 29.1  Sequence of schemes showing different cutaneous inci­
sions used in umbilicoplasty and their implantation on the abdominal
flap. Top: Different cutaneous incisions from other authors on the abdomi­
nal flap and the three cutaneous incisions inside a circle according to
Avelar’s method. Middle: The circular incisions used in other techniques
for the surgery of the umbilicus leave a circular surface on the skin of the
umbilicus. The cutaneous surface of the umbilicus is a triangular one in
Avelar’s method. Bottom: Different shapes of the surgical scar after
implantation of the umbilicus according to other techniques leave a circu­
lar one around it. The triangular scar with three flaps is an atypical Z plasty
in Avelar’s method.
OTHER INCISIONS
AVELAR

292
PART | 5  Abdominal contouring procedures
FIG. 29.2  Sequence of schemes and photos showing cutaneous incisions for umbilicoplasty by Avelar’s technique. (A) Photo of the umbilical
area showing the demarcation of the technique on a patient before surgery – a star-shaped incision is marked inside a circle. (B) Instrument used to lift
the umbilical region to facilitate cutaneous incisions on the umbilicus composed of two parts that join around the umbilical pedicle. (C) Drawings show
the two parts of the instrument already joined lifting the umbilical area.
A
B
C
as well as during treatment of other deformities of the
umbilicus:
1. Star-shaped incisions are performed around the umbili­
cus to create three cutaneous flaps on the umbilicus
instead of a circular one as is done in other techniques
(Fig. 29.2A–F).
2. One of those three flaps is directed downwards and
the others are directed upward to the right and to the
left.13–15 The main reason for the downwards direction
of one flap is to give the postoperative umbilicus a
natural inclination to the bottom (Figs 29.3 and 29.4),
since this is the normal position of the umbilicus before
operation.
3. Three triangular cutaneous flaps are created on the
abdominal wall, which are sutured on the deeper verti­
ces of the umbilicus. This principle means that three
cutaneous flaps of the abdominal wall “go” from the
surface of the abdominal wall to a deeper point of the
umbilicus, making a 90° angle rotation. Such rotation
reproduces the similar “migration” of the umbilicus on
a newborn child a few days after birth, since the skin
around the umbilicus is retracted until it reaches the
muscular-aponeurotic wall. In fact, the umbilicus is the
first scar in the human body healed secondarily due to
its “migration” from outside to the depth.15 Therefore,
my method reproduces the natural phenomenon that
happens to the umbilicus of a newborn child.
4. Defatting the three cutaneous flaps created on the
abdominal wall in order to reduce the thickness of
the panniculus around the new umbilical region. This
concept is very important, since a normal umbilicus is
thinner and gives a depression to the whole umbilical
area (Fig. 29.3A–E).
5. Shortening the pedicle of the umbilicus is an important
procedure in order to reduce the distance between
the abdominal cutaneous flap and the umbilicus itself
(Fig. 29.5). This indication is more frequent on patients

293
Chapter | 29  Umbilicoplasty
FIG. 29.3  Placement and transplantation of the umbilicus. (E) Post­
operative photos of two different patient show that the scars are hidden
inside of the umbilical cavity with its natural depression without external
scar.
E
to an unattractive appearance (Figs 29.6A–G and 29.7A–
C). The treatment and correction of those deformities is
performed with my method, even with reinforcement of the
muscular aponeurosis diastases (Figs 29.6 and 29.7). When
children present with diastasis of the rectus abdominalis it
is possible to perform reinforcement above and below the
umbilicus through the triangular incisions on the umbilicus.
Afterwards, if any redundant skin is present it may be
resected, leaving the three triangular flaps on the external
area of the umbilicus (Figs 29.6 and 29.7).
The umbilical region sometimes needs reconstruction
due to burns causing unesthetic deviation from cicatrization.
I perform the same star-shaped incision on the umbilicus to
create three triangular skin flaps on the umbilicus and
another three triangular flaps on the skin covering the middle
line of the abdominal wall. Therefore the area where the
umbilicus was in the wrong position due formation can be
repaired by suturing those three triangular skin flaps created
on the previous umbilical area (Fig. 29.8A–D). The umbi­
licus is then transposed subcutaneously to the midline of the
abdomen. Its reimplantation is performed through a similar
star-shaped incision at the midline (Fig. 29.8A–D).
FIG 29.6, 29.7, 29.8B APPEARS ONLINE ONLY
In the repair of severe scar retractions, even scar contrac­
tion on the umbilical region after abdominoplasty can be
solved by this technique. The male patient shown in
Fig. 29.9(A–J) underwent traditional abdominoplasty per­
formed elsewhere that left a deep and unesthetic scar on the
pubic region and a very small scar on the umbilical area with
fistula for many years. He complained about the absence of
a belly button as well as hygienic problems. A secondary
abdominoplasty and reconstruction of the umbilicus during
the operation was performed. The infraumbilical panniculus
was undermined up to the umbilical region in order to
F
E
(E) Perioperative photo – one can see the umbilicus already incised with three hooks pulling its three cutaneous flaps inside
the instrument. (F) Close-up of the umbilicus.
FIG. 29.2  Continued
with obese panniculus as well as on those patients
with hernia of the umbilicus with diastasis of the rectus
muscles.
6. The final scar around the new umbilical area is a trian­
gular one created by multiple and atypical Z plasty,
which avoids scar retraction and contraction postopera­
tively (Fig. 29.3).
FIG 29.2D, 29.3A–D, 29.4, 29.5 APPEARS ONLINE ONLY
Patient Selection
Although my umbilicoplasty method was developed
and created during abdominoplasty, I have found several
circumstances to use it for treatment and correction of other
deformities in the umbilical area. Hernia formation, even
with redundancy of skin on the umbilicus, is a very common
unesthetic abnormality that may happen in children, leading

293.e1
Chapter | 29  Umbilicoplasty
FIG. 29.2  Sequence of schemes and photos showing cutaneous inci­
sions for umbilicoplasty by Avelar’s technique. (D) Photo during
surgery shows the instrument lifting the umbilical area with the cutaneous
incisions on the umbilicus avoiding risk of damage to the abdominal intra-
cavity structures.
D
FIG. 29.3  Placement and transplantation of the umbilicus. (A) Demarcation of the new umbilicus using the articulated instrument on the abdominal
flap. (B) A circle of 2 cm diameter is marked with three triangular flaps inside – one is superior and the others inferior on right and left. (C) A patient
7 days after abdominoplasty still with stitches inside the umbilicus. (D) Postoperative photos of two different patients show that the scars are hidden
inside the umbilical cavity with its natural depression, without an external scar.
A
B
C
D

293.e2
PART | 5  Abdominal contouring procedures
FIG. 29.4  Placement and transplantation of the umbilicus, before (A, B, C, D) and after (E, F, G, H). Postoperative photos of two different
patients show that the scars are hidden inside the umbilical cavity with its natural depression, without an external scar.
A
B
C
D
E
F

293.e3
Chapter | 29  Umbilicoplasty
G
H
FIG. 29.4  Continued

293.e4
PART | 5  Abdominal contouring procedures
FIG. 29.5  Reinforcement of the aponeurosis. Sequential drawings (A, B, C) show plication of the aponeurosis and (D) shortening the pedicle of
the umbilicus.
A
B
C
D

293.e5
Chapter | 29  Umbilicoplasty
A
B
C
D
FIG. 29.6  The use of Avelar’s technique for transposition of the umbilicus on an abdomen wall presenting lateral deviation of the umbilicus
due to severe scar retraction after burns. Sequential drawings (A, B, C, D) show how to use the technique. (A) The umbilicus deviated from the
middle line. (B) Cutaneous incisions are done on the deviated umbilicus as well as on the middle line. (C) The pedicle of the umbilicus is deviated from
the middle line of the abdomen. (D) Final aspect of the umbilicus already transposed. (E, F, G) Photos of a patient with deviation of the umbilicus due
to severe scar retraction after burns on the abdominal wall.
Continued

293.e6
PART | 5  Abdominal contouring procedures
FIG. 29.7  The use of Avelar’s technique for correction of the umbilical hernia with redundancy of skin. (A) Preoperative photo showing hernia on the
umbilicus with excess of skin. (B) Photo during surgery showing the triangular cutaneous surface of the umbilicus after incisions. (C) Postoperative result with
smooth scars inside the umbilicus cavity.
A
B
C
FIG. 29.8  The use of Avelar’s method for reconstruction of the
umbilical region for correction of severe and unesthetic deformity of
the umbilicus due to scar retraction and contraction after full abdomi­
noplasty. (B) Final result after reconstruction of the umbilicus with its
implantation on the abdominal wall.
B
E
F
G
(E) On the perioperative photo, the deviated umbilicus with demarcations of the technique – three cutaneous incisions are made inside the
umbilical area and three cutaneous incisions on the middle line. (F) The umbilicus is already transplanted, passing underneath the panniculus creating a natural
umbilical area on the middle line of the abdomen. (G) Final result 6 months after surgery showing the new umbilical region created on the middle line as well as
the scars on the previous location of the umbilicus.
FIG. 29.6  Continued

294
PART | 5  Abdominal contouring procedures
E
F
G
H
FIG. 29.9  The use of Avelar’s
method for correction of umbilical
hernia in a child, with reinforcement
of the muscular abdominal structures
through the umbilicus. Preoperative
photos demonstrate the use of the tech­
nique. (E) Demarcation of the triangular
incisions inside the umbilicus. (F) The
panniculus of the supraumbilical region
is undermined with scissors in order to
perform reinforcement of the aponeuro­
sis. (G) Internal view after plication
through the umbilical incisions. (H)
External view of the umbilicus after
plication.
FIG. 29.8  The use of Avelar’s method for reconstruction of the umbilical region for cor­
rection of severe and unesthetic deformity of the umbilicus due to scar retraction and
contraction after full abdominoplasty. (A) Preoperative photo shows unesthetic aspect of the
abdomen with umbilical scar retraction and contraction. (C) Photo during operation shows the
umbilicus with severe scar contraction. (D) After cutaneous incisions on the skin of the umbi­
licus it was possible to create three cutaneous flaps according to the technique.
A
D
C

