We do not routinely use low molecular weight heparin, but patients are ordered to get out of bed the next morning. A binder is placed immediately after surgery, and we recommend using it for at least 6 weeks. Drains are usually removed before discharge on the second day (after shower) but only if drainage is less than 30 mL/24 h per reservoir. If drainage persists, they go home with the drains and return after 2 days for observation.
The following variables were measured: age, sex, height, weight, body mass index (BMI), abdominal perimeter at umbilicus, abdominal perimeter at projected scar position, total flap (excised specimen) weight, classic flap (specimen without extended fat excision) weight, total flap width (straight line connecting the lateral ends of specimen), maximum classic flap thickness, adipose flap (extended fat excision specimen) weight, adipose flap height (maximum height, considering the upper skin border as the starting point), deep fat pad thickness at lower abdomen, and days until drainage removal. Complications were also recorded, including hematoma, seroma, flap necrosis (partial or total); umbilical epidermolysis or necrosis; suture dehiscence; and need for reintervention.
Statistical analysis was performed with SPSS 20.0. Pearson product-moment correlation coefficient was used to analyse the correlation between quantitative variables and its strength classified according to Dancey and Reidy categorization. Student t test and 1-way analysis of variance were used when comparing the mean, respectively, of 2 or 3 groups, on dependent and quantitative variables. To examine the independence of qualitative variables, we used the χ2 test. The level of significance was set at α = 0.05.
The study’s population consisted of 74 consecutive female patients, aged 23 to 63 years, with a mean of 41.8 years. Table 1 shows the results of all measured variables.
The geometric pattern of the adipose flap was varied, with some having a homogeneous distribution throughout their width, others being localized in the medial part (up to xiphoid process), and some with little fat in the central portion (Fig. 4). In only 1 case was there no fat below Scarpa’s fascia amenable to excision, and 3 other patients with total flap weight greater than 2.5 kg had an adipose flap with less than 50 g (which may have been limited by a more conservative dissection).
We identified 3 groups: “massive weight-loss” (MWL) patients (n = 36), defined as having more than 40 kg of weight loss or a reduction of excess weight greater than 50% (most of them after bariatric surgery, weight stabilized for at least 1 year); a group of “obese” patients with BMI of 30 kg/m2 or greater that did not satisfy MWL definitions (n = 12), operated due to extensive abdominal aprons; and finally, a group of “nonobese” patients (BMI, <30 kg/m2), which vastly corresponded to postpregnancy sequelae (n = 26).
The most frequently associated pathology with systemic impact was depression (n = 18), followed by hypertension (n = 7), diabetes mellitus type 2 (n = 6), asthma (n = 5), and hypothyroidism (n = 5). Fifteen patients had smoking habits (20.3%), although most of a few cigarettes per day (6 patients smoked ≥10 cigarettes/day). Patients were asked to stop smoking at least 3 weeks before surgery.
The rate of complications seems to be within the range of what has been reported in other articles. Table 2 summarizes the occurrences. There was one partial umbilical necrosis requiring a small local debridement at the office, but after 2 months, the aesthetic result was normal. There were no necroses, partial or complete, of the abdominal flap, and no reoperation was required for any reason. The global rate of seroma was 14.9%. The “nonobese” group had a seroma rate of 11.5% versus 22.2% in the “massive weight-loss” group, and no seroma occurred in the “obese” group. Within smokers (n = 15), the rate was 20.0%. Seromas were all treated with needle aspiration. The average total volume (including all sessions) of aspirated liquid was 370 mL (n = 11), with a mean of 2.9 sessions of aspiration (range, 1–7 sessions) and 2.6 weeks until seroma production stopped (range, 1–6 weeks). Excluding seroma, all complications occurred within the “MWL” group, except for one umbilical epidermolysis in the “obese” group and the episode of pulmonary embolism (“nonobese”).
With all these measurements, we went on to study possible correlations between variables using Pearson correlation coefficient (Table 3). We verified that the thickness of the preserved deep fat pad increases with BMI and with the umbilical perimeter. The weight of adipose flap removed with the specimen also increases with BMI and with the umbilical perimeter (Fig. 5). It is therefore logical that the adipose flap weight increases with the thickness of the preserved deep fat. The increase in patient weight obviously increases the weight of the total operative specimen and also the extra weight of the adipose flap. The weight of the adipose flap is related to the weight of the total operative specimen, but this correlation is stronger when the total specimen weight is less than 3 kg, probably because of a more conservative approach when treating obese patients, which leads to a reduction in the aggressiveness of dissection. Neither the width of the operative specimen nor patient height was statistically correlated to the adipose flap weight.
Student t test showed that the variation of the weight of the adipose flap is not affected by group (nonobese versus MWL) within the same BMI class, specifically the classes “normal weight” (BMI, <25 kg/m2) and “overweight” (BMI, between 25 and 29.99 kg/m2). However, applying a 1-way analysis of variance with Tukey HSD test resulted in a significant difference between the obese group (average, 248 g) and both the other groups (125 g for the nonobese and 151 g for the MWL), which is expected because the obese subjects are included in a BMI class different from the other 2 groups. Student t test also showed that the difference between groups “nonobese” and “MWL,” when comparing the classic flap’s maximum thickness within the formerly considered BMI groups, was also statistically insignificant.
We conclude that increased patient weight and umbilical perimeter are the best predictors of a heavier adipose flap. Body mass index and total operative specimen weight, especially in specimens with less than 3 kg, may also help. History of a massive weight loss is not an independent factor in this determination, given the same BMI class, and so it cannot help us predict the size