295
Chapter | 29  Umbilicoplasty
The Operation
Epidural anesthesia is my preference when full abdomino­
plasty without panniculus undermining is carried out using
my personal technique.19,20 Even many years before, when
I used to perform traditional abdominoplasty with wide
panniculus undermining, my preference for anesthesia was
the same, combined with intravenous sedation under the
care of an anesthesiologist. Nevertheless, for my new
approach21,22 the use of local infiltration is mandatory.
I infiltrate about 200 ml of solution: lidocaine (0.25 mg%)
with epinephrine (adrenaline) (1/400 000) all over the
abdominal wall, which is a very useful procedure in per­
forming liposuction during the operation. On the lower
abdomen local infiltration is done under the cutis as well as
on the full thickness of the panniculus. However, above the
umbilicus and laterally infiltration is performed on the deep
level, underneath Scarpa’s fascia.
Liposuction
I find it more convenient first to perform liposuction, which
is done using two different approaches. The first one is done
on the full thickness of the panniculus on all the infraum­
bilical region. The second approach is deep liposuction
(below the fascia superficialis) on the upper abdomen or
supraumbilical area.23,24 All perforator vessels (arterial and
venous), lymphatics and connective tissue are preserved
since the cannula does not damage any of these anatomical
elements.
Preparation and Liberation of the Umbilicus
According to previous evaluation, planning and marking,
the whole skin covering the infraumbilical area will be
resected. The first step is to make cutaneous incisions on
the star-shaped drawing inside the umbilicus, following
expose the remaining umbilicus. In fact, in all patients, in
whom I have reconstructed the umbilicus during secondary
abdominoplasty, there is always some skin on the umbilicus.
Therefore, the cutis of the umbilicus is incised to create three
skin flaps similar (Fig. 29.9C) to primary reconstruction.
Three cutaneous incisions are also made on the abdominal
flap to be sutured alternatively to those coming from the
umbilicus. The dressing is done with dry gauze placed inside
the umbilicus, following the same methodology described
above after primary abdominoplasty (Fig. 29.9A–J).
FIG 29.9A–D APPEARS ONLINE ONLY
SURGICAL TECHNIQUE
My method was originated to create a new umbilical region
during abdominoplasty and avoid a circular scar on the
abdominal flap. However, it may be used in other circum­
stances in order to repair several deformities of the umbilical
region (Fig. 29.6A–G, 29.7A–C, 29.8A–D, and 29.9A–J).
Surgical Demarcation
The skin area of the abdomen to be resected is marked fol­
lowing Callia’s technique.9 The midline of the abdominal
wall must be drawn from the top of the xiphoid bone,
passing through the umbilicus down to the pubic region.
Such demarcation is very useful to facilitate the surgical
steps of the abdominoplasty, especially during reimplanta­
tion of the umbilicus on the abdominal wall. A circle of
about 2 cm diameter is drawn around the umbilicus. Inside,
a star-shaped incision with three triangular flaps is also
drawn (Fig. 29.2A–E and 29.5A–D). A flap is directed
downward and the other two flaps are directed obliquely
upward to the right and to the left. Also the areas with
localized adiposities are marked laterally as well as on the
posterior regions of the trunk (Fig. 29.1).
I
J
(I) A preoperative view of a female child patient with hernia on the umbilicus. (J) Postoperative aspect of the umbilical region.
FIG. 29.9  Continued

295.e1
Chapter | 29  Umbilicoplasty
FIG. 29.9  The use of Avelar’s method for correction of umbilical hernia in a child with reinforcement of the muscular abdominal structures
through the umbilicus. Sequential drawings demonstrate the treatment of umbilical hernia in a child. (A) Demarcation of triangular incisions on the
umbilicus and dotted lines delineate the internal border of the rectus abdominalis. (B) The panniculus undermining is done through the incisions on the
umbilicus in order to perform reinforcement of the muscular diastases. (C) Plication of the muscle of the umbilical region combined with shortening of
the pedicle. (D) Final plication through the umbilical incisions.
A
B
C
D

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PART | 5  Abdominal contouring procedures
Reinforcement of the Muscular
Aponeurotic Wall
When reinforcement of the musculoaponeurotic structures
has to be done, this is the appropriate time to do it. I created
a device (a dissector instrument) which is introduced from
the umbilical area upwards on the midline, through the
connective tissue remaining after liposuction, to expose
the medial border of the rectus abdominalis. Plication of
the muscular aponeurosis should be done when necessary.
Interrupted nonabsorbable stitches are inserted along
the midline. The pedicle of the umbilicus is sutured to
the aponeurosis, and may be shortened if necessary
(Fig. 29.5).
Reimplantation of the Umbilicus
Once the abdominal flap has been pulled downwards, the
new umbilical area is marked at the point corresponding to
its projection on the surface. The marking of the midline
gives the correct orientation to the new umbilicus position.
In the beginning I would use my left hand under the abdom­
inal flap, to determine the new location.13–15 However, since
198316 I have developed and created a new and appropriate
instrument that permits finding the exact position of the
new umbilicus area and simultaneously where the adequate
distance from the final scar will be, since the instrument is
a marker as well as a ruler (Fig. 29.11A–E). This instrument
protects the aponeurotic wall below as well as avoiding any
damage to the intraabdominal organs.
FIG 29.11A–D APPEARS ONLINE ONLY
I have already described15,16 that on late follow up, the
umbilicus is pulled upward by the upper abdominal segment.
For this reason, the final position of the umbilicus is marked
l cm lower than its projection on the abdominal flap
(Fig. 29.11A–E).
My instrument to determine the new umbilical area
(Fig. 29.11) has two segments like a forceps, with the upper
one being l cm shorter than the inferior one in order to
achieve the exact projection of the umbilicus. Usually it is
placed approximately 7 to 9 cm above the suprapubic inci­
sion. Frequently, 1 year after surgery, some patients have
presented an increase of 2 to 4 cm.
Suture of the Umbilicus
The three flaps of the umbilicus (Fig. 29.2E, F) are then
sutured alternating with the three flaps coming from the
abdominal wall, with interrupted stitches. The tips of the
three cutaneous flaps of the umbilicus are sutured between
each small triangular skin flap created on the future umbili­
cal region on the abdominal flap. On the other hand, the
tips of the skin flaps of the abdominal wall are sutured
previous markings (Figs 29.10A–E and 29.2A–F). In order
to do this, I created and already published a new surgical
instrument,16–18 which is a two-in-one type, to be articulated
around the umbilical pedicle. Using this double half-moon
instrument, the assistant pulls the umbilical area upward to
avoid any accidental perforation (Figs 29.2 and 29.3).
Those severe complications can happen even when per­
formed by well-qualified plastic surgeons.
FIG 29.10B–E APPEARS ONLINE ONLY
Afterwards, the pedicle is dissected up to the musculo­
aponeurotic level with scissors, to isolate the umbilicus
preserving subcutaneous tissue around the pedicle. At the
end of this stage the umbilicus presents its cutaneous
surface, showing a triangular shape (Figs 29.10A–E and
29.2A–F).
Skin Resection
The next step of the operation is to perform full-thickness
resection of the skin on the infraumbilical area on which
liposuction was previously done. The upper incision begins
at the junction of the curved line on both sides of the umbi­
licus, with a slight curvature downwards following the
marking (Figs 29.10 and 29.2). Care has to be taken not to
damage the subdermal layer to avoid bleeding.
Due to deep liposuction the remaining abdominal pan­
niculus flap is more mobile and easily slides downwards as
a block. All perforator vessels are preserved and they work
as multiple pedicles to supply normal vascularization to the
abdominal panniculus.23,25
FIG. 29.10  Sequential drawings showing the technique of full
abdominoplasty. (A) Demarcation of the technique. The skin of the area
below the umbilicus is the one to be resected. The umbilical region is
marked according to Avelar’s technique.
A

296.e1
Chapter | 29  Umbilicoplasty
D
FIG. 29.10  Sequential drawings showing the technique of full abdominoplasty. (B) Incisions on the umbilicus – a special instrument lifts the
umbilical area. (C) Liposuction is performed on the full thickness of the panniculus all over the infraumbilical area. The raw area showing the perforator
vessels and the connective tissue is preserved. One can see the umbilicus with a star-shaped surface. (D) The lower segment of the umbilicus marker
is placed on the umbilicus. The upper segment will determine the new umbilicus region. (E) Final aspect of the full abdominoplasty surgery. The
umbilicus is reimplanted according to the technique.
B
C
E

296.e2
PART | 5  Abdominal contouring procedures
FIG. 29.11  Articulated instrument for placement of the new umbilicus region during full abdominoplasty. (A) Profile view photo showing that
the upper segment is shorter than the inferior one. (B) Drawing of the articulated instrument showing a difference of l cm in length. The upper part is
shorter than the lower one. (C) Oblique view. (D) View from above shows that the upper part of the instrument is also a ruler to measure the distance
from the umbilicus to the pubic incision.
A
1cm
B
C
D

297
Chapter | 29  Umbilicoplasty
with dry gauze is placed inside the umbilicus, and changed
every 10 days for at least 2 months.
OUTCOMES, PROGNOSIS,
COMPLICATIONS
Creating a new umbilical region during abdominoplasty is
challenging, since it is located in the geometric central area
of the abdomen and it is a very important esthetic unit.
Unesthetic results for the umbilicus are responsible for
unfavorable results after abdominoplasty. Any alteration on
the final scar such as hypertrophy, retraction, even contrac­
tion, produces an ungraceful appearance of the abdomen.
The umbilicus is the first scar on the human body, due
to the natural phenomenon of necrosis and retraction of the
umbilicus on a newborn child a few days after birth.15 The
final scar is placed and hidden inside the umbilicus on
the midline of the abdomen, with a natural depression to
the region even with reduced fat tissue layers all around.
The position and appearance of the umbilicus change as
time goes by, presenting some inclination downwards from
a frontal view. When abdominoplasty is performed it is
challenging to reproduce all those natural characteristics on
the umbilical region.
REFERENCES
1. Kelly HA. Report of gynecological cases. John Hopkins Med J
1899;10:197.
2. Demars, Marx. As mentioned in Voloir, R. Opérations Plastiques
Susaponérotiques sur Ia Paroi Abdominale Antérieure. Paris: These;
1960.
3. Sinder R, editor. Cirurgia Plástica do Abdome. Brazil: R. Niterói;
1979.
4. Voloir P. Opérations Plastiques Susaponérotiques sur la Paroi
Abdominale Antérieure. Paris: Thése n° 365; (Travail base sur les
techniques de Morel Fatio et de R. Vilain), Paris, 1960.
5. Malbec EF. Lipectomia abdominal. La Prensa Med Arg 26, June,
1948.
6. Pitanguy L. Abdominal lipectomy: an approach to it through an
analysis of 300 consecutive cases. Plast Reconstr Surg 1967;
40(4):384–91.
7. Sinder R. Cirurgia Plástica do Abdome – Personal technique. thesis
presented in the open competition to teacher vacancy in Plastic
Surgery at the Faculty of Medicine Federal University Fluminense,
Niterói, Rio de Janeiro, 1975.
8. Vernon S. Umbilical transplantation upward and abdominal con-
touring in lipectomy. Am J Surg 1957;94:490–2.
9. Callia WEP. Contribuição para o estudo da correção cirúrgica do
abdome pêndulo e globoso – técnica original. Tese de Doutorado
Fac. Brazil: Med. USP, São Paulo; 1965.
10. Juri J, Juri C, Raiden G. Reconstruction of the umbilicus in abdomi­
noplasty. Plast Reconstr Surg 1979;63(4):589.
11. Sinder R. Plastic surgery of the abdomen – personal technique. In
Abstracts of the 6th International Congress on Plastic and Recon­
structive Surgery. Paris: Masson; 1975. p. 58.
between the cutaneous flaps of the umbilicus. Therefore,
the final scar, instead of being circular around the umbili­
cus, will be a “broken” line like an atypical Z plasty.13–15
The final scar has a triangular shape, which is very impor­
tant to avoid scar retraction and contracture.
One of the most important surgical principles of my
technique is to push the skin flaps of the abdominal wall
to the deep structures of the musculoaponeurosis, giving
a natural depression in the umbilical region. In other
methods described in the literature the umbilicus is pulled
from the depth to the surface of the abdominal wall,
which may not create the normal depression of the umbili­
cal region.
More than three flaps on the umbilical surface, as well
as more than three skin flaps on the skin covering of the
abdominal panniculus, will result in a final scar that has a
tendency to look like a circle. Therefore, a main surgical
principle is to avoid a circular scar afterwards.
POSTOPERATIVE CARE
Dressing
Dry gauze is placed inside the umbilical cavity and more
gauze over it to exert slight pressure over the umbilical
area. Such a procedure keeps the flaps in their adequate
position, avoiding scar tissue contracture. The dressing is
removed 4 or 5 days after surgery, when another dressing
FIG. 29.11  Articulated instrument for placement of the new umbi­
licus region during full abdominoplasty. (E) The use of the instrument
during full abdominoplasty surgery. Its lower segment is placed on the
umbilicus and the upper one lies on the abdominal flap after its traction
and resection.
E

298
PART | 5  Abdominal contouring procedures
12. Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with
emphasis on complications. Plast Reconstr Surg 1977;59(4):
513–7.
13. Avelar JM. Umbilicoplastia – uma técnica sem cicatriz externa.
Anais do XIII Congr. Brás Cir Plast Porto Alegre 1976;81–2.
14. Avelar JM. Abdominoplasty – systematization of a technique without
external umbilical scar. Aesth Plast Surg 1978;2:141–51.
15. Avelar JM. Umbilical scar - importance and technique for abdomi­
noplasty. Rev Brás Cir 1979;1/2:41–52.
16. Avelar JM. Abdominoplasty: Technical refinements and analysis of
130 cases in an 8-year follow-up. Aesth Plast Surg 1983;7:205.
17. Avelar JM. Fat-suction versus abdominoplasty. Aesth Plast Surg
1985;9:265–76.
18. Avelar JM. Combined liposuction with traditional surgery in
abdomen lipodystrophy. Madrid: XXIV Instructional Course of Aes­
thetic Plastic Surgery of ISAPS; Sept. 19, 1985.
19. Avelar JM. Uma nova técnica de abdominoplastia – sistema vascular
fechado de retalho subdérmico dobrado sobre si mesmo combinado
com lipoaspiracão. Rev Bras Cir 1999;13,88/89(1/6):3–20.
20. Avelar JM. A new technique for abdominoplasty subdermal flap
folded over itself. Tokyo, Japan: XV ISAPS Congress; April
2000.
21. Avelar JM. The new abdominoplasty and derived technique. ISAPS
and ASERF Annual Meeting. The Aesthetic Meeting. New York.
May, 2001.
22. Avelar JM. Abdominoplasty without panniculus undermining and
resection: analysis and 3-year follow-up of 97 consecutive cases.
Aesth Surg J 2002;22(1):16–25.
23. Avelar JM. Surgical anatomy and distribution of the subcutaneous
fat tissue on human body. In: Avelar JM, Illouz I-G, editors. Lipoaspi­
ração. São Paulo: Hipócrates; 1986. p. 45–57.
24. Avelar JM. Regional distribution and behavior of the subcutaneous
tissue concerning selection and indication for liposuction. The best
scientific work presented in Zurich, Suisse. Aesth Plast Surg 1989;
13:155–65.
25. Avelar JM, Illouz YG. Lipoaspiração. São Paulo: Hipocrates;
1986.
Fig. 29.1, Fig. 29.2D, Fig. 29.3A–D, Fig. 29.4, Fig. 29.5, Fig. 29.6,
Fig. 29.7, Fig. 29.8B, Fig. 29.9A–D, Fig. 29.10B–E, Fig. 29.11A–D
can be found online
Bonus images for this chapter can be found online at

299
© 2013 Elsevier Inc
Chapter 30 
Key Points
●
The optimal preoperative management that will
improve outcomes and prevent complications is
outlined.
●
The technique of preoperative markings is described.
●
The objectives of an excellent abdominoplasty are
outlined.
●
The technique of abdominal flap elevation is
described.
●
The methods of musculoaponeurotic abdominal wall
repair are described.
●
Postoperative management and treatment of
complications are described.
Combining abdominal contouring with
hernia repair
Oscar Ramirez
INTRODUCTION
Patients requesting abdominal contouring to improve their
appearance can present with defects of the skin/subcutaneous
layer only, or external lamellar problems can be combined
with musculoaponeurotic abdominal wall defects. These
abdominal wall defects can vary from simple minor dia­
stases of the recti muscles with weakness in the midline to
frank midline hernias with significant separation and retrac­
tion of the recti muscle. In addition, between these two
extremes, there is a spectrum of problems that requires
attention.
Plastic surgeons should be prepared to repair these
defects. The degree of confidence, previous training and the
nature of the defect will dictate if these are repaired with
or without the help of a general surgeon. The aim of this
chapter is to describe the combined technique of abdominal
wall contouring with the correction of abdominal wall
bulges and/or hernias in the same operative setting.
PREOPERATIVE PREPARATION
The patient is prescribed Betadine showers and a routine
antibiotic regime for gastrointestinal cleansing similar to
that used for gastrointestinal surgery. This includes a clear
liquid diet, laxatives, enemas, and antibiotics to decrease
growth of the bacterial flora responsible for intestinal gas
and stool production. Adequate intake of fluids and electro­
lytes during this process is recommended. In addition
Reglan (chlorpropamide) 10 mg every 6 hours is prescribed
to stimulate peristalsis in the early postoperative period.
This regimen aims to reduce intraabdominal pressure
and prevent ileus paralyticus that is occasionally seen fol­
lowing major plications or myofascial advancements. This
is more critical if the peritoneum is going to be invaded.
Increased
intraabdominal
pressure
will
produce
increased tension on the myofascial line of closure and
cause compression on the inferior vena cava. This, in turn,
will produce stagnation of the venous return with the sub­
sequent development of deep venous thrombosis (DVT).
This bowel preparation seems to diminish postoperative
abdominal pain and provides more comfort for the patient.
Review of my cases has revealed that since we have rou­
tinely implemented this regimen, we have no reported cases
of DVT despite lack of routine anticoagulant usage. There
have also been no cases of ileus paralyticus or abdominal
distention. The use of anticoagulants is not without signifi­
cant side effects, mainly postoperative bleeding and large
seroma formation.
Another important preoperative regimen is the patient
wearing a progressively tighter abdominal binder or corset.
This is particularly critical in those cases where you antici­
pate repair of large defects or significant tension and
can preoperatively assess if the patient can tolerate large
degrees of closure. The abdominal binder or corset is
worn for a month at least but should ideally be worn for
3 months preoperatively. The abdominal binder also aims
to prevent postoperative atelectasis and postoperative lung
complications.
Prior to surgery the patient’s abdominal flaps are marked
typically in a U-M pattern while they are standing (Figs
30.1 and 30.2). When the patient is lying down, all the
reference points are lost and we cannot be precise in the
degree of symmetry of the incisions. See references 1 and
2 for details of marking.1,2 These markings can be pro­
gressed to a grid type of pattern.3
Part 5  Abdominal contouring procedures

300
PART | 5  Abdominal contouring procedures
SURGICAL TECHNIQUE
The operation is performed under general anesthesia. Inter­
mittent compression devices (ICD) are applied to the lower
extremities. Tumescent solution is infiltrated in the inter­
face between the fat layer and fascia/muscle, and less to the
panniculus itself. The thick portions of the subcutaneous
layer of the flap to be advanced inferiorly are suctioned with
2 or 3 mm cannulas. This should follow the orientation
of the vascular supply to the flaps to prevent injuries of
these arcades. To create the xiphoumbilical depression, the
central portion of the flap is suctioned, starting from the
position of the new umbilicus going up to the xiphoid
process and suctioning up to the subdermal layer. This
etching of the midline is not carried out below the new
position of the umbilicus because this will compromise the
blood supply and is not needed esthetically.
Dermolipectomy is done by initially incising on the “U”
landmark. Large vessels are ligated or hemoclips applied.
Smaller vessels are electrocoagulated. I prefer bipolar coag­
ulation to prevent thermal damage to the vascular trees of
FIG. 30.1  Reference landmarks and the U-M markings in a patient with
a moderate abdominal pouch. The peaks of the M are moderate in height
and located on the flanks. Closure of this wider gap will lift the anterolat­
eral thigh skin. The mark on the pubis is 5 cm from the vulvar
commissure.
FIG. 30.2  Observe the lateral extent of the markings as well as the
general orientation and the peaks of the M.
the vessels being coagulated. Monopolar cautery will com­
promise the vascular supply of the flaps.
When the dissection approaches the navel, this is cored
out after a heart-shaped incision is made. Early coring out
of the navel will prevent its accidental tran­section during
flap elevation, especially on very thick flaps. Dissection
extends up to the costal margins and the xiphoid area. After
a trial of advancement of the flap and changing the opera­
tive table to about 45°, the previously marked M compo­
nent is re-assessed by matching it against the lower incision
line. Any discrepancies are adjusted at this point. Trimming
of the flap is made initially by incision perpendicular to the
skin and then very quickly the knife is turned up to 45° in
order to remove as much as possible of the deep fat layer
of the upper flap (Figs 30.3 and 30.4).
This deep fat layer is between the Scarpa’s fascia (deep)
and Camper’s fascia (superficial). In the middle and upper
abdominal skin (to be advanced inferiorly) these two layers
are well defined and easy to recognize. This is an excellent
way to thin out the advanced flap. Scarpa’s fascia is left
attached to the abdominal myofascial layer. In previous
publications it has been noted that this maneuver decreases
postoperative seroma formation.4

301
Chapter | 30  Combining abdominal contouring with hernia repair
Abdominal Wall Weakness and/or
Hernia Repair
This is done after the skin flap is elevated. A well-executed
musculoaponeurotic repair will provide a significant
improvement of the abdominal contour (Figs 30.5 and
30.6). There are different variations of repair according to
the anatomical problem. If the problem is generalized
weakness of the abdomen without any definite bulging or
there is a large rectus diastasis, this is repaired after the
myofascial release previously described.2
An elliptical shaped marking from xiphoid to pubis on
the anterior rectus sheath is done with the widest portion
around the waistline, which usually is above the navel. The
navel is usually located at the level of the iliac crest. This
FIG. 30.3  The deep fat of the upper abdominal flap is resected by an
initial 45° tangential incision and then axial excision.
FIG. 30.4  Observe in the center of the screen the fatty defect of the
navel. For comparison the height of the resected fat is almost of the same
height as the skin flap.
FIG. 30.5  The recti fascia partition extends from xiphoid to pubis. The
ellipse has its widest dimension above the navel area.
Preop
Linea alba
Diastasis recti
FIG. 30.6  The recti myofascial advancement will redefine the waistline
and will tighten the entire abdominal wall.
Postop

302
PART | 5  Abdominal contouring procedures
neurovascular bundles to the groin. The external oblique
fascia and muscle are plicated using inverted 2-0 nylon
sutures. For reinforcement, you can use Vicryl mesh,
Marlex mesh, or one of the biological materials available
in the market.
If a typical midline hernia is found then this should be
repaired by a direct closure of the hernia sac, after which
the myofascial release and repair is done. This myofascial
release will reinforce the hernia repair very effectively.
For larger defects you may need to use the more tradi­
tional component separation technique(CST).5,6 The muscle
repair can be reinforced with one of the alloplastic or allo­
grafting materials available (Figs 30.9–30.11). The material
of choice will depend on the surgeon’s preference and expe­
rience. If the residual weakness is minimal, I reinforce it
with Vicryl mesh because this will create scarring and
ellipse varies from 6 to 18 cm in its largest width, with an
average of 10.5 cm. The myofascial release is done initially
by making 1 cm incisions every 3 to 4 cm on the anterior
rectus sheath using a cold knife. The hemostat is introduced
and the fascia elevated and in between the blades of the
open hemostat incisions are made with electrocautery.
During this process, the areas of the tendinous insertions
are avoided. I do not recommend making a direct incision
into the fascia with the electrocautery device as the muscle
tends to contract and jump, which will potentially make the
incision deeper, with bleeding in the muscle. After the myo­
fascial incision is completed, the repair is done by applica­
tion of inverted figure-of-eight 2-0 nylon sutures applied to
the lateral edge of the rectus sheath incision (at the border
at the myofascial incision). The suture bites should include
muscle layer. The muscle will work as a pledget to the
fascia and prevent its disruption. Two key sutures are
applied initially, one above the navel and one below the
navel. This will set an easy closure because immediately
you will see a drop of the muscle below the level of the
rectus repair line (Figs 30.7 and 30.8). Since this will sig­
nificantly bury the navel it is important to tag the navel with
3-0 nylon sutures to retrieve it later. The rest of the myo­
fascial repair is completed from xiphoid to pubis.
To avoid postoperative pain and also to relax the
abdominal wall musculature, I routinely use a bupivacaine
pump (On Q pain pump, I-Flow pump), which is delivered
through a catheter that is introduced in the plane between
the external oblique fascia and the internal oblique fascia
using a blunt cannula. For pain control I use 100 ml of 0.5%
bupivacaine plus 200 ml of saline plus 1 ml of 1 : 1000
epinephrine (adrenaline) solution. The weakness of the
patient’s abdomen may occasionally be more on the lower
quadrants than on the midline, or there may be a combina­
tion of central midline weakness and flank weaknesses. In
those circumstances, the repair of the flank weaknesses is
done in an oblique direction following the direction of the
FIG. 30.7  Axial view of the repair. The recti fascia is partitioned to perform the so-called “myofascial release”. The released recti muscle will push
itself toward the midline. This will enable closure of the muscle/fascia layer with lesser tension.
A
C
B
D
FIG. 30.8  Intraoperative view showing several aspects of the myofascial
release. The fascia/muscle is being repaired. Below the navel the centrifu­
gal forces of the muscle disengaged from the rectus sheet are pushing the
midline. The navel is partially buried in the recti repair. It has been tele­
scoped and fixed to the fascia at the border of the myofascial repair.

303
Chapter | 30  Combining abdominal contouring with hernia repair
collagen deposition, which will mimic an additional fascial
layer. If the weakness is significant, then I use Marlex
mesh.6,7 If there are doubts about the thickness of the
abdominal flap or the thickness of the tissue covering the
peritoneum, or there is a potential for infection then I use
a sheet of biological material.
Abdominal Flap Closure
After the myofascial repair is done and the umbilicus is
inset in the advanced abdominal flap, the abdominal flap is
closed in three layers: Camper’s fascia, subdermis, and
skin. I prefer using nonabsorbable monofilament sutures for
all the layers. One or two closed suction drains are left in
the lower abdomen.
OPTIMIZING OUTCOMES
To improve the outcome of the procedure a thorough evalu­
ation of the patient’s body constitution and his/her abdomen
is critical to plan the best operation for that patient. The
following factors are taken into consideration:
1. Body mass index (BMI).
2. The amount and thickness of subcutaneous fat.
3. The quality and elasticity of the skin.
4. The position and distance of the navel in relation to the
xiphoid process and symphysis pubis.
5. The presence of abdominal wall weakness and its local­
ization and type.
6. The presence of back pain.
7. Waist line definition.
8. Concomitant ptosis of the buttocks and/or excess fat on
the back.
These factors will determine the procedures you are
going to select, the sequence of the operation, and if the
procedures are going to be staged or not.8–10 Likewise, these
will determine the aggressiveness or the conservatism to
each one of the components of the surgery. In this context,
abdominal wall contour and muscle wall surgery is indi­
vidualized and tailored to each patient’s respective prob­
lems and not approached in a generic standard way.
Another important consideration to improve the outcome
is the objectives that should be sought during the abdomi­
noplasty. In a prior publication these objectives have been
described1 (see Box 30.1).
POSTOPERATIVE CARE
The ICD is used for 2 or 3 days until the patient is fully
mobilized. A liquid diet for 2–3 days is gradually pro­
gressed to a regular diet. Chlorpropamide is continued until
the patient has the first bowel movement. The use of the
pain pump decreases the need for narcotic pain medication.
FIG. 30.9  The large ventral defect has been dissected. The recti muscles
have been freed up (hemostats). The white structure in the middle is a
laparotomy sponge.
FIG. 30.10  Components separation of the abdomen has been used to
repair the defect and a Marlex mesh sheet has been cut out to reinforce
the defect. The navel is in the middle.
FIG. 30.11  The Marlex mesh has been stabilized with fascial staples and
monofilament sutures.

304
PART | 5  Abdominal contouring procedures
with or without reinforcement using alloplastic or allograft
material. Not included are patients that received CST fol­
lowing trauma or complicated infected abdominal hernias.
A few patients (3%) required external oblique plication for
lower quadrants or flanks. The rate of surgical revision has
been very small (2%). Two patients developed deep tissue
granulomas due to braided suture material. Since then the
use of braided suture materials for this procedure has been
abandoned. One patient died 3 days after surgery at home
due to a cardiac arrhythmia secondary to an adverse drug
reaction from medication not prescribed by our staff. Only
two patients developed thromboembolic disease presenting
as pulmonary emboli and DVT, with minimal morbidity.
Retrospectively, these patients did not comply with the
prescribed gastrointestinal prep discussed here.
One patient had significant skin necrosis (5 × 7 cm) that
required secondary revision. This patient was an unknown
active smoker.
A well-planned and -executed abdominal contour
surgery with or without hernias should lead to few and
manageable complications. These complications are man­
ageable by the surgical staff. Over 90% of patients were
extremely satisfied with the results (Figs 30.12–30.16).
Some of the dissatisfactions have been related to the pro­
longed discomfort (tightness) and numbness in the operative
site (abdominal skin). There were two cases where esthetic
results were not optimal. One was scar hyperpigmentation
in a dark skinned Latin-American patient, and a scar depres­
sion secondary to the removal of braided suture granulomas.
The scar depressions were corrected with minor scar revi­
sions. Treatment for the hyperpigmentation was challenging
and in my experience hydroquinone, lasers and other treat­
ment modalities are not effective in these areas. I have
noted that prolonged taping with micropore tape is good at
preventing this problem and to prevent granuloma forma­
tion I no longer use braided suture material.
To prevent DVT and thromboembolic disease we
enforce the bowel preparation as described. In patients with
high risk for pulmonary emboli I now routinely use
anticoagulants.
CONCLUSION
Abdominoplasty with repair of abdominal wall weakness
or hernia for patients with moderate elevation of BMI
that present with large abdominal panniculus, fat accumula­
tion in the central /lower trunk, undefined abdominal
contour, and lax tissues around the pubis and upper thighs
will require the integration of several surgical components
described herein. Repair of an obvious hernia or abdominal
weakness requires special attention to preoperative plan­
ning and to the meticulous details of the surgery as well as
A two-drain system is used and usually the patient’s care­
giver alternates the delivery of the anesthetic solution every
2 hours, clamping the right or the left tube alternatively.
With the addition of epinephrine (adrenaline), the bupiva­
caine absorption will be slowed down; therefore it will last
longer at the action site for each fraction of time used. This
will also prolong the total amount of time that the pain
pump can be delivered, typically from about 48–72 hours
to 100–120 hours. Suction drains are gradually advanced
every 2–3 days and stabilized with a large Tegaderm dress­
ing. The drains are left in place for about 8–10 days. To
prevent infection at the exit site, a rolled 2 × 2 dressing
moistened in Betadine solution is applied and changed
every 2 days. Seroma usually occurs around the 5th day
after the drains are removed and the blood clots start to
dissolve. In this way the rate of seroma formation is dimin­
ished significantly.
The abdomen is supported with an abdominal binder.
The binder is marked with vertical lines for adjustments
during supine position (looser) and during standing (tighter).
This is worn for 4–6 weeks. Patients can return to normal
activities after 4–6 weeks and to unrestricted exercises if
indicated after 12 weeks.
COMPLICATIONS AND
THEIR MANAGEMENT
I have done close to 300 abdominoplasty procedures from
which about half have needed abdominal wall musculoapo­
neurotic repair, as described previously. The majority of
them needed significant advancement of the recti muscle/
fascia after the myofascial release. About 10% of this sub­
group presented with large hernias that required the CST
1. Place the incisions within the bikini line.
2. Reduce or eliminate striae.
3. Flatten and tighten the abdomen.
4. Decrease the size of the waistline.
5. Decrease the thickness of the subcutaneous fat
throughout the abdomen, flanks, and iliac areas.
6. Rejuvenate the pubis from a triangular senescent to an
oval youthful form.
7. Lift the lax anterolateral thigh skin near the groin
crease and iliac areas.
8. Create a well-defined xiphoumbilical depression.
9. Give an illusion of an athletic abdomen.
10. Change the body posture.
11. Correct any hernia.
12. Relieve back pain if this is related to muscle laxity of
the abdomen.
BOX 30.1  Cardinal Objectives of a Comprehensive
Abdominoplasty
Text continued on page 310

305
Chapter | 30  Combining abdominal contouring with hernia repair
Fig 30.12  (A–D) Preoperative and comparative postoperative frontal and lateral views of an obese patient with large ventral hernia. She had a reverse
T abdominoplasty and a components separation repair. Her intraoperative photo is shown in Figs 30.9–30.11. The improvements in the contour, waistline
reduction and the xiphoumbilical definition are obvious.
A
B
C
D

306
PART | 5  Abdominal contouring procedures
FIG. 30.13  A 44-year-old patient after U-M abdominoplasty and myofascial release and advancement. Observe the changes in pubis shape, improve­
ment of the thighs, and overall contour of the abdomen. The abdominal shape in profile is a more feminine shape as opposed to the “too tight lower
abdomen with a pouch on the upper abdomen”, more typical of a male shape. Patient had a small supraumbilical hernia repaired during this surgery.
A
B
C
D

307
Chapter | 30  Combining abdominal contouring with hernia repair
FIG. 30.14  Lateral view of the same patient shown in figure 30.13. Observe the significant improvement of the abdomen and the creation of the
contour of the feminine abdomen.
A
B
A
B
FIG. 30.15  (A–F) 53-year-old female, who was operated on using the four integrated components, Observe the waistline definition, excellent xiphoum­
bilical depression among other improvements. The patient was of Spanish background and requested preservation of the hip volume.
Continued

308
PART | 5  Abdominal contouring procedures
C
D
E
F
FIG. 30.15  Continued

309
Chapter | 30  Combining abdominal contouring with hernia repair
FIG. 30.16  (A–D) A 46-year-old female, who was operated on following the four components, Observe the significant changes in abdominal contour.
This patient decreased 22 cm in waistline circumference. Patient had a prior subcostal cholecystectomy scar that was advanced inferiorly. Because of
the details of the technique described here, we rarely see vascular problems in the flaps.
A
B
C
D

310
PART | 5  Abdominal contouring procedures
to postoperative care. Each of them is as important and
critical as the others. These will guide you to good results,
minimal complications, and high patient satisfaction.
REFERENCES
1. Ramirez OM. U-M abdominoplasty. Aesthetic Surg J 1999;19:
279–86.
2. Ramirez OM. Abdominoplasty and abdominal wall rehabilitation: a
comprehensive approach. Plast Reconstr Surg 2000;105:425–35.
3. Petcher EA. The grid/staple adjunct to abdominoplasty. Plast Reconstr
Surg 2006;118:1624–30.
4. Ramirez, OM. The U-M Dermolipectomy and Myofacial Release in
Abdominoplasty. Operative Techniques. Plastic Reconstr Surg 2003;
40–52.
5. Ramirez OM, Ruas E, Dellon AL. Components separation method for
closure of abdominal wall defects: An anatomical and clinical study.
Plast Reconstr Surg 1990;86:519–26.
6. Ramirez OM, Girotto, JA. Closure of abdominal wall defects: The
components separation technique. In: Bendavid R, Abrahamson J,
Arregui M, et al, editors. Abdominal Wall Hernias. Principles and
Management. New York: Springer-Verlag; 2001. p. 87–496.
7. Ramirez OM. Inception and evolution of the components separation
technique: personal recollections. Clin Plast Surg 2006;33:241–6.
8. Abhyankar SV, Rajguru AG, Patil PA. Anatomical localization of the
umbilicus: An Indian study. Plastic Reconstr Surg 2006;117:
1153–7.
9. Faria-Correa MA. Abdominoplasty: the South American style. In:
Ramirez OM, Daniel RK, editors. Endoscopic Plastic Surgery. New
York: Springer-Verlag; 1996.
10. Baroudi R, Ferreira CA. Contouring the hip and the abdomen. Clin
Plast Surg 1996;23:551–73.

311
© 2013 Elsevier Inc
Chapter 31 
Key Points
●
Liposuction is one of the most common esthetic
procedures performed and the incidence of
complications is low.
●
Liposuction is more of an art than a surgical
procedure.
●
Liposuction entails a practical application of scientific
knowledge with precision and craftsmanship and is a
skill attained with clinical experience.
●
In this chapter the technique, the pearls and the
pitfalls of liposuction are described in detail. A series
of patients who underwent liposuction of abdomen
and trunk are presented.
●
The long-term results of liposuction depend on the
preoperative condition of the patient’s skin, the
patient’s overall health and expectations, and the
ability of the patient to maintain a healthy weight and
lifestyle postoperatively.
Liposuction of the abdomen and trunk
Luiz Haroldo Pereira and Aris Sterodimas
INTRODUCTION
Concepts of beauty have been continuously evolving
throughout the history of mankind. The voluptuous figures
that were idealized by artists in the past have been substi­
tuted by slimmer forms. In many countries, liposuction is
the most frequently performed esthetic procedure.1,2 Lipo­
suction has evolved tremendously over the past three
decades. Since its introduction, it has progressed into one
of the most popular procedures in plastic surgery.3,4 The
“Illouz Method” featured a technique of suction-assisted
lipolysis after infusing fluid into tissues using blunt can­
nulas and high-vacuum suction and demonstrated both
reproducible good results and low morbidity. Liposuction
is more of an art than a surgical procedure. It entails a
practical application of scientific knowledge with precision
and craftsmanship and is a skill attained with clinical expe­
rience. The development of liposuction provided plastic
surgeons with a safe and effective way to sculpt the human
figure.5 It brings as much contentment and joy to the person
undergoing it, as to the surgeon practicing the intimidating
task of delivering that eventual result. The goal of liposuc­
tion is the reduction of localized fatty tissue to produce
well-proportioned body contours. Although liposuction has
been considered a safe surgical procedure for the last 30
years, to maximally avoid complications, one should be
mindful of all the factors that could predispose to them.6
PREOPERATIVE PREPARATION
Liposuction patients must be properly evaluated and coun­
seled appropriately and adequately on risks and potential
outcomes of the liposuction procedure. A documented
medical history, physical examination and the appropriate
laboratory tests based upon the patient’s general health and
age should be performed on all liposuction patients. Com­
plete blood cell count, platelet assessment, INR, chemistry
profile including liver function tests, and pregnancy test for
women of childbearing age must be performed.
Known contraindications should be ruled out and their
absence noted in the clinical record, including:
● Significant medical conditions that may be aggravated
by surgery or anesthesia, and use of all medications,
vitamins and herbs must be documented.
● Local conditions of skin or subcutaneous tissue that
make liposuction hazardous.
● Morbid obesity.
● Psychological contraindications such as mood disor­
ders, thought disorders, severe anxiety, or unrealistic
expectations.
Because esthetic surgery is elective, whenever there is
a question about a preoperative medical condition, the pro­
cedure is postponed until appropriate consultations are
obtained and all issues settled.
Appropriate indications should be recorded in the clini­
cal record which may include:
● The removal of localized or regional deposits of adipose
tissue for the purpose of body contouring.
● The treatment of specific conditions of adipose and sub­
cutaneous tissues but not the management of obesity.
Part 5  Abdominal contouring procedures

312
PART | 5  Abdominal contouring procedures
2. Preoperative sedation in the surgical suite is adminis­
tered. Anesthesia consists of an epidural block and intra­
venous sedation. The patient is placed in supine
position.
3. After the injection of normal saline wetting solution
containing 1 : 500 000 of epinephrine (adrenaline) by a
small-bore cannula and waiting 15 minutes, a 60 ml
syringe attached to a 4 mm blunt cannula is inserted
through two small incisions in the area to be
liposuctioned.
4. Fat is aspirated using the syringe method in the dorsum
and the flanks (Fig. 31.2).
5. If autologous fat transfer is being considered, the aspi­
rated fatty tissue is treated in the following manner:
With the syringe held vertically with the open end
down, the fat and fluid are separated. Isotonic saline is
added to the syringe, the fat and saline are separated and
the exudate discarded. The procedure is repeated until
At the time of the preoperative consultation the patient
is given written information concerning the planned proce­
dure that reinforces the verbal information provided. In
addition to describing to the patient the anticipated results
of the procedure, it is necessary to point out the areas where
little or no benefit is expected.
Preoperative photographs are essential for assistance
in preoperative planning; communication with patients
preoperatively and postoperatively; intraoperative decision
making; and medicolegal documentation.
Informed consent should include the provision of
written educational material and discussion with the patient.
SURGICAL TECHNIQUE
1. Markings of the areas to be liposuctioned and fat grafted
are made while the patient is in the standing position
(Fig. 31.1A, B).
FIG. 31.1  The marking of areas to be liposuctioned and fat grafted is done while the patient is in standing position.
A
B

313
Chapter | 31  Liposuction of the abdomen and trunk
FIG. 31.2  Intraoperative views of syringe-assisted low pressure
liposuction.
FIG. 31.3  Intraoperative views of autologous gluteal graft.
FIG. 31.4  Intraoperative view of liposuction of the breasts.
FIG. 31.5  Intraoperative view of liposuction of the abdomen.
the fat becomes yellow in color, free of blood and tri­
glyceride oil. Our experience with autologous fat trans­
plantation in treating various tissue defects has been
published previously.7–9
6. When gluteal augmentation is scheduled, a deep plane
to the gluteal muscles is created by the 4 mm cannula.
Then other planes are created by the same cannula in
different trajectories, always from the deeper aspect to
the gluteal surface. The fat is inserted into these tunnels
beginning at the deep layer and working up into the
intermediate fat compartments. The fat is injected as the
cannula is withdrawn. Care should be taken to avoid
injection of more fat in the superficial fat compartment.
Separate incisions, if necessary can be used to treat the
whole gluteal region (Fig. 31.3).
7. When needed, fat grafting to the female breast (Fig.
31.4) and liposuction to the abdomen is then performed
(Fig. 31.5). When indicated, lipoabdominoplasty is
performed. The combination of circumferential liposuc­
tion, fat grafting of the buttocks and lower limbs, and
modified transverse abdominoplasty has been described
as composite body contouring in the literature.10
8. The patient remains hospitalized for 24 hours. Anti­
biotics, analgesics and anti-inflammatory medications
are prescribed during the following 7 postoperative
days.
A video demonstrating the technique is presented.
Nine illustrative cases are presented.
Case 1
This 24-year-old lady presented complaining of “extra fat”
which made her “unattractive” (Fig. 31.6A–C). Liposuction
of the back, flanks, and abdomen and autologous gluteal
lipograft was performed. Photos were taken 3 years after
the procedure (Fig. 31.6D–F). Breast augmentation by sili­
cone implant was also performed.

314
PART | 5  Abdominal contouring procedures
OPTIMIZING OUTCOMES
The shape, volume, and size of the body contour vary
greatly. These variations can be observed in the same
person during his/her lifespan. Ethnic background, sex,
genetics, hormones, physical exercise, and diet are some of
the factors that influence body contour. True body sculpting
demands a three-dimensional understanding of the ana­
tomic and surgical adipose layers of the abdomen and the
trunk when performing liposuction.11 Although liposuction
is not a technically difficult procedure, it requires thought­
ful planning and an artistic eye to achieve esthetically
pleasing results.
● Thorough clinical examination should include a detailed
evaluation of the regions to be lipocontoured, including
a notation of hernias, scars, asymmetries, cellulite, and
stretch marks.
● The safety of the liposuction technique relates not only
to the amount of tissue removed but to the patient’s
Case 2
This 41-year-old woman presented for liposuction and
moderate buttock enhancement (Fig. 31.7A–C). Liposuc­
tion of the back, flanks, and abdomen and autologous
gluteal lipograft was performed. Photos were taken 4 years
after the procedure (Fig. 31.7D–F).
Case 3
A 40-year-old man requested a better definition of his trunk
(Fig. 31.8A–C). He underwent liposuction. Photos were
taken 4 years after the procedure (Fig. 31.8D–F).
Case 4
A 35-year-old man requested reduction of his gynecomastia
by liposuction (Fig. 31.9A, B). He underwent bilateral
breast liposuction. Photos were taken 3 years after the pro­
cedure (Fig. 31.9C, D).
FIG. 31.6  (A–C) Preoperative views of a 24-year-old woman complaining of “extra fat” in her body. (D–F) Postoperative views of a 24-year-old
woman, 3 years after liposuction of the back, flanks, abdomen and autologous gluteal lipograft was performed.
A
B
C
D
E
F

315
Chapter | 31  Liposuction of the abdomen and trunk
● In the back all the fibrous bands separating the rolls
are aggressively lysed with the Mercedes tip
cannula.
● Improvement of the gluteal contour can be attained
through augmentation of the gluteal region by means of
autologous fat transplantation.
● Fat deposits may extend above the rib margin, and
the cannula must be torque to get above the ribs. Using
the flat of the hand to press the ribs downward allows
free passage of cannulas from several directions. The
opposite hand is also needed to judge how much fatty
tissue is left in place.
overall health. It is ideal for the patient to be as fit as
possible before the procedure and not to have smoked
for several months.
● Standardized photo documentation is required. Contour
lines are drawn about the fat to be extracted and the
areas that need to be lipografted.
● Liposuction is performed by three plastic surgeons
simultaneously, coordinated by the chief surgeon, with
a significant saving of surgical time.
● Appropriate measurements of the extracted fat of each
region must be recorded and the contralateral side must
be treated in a similar manner.
FIG. 31.7  (A–C) Preoperative views of a 41-year-old woman requesting liposuction and moderate buttock enhancement. (D–F) Postoperative views
of a 41-year-old woman, 4 years after liposuction of the back, flanks, abdomen and autologous gluteal lipograft was performed.
A
B
C
D
E
F

316
PART | 5  Abdominal contouring procedures
of patients undergoing liposuction increasing, it is likely that
plastic surgeons will see more patients requesting secondary
liposuction procedures in the future.15 The abdominal area
is a difficult region for liposuction and can be responsible
for serious local sequelae that are difficult to correct and
generally require fat grafts to correct contour issues.16
● The flat-bladed cannula should always be used with the
suction hole facing downward and never upwards, in
order to prevent contour irregularities.
According to a recently published article, there is a
growing contingent of nonsurgery trained physicians pro­
viding liposuction.12 Physicians practicing liposuction
surgery should have adequate training and experience in the
field.13,14 This training and experience may be obtained in
residency training, cosmetic surgery fellowship training,
CME-accredited postgraduate didactic and live surgical pro­
grams, or via proctorship with trained credentialed surgeons
experienced in liposuction techniques. With the overall
acceptance of esthetic surgery increasing, and the number
FIG. 31.8  (A–C) Preoperative views of a 40-year-old man who requested a better definition of his trunk. (D–F) Postoperative views of a 40-year-old
man, 4 years after liposuction was done.
A
B
C
D
E
F

317
Chapter | 31  Liposuction of the abdomen and trunk
more difficult it is to achieve a satisfactory degree of
liposuction. The use of the smallest diameter cannulas
(3 mm) greatly facilitates liposuction in areas that are
especially fibrous, such as the midlateral back.
● The skin on the back is especially susceptible to hyper­
pigmentation of scars from incisions for liposuction.
The number of scars should be minimized and care
taken to avoid unnecessary trauma to the epidermis
● One of the most important factors for surgeons to con­
sider when performing liposuction is whether the pro­
cedure can be performed during a single surgical session,
or whether it will require several sessions. The overall
amount of fat removed should not exceed 7% of the
total body weight.
● The greater the fibrous content of a fat compartment,
the more resistance to penetration by a cannula, and the
FIG. 31.9  (A, B) Preoperative views of a 35-year-old man who requested reduction of his gynecomastia by liposuction. (C, D) Postoperative views
of a 35-year-old man, 3 years after bilateral breast liposuction was done.
A
C
B
D

318
PART | 5  Abdominal contouring procedures
constitutes an ideal methodology for fat grafting, there are
some proven points that should be taken into account.
● No statistical differences in adipocyte viability have
been demonstrated among abdominal fat, thigh fat,
flank fat, or knee fat donor sites.19 The donor site can
be chosen according to the preference of the surgeon
and the patient.
● Recent reports have shown that mechanical centrifuga­
tion does not appear to enhance immediate fat tissue
viability before implantation.20 An important consider­
ation for harvesting and refinement in preparation for
grafting is to respect and maintain the tissue architecture
of living fat. Any mechanical or chemical insult that
damages the fragile tissue architecture of fat will result
in eventual necrosis of the injected fat.
● The transplanted fat must have access to blood supply.
The creation of multiple tunnels ensures adequate blood
supply to the grafted fat. Intramuscular fat grafting
should be done in tunnels also and retrograde injection
should be performed, in order to avoid intravascular fat
injection.
● For predictable results, the surgeon should refine the
fat into relatively pure living tissue, using sterile
con­ditions and avoiding external contact, thus prevent­
ing contamination. Transplanting a high percentage
of nonviable components such as blood and triglyc­
eride oil reduces the potential for accurate volume
estimation.21
● Surgeons have come to realize that transplanted fat can
create not only satisfying changes in contour, but also
long-lasting results.22,23
Lipoaspirate, an otherwise disposable byproduct of cos­
metic surgery, has been shown to contain a putative popula­
tion of stem cells, termed adipose-derived stem cells
(ADSCs) that share many similarities to marrow stromal
cells (MSCs) from bone marrow.24 ADSCs reside within the
stromal-vascular fraction (SVF) in fat tissue, which is
thought to harbor cells that display extensive proliferative
near incision sites on the back. Trauma to the dermal-
epidermal junction predisposes to postinflammatory
hyperpigmentation.
● Any alteration to the natural look of the gluteal fold may
result in a cosmetically disturbing complication. Lipo­
suction corrects the fat bulging, but not the skin laxity.
A useful test is done when the patient is lying in the
prone position. If the “banana” fold of the infragluteal
region disappears, there is excess of skin and lipograft­
ing or more complex procedures should be performed.
If the “banana” fold continues to be present, there is
residual adipose tissue that needs to be corrected by
liposuction.
● Irregularities ranging from “oversuctioning” to bumpy
skin (Fig. 31.10) and asymmetries result from inade­
quate experience of the surgeon.17,18
● An overaggressive approach to liposuction of the flanks
can injure the subdermal vascular plexus and produce
chronic erythema.
● Postoperative fluid collection and hematoma require
active intervention by draining of fluid collection using
a syringe (Fig. 31.11).
● To enhance patient satisfaction, minor complications
related to surgical trauma need to be addressed
aggressively.
The success of autologous fat grafting is dependent
upon many factors: the techniques and instruments used to
harvest the fat tissue, the fat processing, the volumes of fat
implantation, the sites to be implanted, the levels of place­
ment, and even the individual patient. Because of this vari­
ability and perhaps because of other factors that are not yet
understood, the results of fat grafting with some techniques,
in some patients, and in some areas can be unpredictable.
Although there is no universal agreement on what
FIG. 31.10  Preoperative views of irregularities ranging from “over­
suctioning” to bumpy skin.
FIG. 31.11  Postoperative drainage of fluid collection and hematoma
by syringe.

319
Chapter | 31  Liposuction of the abdomen and trunk
Careful selection of patients and proper surgical tech­
niques help avoid contour irregularity, and diligent peri­
operative care of the patient helps avoid postoperative
complications.
CONCLUSION
Liposuction is currently the most frequently performed
esthetic operation in the world. Despite its widespread
popularity, it must be practiced with maximum care and
safety. Liposuction can be performed safely on properly
selected patients who have realistic expectations and under­
stand the limitations of the procedure. They tend to be very
satisfied with the results. The long-term results of liposuc­
tion depend on the preoperative condition of the patient’s
skin, the patient’s overall health and expectations and the
ability of the patient to maintain a healthy weight and life­
style postoperatively.
REFERENCES
1. Sterodimas A, Huanquipaco JC, de Souza Filho S, et al. Autologous
fat transplantation for the treatment of Parry-Romberg syndrome.
J Plast Reconstr Aesthet Surg 2009;62(11):e424–6. Epub 2008
Aug 15.
2. Haeck PC, Swanson JA, Gutowski KA, et al. Evidence-based patient
safety advisory: liposuction. Plast Reconstr Surg 2009;124(4 Suppl):
28S–44S. Review.
3. Pereira LH, Sterodimas A. Treatment of iatrogenic abdominal
contour irregularities. Aesth Plast Surg 2010;34(2):129–35. Epub
2008 Aug 28.
4. Jewell ML, Fodor PB, de Souza Pinto EB, et al. Clinical application
of VASER–assisted lipoplasty: a pilot clinical study. Aesth Surg J
2002;22(2):131–46.
5. Triana L, Triana C, Barbato C, et al. Liposuction: 25 years of experi­
ence in 26,259 patients using different devices. Aesth Surg J
2009;29(6):509–12.
6. Pitanguy I. Evaluation of body contouring surgery today: a 30-year
perspective. Plast Reconstr Surg 2000;105(4):1499–514; discussion
1515–26.
7. Pereira LH, Radwanski HN. Fat grafting of the buttocks and lower
limbs. Aesth Plast Surg 1996;20(5):409–16.
8. Pereira LH, Sterodimas A. Free fat transplantation for the aesthetic
correction of mild pectus excavatum. Aesth Plast Surg 2008;
32(2):393–6.
9. Haroldo Pereira L, Sterodimas A. Aesthetic restoration of axillary
contour deformity after lymph node dissection. J Plast Reconstr
Aesth Surg 2008;61(2):231–2. Epub 2007 Nov 19.
10. Pereira LH, Sterodimas A. Composite body contouring. Aesth Plast
Surg 2009;33(4):616–24. Epub 2009 May 12.
11. Rohrich RJ, Smith PD, Marcantonio DR, et al. The zones of adher­
ence: role in minimizing and preventing contour deformities in lipo­
suction. Plast Reconstr Surg 2001;107(6):1562–9.
12. Camp MC, Wong WW, Wong RY, et al. Who is providing aesthetic
surgery? A detailed examination of the geographic distribution and
capacity and multilineage potential.25 Recently, approaches
based on ‘ADSCs enriched lipograft’ have been published.26
ADSCs have a great potential for use in tissue repair and
regeneration in the field of plastic and reconstructive
surgery. Although the currently applied strategies for
adipose tissue engineering have advanced in recent years,
complete understanding of the mechanisms of interactions
among adipose stem cells, growth factors, and biomaterials
in tissue engineering is needed in order to advance the
end goal of developing ‘off-the-shelf’ tissue engineering
products.
POSTOPERATIVE CARE
Prophylactic antibiotic therapy (Zinadol, cefuroxime axetil
500 mg twice a day) for 7 days is prescribed. Reasonable
early ambulation of liposuction patients is advisable to
avoid venous stasis and shorten the postoperative recu­
peration period. Postsurgical compression garments
including binders, girdles, foam tape, closed-cell foam,
and other specialized equipment have been effectively uti­
lized. The use of compression is considered important and
appears to be most helpful in the first month following
surgery. Lymphatic drainage by a trained physiotherapist
three times a week for a month is standard in our
practice.
COMPLICATIONS AND THEIR
MANAGEMENT
Surgeons of multiple specialties perform liposuction surgery
today. The increasing number of liposuction procedures,
often performed by inadequately trained physicians, has led
to a growing number of liposuction complications.
● Edema, ecchymosis, dysesthesia, fatigue, soreness,
scarring, asymmetry, and contour imperfections are
expected sequelae after liposuction.
● Persistent edema, long-term dysesthesia, hyperpigmen­
tation, pruritus, hematoma and seroma are occasional
side effects after liposuction.
● Skin necrosis, severe hematomas, recurrent seromas,
nerve damage, systemic infection, hypovolemic shock,
intraperitoneal or intrathoracic perforation, deep vein
thrombosis, pulmonary edema, pulmonary embolism
(ARDS) and loss of life are uncommon sequelae after
liposuction.
Although plastic surgeons have developed safety mea­
sures to perform the technique, there are serious risks,
including death at a rate of 1/5000 procedures. Major surgi­
cal complications can be avoided by following well-known
safety guidelines.27

320
PART | 5  Abdominal contouring procedures
and harvest site. Plast Reconstr Surg 2004;113(1):391–5; discussion
396–7.
21. Nicareta B, Pereira LH, Sterodimas A, et al. Autologous gluteal
lipograft. Aesth Plast Surg 2010;35(2):216–24.
22. Pereira LH, Sterodimas A. Macroscopic and microscopic proof of
long-term survival of gluteal fat transplantation. Plast Reconstr Surg
2009;123(4):162e–3e.
23. Pereira LH, Sterodimas A. Long-term fate of transplanted autologous
fat in the face. J Plast Reconstr Aesth Surg 2010;63(1):e68–9. Epub
2009 Mar 12.
24. Sterodimas A, de Faria J, Nicaretta B, et al. Tissue engineering with
adipose-derived stem cells (ADSCs): current and future applications.
J Plast Reconstr Aesth Surg 2009;63(11):1886–92.
25. Sterodimas A, de Faria J, Nicaretta B, et al. Cell assisted lipotransfer.
Aesth Surg J 2010 Jan-Feb;30(1):94–100. Rubin JP, Marra KG.
Commentary. Cell-assisted lipotransfer (CAL). Aesth Surg J. 30(1):
82, 2010.
26. Sterodimas A, de Faria J, Nicaretta B, et al. Autologous fat trans­
plantation versus adipose derived stem cells enriched lipograft: a
study. Aesth Surg J 2011;31(6):682–93.
27. Toledo LS, Mauad R. Complications of body sculpture: prevention
and treatment. Clin Plast Surg 2006;33(1):1–11, v.
training backgrounds of cosmetic practitioners in Southern Califor­
nia. Plast Reconstr Surg 2010;125(4):1257–62.
13. Sterodimas A, Radwanski HN, Pitanguy I. Aesthetic plastic surgery:
junior plastic surgeons’ confidence in a training program. Aesth Plast
Surg 2009;33(1):131–2. Epub 2008 Dec 31.
14. Sterodimas A, Boriani F, Bogetti P, et al. Junior plastic surgeon’s
confidence in aesthetic surgery practice: a comparison of two didac­
tic systems. J Plast Reconstr Aesthet Surg 2010;63(8):1335–7.
15. Matarasso A, Wallach SG, Rankin M, et al. Secondary abdominal
contour surgery: a review of early and late reoperative surgery. Plast
Reconstr Surg 2005;115(2):627–32.
16. Illouz YG. Complications of liposuction. Clin Plast Surg
2006;33(1):129–63, viii.
17. Pereira LH, Sterodimas A. Correction for the iatrogenic form of
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18. Pereira LH, Sterodimas A. Treatment of iatrogenic abdominal
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2008 Aug 28.
19. Ullmann Y, Shoshani O, Fodor A, et al. Searching for the favorable
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20. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat
transfer viability: a quantitative analysis of the role of centrifugation

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Chapter 32 
Key Points
●
Presentation of the massive weight loss patient to the
plastic surgeon is quite variable.
●
Lower truncal excess in the massive weight loss
patient is most often circumferential in nature.
●
Circumferential dermatolipectomy is usually required
to treat the entire lower truncal unit in the massive
weight loss patient.
●
Photographing the markings and comparing them to
the final result is essential in improving technique.
●
In a belt lipectomy, the inferior markings anteriorly
control final scar location and the superior markings
control final scar location posteriorly.
●
To avoid dehiscence, the back midline markings
should be performed with the patient in a flexed
position.
●
The anterior resection takes priority over the posterior
resection.
●
Results and complications correlate with BMI at
presentation.
Belt lipectomy/circumferential
abdominoplasty
Al S. Aly, Garrett Wirth, Donald Mowlds and Thomas Scholz
INTRODUCTION
Body contouring’s deeply rooted history involves the evo­
lution of specialized surgical techniques to sculpt and
reshape the human physique. The concepts of panniculec­
tomy and dermolipectomy were defined at the tail end of
the 19th century as pioneers of this craft began to remove
pendulous adipocutaneous tissue, resulting in improved
functionality.1 In the early 20th century, contour surgery
began its transformation from a purely functional modality
to an esthetic procedure. As such, Thorek described the first
umbilicus preserving abdominoplasty in 1924.2 The 1960s
and 1970s saw major advances in this field as techniques
involving aponeurotic plication,3 refinement in scar place­
ment3–6 and tissue anchoring utilizing the anatomy of the
superficial fascial system7 were made popular. At the turn
of the 21st century, the explosive growth and widespread
acceptance of bariatric surgery created a new group of
patients, collectively referred to as “massive weight loss
patients.” New procedures were necessary to excise the
redundant tissue in all areas of the body while achieving an
esthetic result. The range of contour deformities seen in
these patients experienced a dramatic expansion from
“anterior only” to “circumferential,” establishing the cir­
cumferential dermatolipectomy as a mainstream operation
in plastic surgery today.
Body contour deformities of the lower trunk exist on a
spectrum from “anterior only” to “circumferential” defor­
mities. If the lower truncal deformity is limited to moderate
lipodystrophy deposits, then liposuction may be the only
treatment modality required. Abdominoplasty techniques
are useful if anterior skin laxity and/or abdominal wall
weakness are encountered. If lateral and posterior lipodys­
trophy accompany the anterior deformities, then liposuction
may be added to abdominoplasty in order to achieve the
best possible contour. If circumferential skin and subcuta­
neous laxity is additionally present, then belt lipectomy
procedures are usually required to adequately address the
deformities.
Belt lipectomy procedures treat deformities of the lower
trunk, from the ribcage to the pelvic rim, and improve the
contour of the lower back and the anterior, medial and
lateral thighs. It does not, however, address upper back
rolls/lateral back rolls, breast, or arm contour. The belt
lipectomy procedure, therefore, will not address the upper
trunk, which anatomically originates at the inferior border
of the neck and extends to include the inframammary fold.
To correct deformities of this anatomic unit, the authors
suggest using an “upper body lift” procedure.
RELEVANT ANATOMY
It is critical to understand the anatomy, in particular the
blood supply, of the abdomen and all its variations when
considering a circumferential dermatolipectomy of the
lower trunk. This chapter will stop short of a detailed
Part 5  Abdominal contouring procedures

322
PART | 5  Abdominal contouring procedures
Although the pathophysiologic processes are similar and
the indications and principles in operative design are com­
parable, their individual BMI at presentation, fat deposition
pattern, and quality of their skin–fat envelope can result in
a wide divergence in the nature of their physical deformity.
Massive weight loss patients must therefore be well
informed regarding the expected body contour outcome to
avoid disappointment. Bariatric surgeons tend to emphasize
overall weight reduction and often neglect to inform patients
that many of the changes in their body habitus are not
reversible with weight loss and that normalcy from an
esthetic standpoint is often unattainable. The redundant
skin with irreversible laxity is almost always circumferen­
tial in these patients, resulting in a truncal pattern of an
inverted cone.
The second group of patients that may benefit from
body lift/belt lipectomy are the 9–13 kg (20–30 pounds)
overweight patients (BMI of 26–28). These patients have
never lost significant weight despite reasonable exercise
and nutritional support, which very often results in circum­
ferential lipodystrophy and an overall lack of definition of
the lower trunk. A third group is comprised of normal
weight patients who desire more dramatic improvements in
lower truncal contour than a conventional abdominoplasty
can achieve. These normal BMI patients often seek drastic
improvement in the contour of their anterior and lateral
thighs, buttocks and lower back. Some of these patients can
be treated with an abdominoplasty combined with liposuc­
tion of specific areas; however, if significant lifting and
contour manipulation is required, a circumferential exci­
sional procedure becomes necessary. A subset of this group
is made up of older patients whose skin laxity requires the
pull created by the circumferential excision. Liposuction
alone will not sufficiently address the deformity as irrevers­
ible skin laxity precludes the contraction necessary to
achieve the desired contour.
DIAGNOSIS AND PRESENTATION
The discussions to follow will focus on the massive weight
loss patient, with occasional reference to the other groups
when appropriate. As discussed previously, massive weight
loss patients vary in their BMI level, fat deposition pattern
and quality of skin–fat envelope, which influences their
presentation. Even though massive weight loss patients,
through lifestyle changes or bariatric surgery, will tend to
eventually attain a stable BMI, they will still present to the
plastic surgeon at different levels. It is important for the
plastic surgeon to elucidate a timeline of weight stabiliza­
tion, as some patients will have a false plateau after which
they will resume weight loss. Therefore, it is wise to consult
with the bariatric surgeon before considering body-
contouring procedures. If the patient loses weight through
description of the vascular supply as this is covered else­
where in this textbook. Preservation of the vascular supply
as well as the peripheral innervation to the abdomen is a
critical consideration in thwarting major complications of
these procedures. The superficial fascial system, called
Scarpa’s fascia in the abdomen, is a connective tissue
network that exists between the subdermal plane and the
deep fascia and it separates subcutaneous fat into superficial
and deep layers. In thin patients, the two layers are of rela­
tively similar thickness. Both layers demonstrate vertical or
oblique fibrous septae; however, the vertically oriented
compartments of the superficial layer thicken with increas­
ing body weight and grow proportionally with the body
mass index (BMI). Therefore, the superficial layer is often
thicker with respect to the deep layer in patients with
increased BMI. In well-defined areas of the trunk the super­
ficial fascial system is tightly tethered to the underlying
musculoskeletal surface, resulting in restriction of either
descent or elevation, which typically occurs with age, fluc­
tuations in weight, or surgical manipulation. These areas
are referred to as “zones of adherence,” which behave like
“hooks” that grasp the fat/skin envelope as it succumbs to
gravitational forces, most noticeably following skin defla­
tion from massive weight loss. It is important to know the
anatomy of these zones and how they influence tissue
draping. The zones of adherence are located in the inframa­
mmary, inguinal, suprapubic, and gluteal regions. The
zones of adherence overlying the spine and sternum as well
as the area located between the hip and lateral thigh fat
deposits are strong and consistently present. On the other
hand, the zone of adherence overlying the midline linea
alba of the abdomen is relatively weak and occasionally
nonexistent. Another strong zone of adherence is in the
inguinal region, which plays an integral role in the final scar
position following a belt lipectomy. A weaker zone of
adherence exists in the horizontal suprapubic area, creating
a suprapubic crease, which varies between individuals.
Along with the inguinal zones of adherence, the suprapubic
zone is responsible for the panniculus overhanging the
mons pubis. The zone of adherence between the hip and the
lateral thigh fat deposits mentioned above is an important
anatomic structure because it prevents superior and inferior
movement of lateral thigh tissue, especially during surgical
manipulation. Destruction of this zone is often necessary if
substantial elevation and redraping of the lateral thigh soft
tissue envelope is desired, such as with the lower body lift
type II as described by Lockwood.
DISEASE PROCESS
In general, there are three groups of patients for which
a belt lipectomy is beneficial.8 The majority are massive
weight loss patients,8 who are not a homogeneous group.

323
Chapter | 32  Belt lipectomy/circumferential abdominoplasty
and lower back region that add to this blunting. The anterior
and lateral thighs are greatly affected by the weight gain/
weight loss process and are therefore typically ptotic. The
effect on the thighs is less dramatic in the “20–30 pound
overweight group” and the “normal weight group,” but
nevertheless it remains an area of concern for these patients.
Similar to the thighs, the buttock in the massive weight
loss patient is usually ptotic as a result of the weight loss
process. The projection of the buttocks is generally corre­
lated with the patient’s BMI, with patients above a BMI of
35 presenting with overly projected buttocks and patients
with BMI under 26 with flat appearing and underprojected
shape. Many massive weight loss patients also display poor
demarcation between the lower back and buttocks.
Back rolls can be located in the lower, mid or upper
back and are particularly displeasing to many patients. High
back rolls, which are usually contiguous with breast rolls,
are not affected by the belt lipectomy and require an upper
body lift. Low back rolls are generally improved with the
bariatric surgery, the type of procedure chosen for the patient
will likely affect their final BMI. Lap-Band® procedures
tend to induce the least amount of weight loss, followed by
gastric sleeve resection and gastric bypass, while duodenal
switch patients tend to have the most dramatic fall in BMI.
The unique fat deposition pattern also plays an impor­
tant role in determining the specific contour deformity in
massive weight loss patients. A patient’s fat deposition as
well as fat loss pattern is genetically regulated and is there­
fore quite individualistic. For example, men tend to deposit
fat intraperitoneally and in the flank region (“love handles”),
presenting with mostly central, or “apple shaped,” obesity.
Women, on the other hand, tend to store fat in a “pear
shaped pattern” in the extraperitoneal space, the lower
abdomen, hips, and thighs. These patterns are just two of
many potential fat deposition presentations. Weight loss
varies similarly, with some patients losing fat in equal pro­
portions throughout their body while others experience
more of an asymmetric pattern with relatively more or less
lost in different areas. While fat deposition undoubtedly
plays a major role in determining overall body contour, it
is important to recognize that the underlying musculoskel­
etal foundation also contributes to the overall appearance
of the individual and therefore must be considered when
establishing expectations of the final cosmetic result.
The characteristic of the skin–fat envelope is a third
factor that affects the presentation of massive weight loss
patients. The envelope is of major interest to the plastic
surgeon and its intrinsic qualities are critical as it influences
overall cosmetic outcome. The thickness of the post-weight
loss subcutaneous fat tissue is important, as thin layers
generally allow for greater pliability and movement of
overlying skin, which is important in predicting the final
cosmetic result. The authors introduced the concept of
“translation of pull” as an excellent predictor of the final
results. Prior to surgery, the lateral abdominal tissues are
pinched in order to simulate the effect of the lateral abdomi­
nal resection on the distal thigh contour (see Fig. 32.1).
Thicker nonpliable skin–fat envelopes, which are typical of
patients with higher presenting BMIs, have little translation
of pull in these areas, indicating that the potential overall
improvement in body contour is limited. As a general
guideline, the greater the drop in BMI for an individual
patient, the greater the “translation of pull.”
Nearly all massive weight loss patients present with a
“hanging panniculus,” the size and shape of which varies
with the patient’s intrinsic fat deposition pattern. Addition­
ally, almost every massive weight loss patient will present
with “ptotic mons pubis,” most commonly exhibiting verti­
cal excess and varying degrees of horizontal excess. The
hanging skin/fat envelope often blunts the waistline as it
drapes from the ribs to below the pelvic brim. Despite
weight loss, there are often residual fat deposits in the hip
FIG. 32.1  The “translation of pull” is shown by the red arrow, which
demonstrates the extent of improvement away from the area of resec­
tion (simulated by the pinching of tissues).

324
PART | 5  Abdominal contouring procedures
most centers. Additionally, gastric sleeve resection is
gaining considerable popularity over the past few years and
is currently considered the treatment of choice by many
bariatric surgeons.
Intraabdominal content is an important determinant of
overall abdominal contour. Adequate flattening of the
abdominal contour via muscle wall plication is heavily
dependent on the amount of intraabdominal content. If
excess exists, then the result of a circumferential procedure
is similar to that attainable by panniculectomy.10 Therefore,
in these situations it would be sensible to limit the proce­
dure to a panniculectomy and avoid the increased risk that
accompanies the circumferential excision.
Workup
Although many massive weight loss patients experience
significant improvement in their medical problems fol­
lowing weight loss, they still require a thorough medical
workup by the plastic surgeon during preoperative plan­
ning and evaluation. Patients should be carefully exam­
ined for cardiovascular disease, high blood pressure,
diabetes, collagen vascular disease, bleeding disorders,
smoking history, alcohol history, history of deep venous
thrombosis/pulmonary embolus, previous abdominal scars,
bariatric surgery, psychological problems, and nutritional
habits. Bariatric surgery patients are typically treated
with oral vitamins, so a history devoid of oral supplemen­
tation probably reflects poor follow up with resultant
nutritional deficits. This should prompt the plastic surgeon
to thoroughly evaluate their laboratory workup. Massive
weight loss patients should additionally be questioned
about signs and symptoms that may point to a history of
anemia, hypocalcemia, iron deficiency, vitamin B defi­
ciency, albumin/protein deficiency, hypomagnesemia, ele­
vated liver function tests, and thiamine deficiency. It is
also important to elucidate abnormalities in the patient’s
bowel habits such as frequent diarrhea, which can put
the patient at risk for nutritional deficiencies and wound
contamination.
Many weight loss patients have life-long psychiatric
problems, even after losing weight. The evaluation of the
patient’s psychiatric stability is critically important as belt
lipectomy surgery is a major life event and is associated
with an arduous recovery. The authors have found it
necessary to obtain psychiatric clearance for each belt
lipectomy patient prior to consideration for surgical inter­
vention. Additionally, mental health care providers must be
alerted that maintenance may be required in the postopera­
tive period.
An extensive history of the patient’s weight should
be elicited from patients presenting for lower truncal con­
touring. First, it is important to ascertain the specific
belt lipectomy. Few patients present with mid back, or “no
man’s land,” rolls, which are difficult to treat with either an
upper body lift or a belt lipectomy.
The psychiatric presentation of the patient requires
special consideration. Although the plastic surgeon may be
successful in reshaping the patient’s abnormal contour,
psychological issues may persist. An obesity-associated
depression may persist as well as estrangement from family
and friends who might feel as if they have lost a fellow
“sufferer.”
PREOPERATIVE PREPARATION
Patient Selection
Patients should be selected for their suitability to undergo
circumferential excisional body contouring. Medical, as
well as psychiatric, stability is of high importance. Condi­
tions with a documented impact on wound healing such
as diabetes, smoking, or connective tissue disorders must
be approached with caution as they greatly increase the
complication rate. Similarly, the BMI at presentation must
be a factor in the plastic surgeon’s decision to operate, as
complications are positively correlated with BMI.9 Reason­
ably, few plastic surgeons agree to operate on patients
with a BMI higher than 32. Higher BMIs require surgeon
acceptance of increased complication rates, with nearly
100% of patients experiencing some complication with a
BMI above 35.
Low intraabdominal fat content and weight stability at
the time of the surgery are critical to achieving the best
overall outcome. Therefore, it may be necessary to delay
body-contouring procedures until the patient can achieve
weight stabilization without “heroic efforts,” such as uncon­
ventional diets and overly excessive exercise. A stable
weight plateau is often difficult to identify with certainty
and many patients will have “false plateaus” during which
weight stabilization will be briefly apparent before the
patient experiences further weight loss. If the patient had
bariatric surgery, it may be beneficial to consult the bariatric
surgeon to assist with delineation of true and false plateaus.
Generally speaking, the length of weight stabilization is
positively correlated with the patient’s chances for long-
term success and most surgeons recognize 3 months as an
acceptable minimum period of weight maintenance. The
length of time necessary to reach maximum weight loss
differs between the various bariatric surgical options.
Empiric data suggest that an average of 2 years is necessary
for Lap-Band® patients, 12–14 months for duodenal switch
patients, and roughly 18 months for gastric sleeve resection
and gastric bypass patients. These ranges are not absolute
and can vary considerably between patients. Duodenal
switch procedures are no longer routinely performed at

325
Chapter | 32  Belt lipectomy/circumferential abdominoplasty
multiple concurrent deformities in areas such as the arms,
breasts, upper back rolls, thighs, face, and lower trunk. The
lower trunk and hanging panniculus is usually the chief
complaint; however, many patients are fixated on improv­
ing just a few areas with less concern over others. In some
situations, it may be necessary to plan and stage multiple
procedures in order to achieve the maximal desired result
and this should be communicated and discussed with the
patient. Typically, the lower trunk deformity is addressed
first, followed by arms, the thoracic region, and then the
thighs.
Facial rejuvenation is also a frequent concern for
patients. The authors often address this after the body con­
touring procedures are completed. In addition to a discus­
sion regarding the risks and complications associated with
each procedure, it should be made clear that the agreed plan
might require modification as the body’s contour changes
with each stage. For all major complications, a full disclo­
sure of its occurrence, prevention, and treatment should be
provided, as proper consultation should result in a well-
informed patient who understands each stage of the con­
touring process.
Surgical Plan and Goals
The belt lipectomy is essentially a circumferential wedge
excision of the lower trunk with variations in the operative
technique.13 On one end of the spectrum exists the “lower
body lift type II” as originally described by Lockwood and
on the other the “belt lipectomy” as described by the
authors, originally in Iowa.8,14,15 Neither procedure is supe­
rior to the other and they are instead used to accomplish
different operative objectives. We will cover the belt lipec­
tomy here in detail.
Markings
The importance of properly marking the patient prior to a
belt lipectomy procedure cannot be overstated. Although
there are often adjustments to be made intraoperatively,
the majority of the planning and decision making is
accomplished through the marking process. This is also
a time for the patient and the surgeon to agree on details
such as final scar position and for the surgeon to reaffirm
previously discussed expectations. Preoperative photo­
graphs should assist the surgeon in identifying areas of
special concern and potential pitfall. Once the patient has
been marked, the surgeon should again photograph the
patient. This set of photos in particular can be used for
preoperative evaluation and last minute adjustments and
also for postoperative comparison at 12 months, allowing
the surgeon to critique and improve his or her technique
(see Fig. 32.2).
etiology of the patient’s lower trunk abnormalities. These
can include aging, childbirth, sun-induced skin laxity, and
massive weight loss. If the major cause is weight loss,
then it is prudent to obtain a more specific history
regarding the patient’s weight progression. This includes
determining the patient’s weight at presentation, length of
time at present weight, method of achieving weight loss
and the patient’s historical maximum and minimum
weights.
A careful physical exam should be followed by an eval­
uation specific to the body contouring procedure. It is
important to note the degree of skin laxity, amount of sub­
cutaneous fat tissue and resultant translation of pull in the
various areas of interest. Waist definition, the presence of
abdominal and/or back rolls, degree of rectus diastasis,
presence of hernias, degree of buttock projection and ptosis,
degree of anterior and lateral thigh lipodystrophy and
ptosis, and the presence of any scars must be additionally
noted. Any abdominal scar will alter the anatomy of the
subcutaneous fat and the superficial fascial system, which
ultimately influences the final contour result. Subcostal
scars from gallbladder, gastric, liver, or pancreatic proce­
dures can have a detrimental effect on the vascularity and
the viability of the flaps. Additionally, vertical midline scars
from previous surgeries may limit the inferior mobility of
the abdominal flap. The amount of intraabdominal content
must be ascertained as it considerably influences the final
cosmetic result. Rather than performing the traditional
“diver’s test,” as the surgeon would do in preparation for
an abdominoplasty, the authors find it more effective to
evaluate the patient’s abdominal contours while in a supine
position. The diver’s test is less effective in a massive
weight loss patient due to the thickness and laxity of the
abdominal wall and subcutaneous fat. If the exam reveals
a scaphoid abdominal contour and the abdominal wall falls
below the ribcage, then rectus fascia plication during body
contouring surgery will likely be effective in flattening the
abdomen.11 However, if the abdominal tissues do not fall
below the ribcage, then it can be inferred that the intra-
abdominal contents are considerable and will blunt the
effect of plication in this area.
The altered absorption and dietary manipulation in the
massive weight loss patient can create significant abnor­
malities that must be addressed prior to surgery.12 Exhaus­
tive lab work should be obtained early on in the care of the
patient so that ample time exists for correction of any
observed abnormalities. The labs should include: CBC,
BUN, creatinine, electrolytes, glucose, urinalysis, LFT,
iron, calcium, albumin, prealbumin, total protein, vitamin
B, magnesium, and thiamine. Chest X-ray and EKG should
be obtained as indicated on an individualized basis.
It is important to elicit and address the patient’s priori­
ties. Massive weight loss patients often present with

326
PART | 5  Abdominal contouring procedures
fourchet in females and the midline of the penis in males
can be helpful in identifying the exact midline.
Horizontal Mons Pubis Marking
The horizontal marking of the mons pubis is done with the
patient lying in the supine position. The abdominal tissue
just above the mons pubis is retraced upwards with the
nondominant hand until the appearance of the mons is
esthetically pleasing. The other hand will then palpate the
bony prominence and make a horizontal mark 1 to 3 cm
superiorly, extending from one lateral edge of the mons to
the other. With the superior hand simulating the tension
generated between the resected abdominal flap and the
suprapubic fascial attachments, this marking maneuver
closely approximates the tissue dynamics at the time of
closure. The horizontal mark is then measured on either
side of the midline so that symmetry is maintained.
Marking from Mons to Anterior Superior
Iliac Spine
The horizontal mark from the mons pubis to the anterior
superior iliac spine (ASIS) requires the patient to be in a
slightly flexed position. The nondominant hand is used to
Markings are only guidelines and do not represent a
standardized pattern to be applied uniformly. It is most
important to learn and understand the principles behind
the technical details so that they may be individually tai­
lored to each unique presentation. One exceedingly impor­
tant skill used in the marking process is the simulation of
tissue dynamics at closure in order to estimate and appro­
ximate the final scar position. Although some basic prin­
ciples apply universally, it is important that surgeons strive
to master the art of scar positioning by integrating simu­
lated tissue dynamics with their individualized surgical
technique.
The abdomen is often the patient’s foremost concern
and the surgeon should be reluctant to compromise abdomi­
nal contour for improved lateral or posterior contour. There
is often inferomedial rotation of tissues around the sacrum,
which requires generous lateral resections in order to attain
a harmonious truncal contour.
Vertical Midline
It can sometimes be quite challenging to find the anterior
midline in the massive weight loss patient. The epigastric
vellus hair pattern and landmarks such as the vaginal
FIG. 32.2  (A–F) This figure demonstrates the markings in a typical low BMI massive weight loss patient. Note that there are two sets of
superior anterior markings. The level utilized during the resection is based on how the tissues mobilize.
A
B
C
D
E
F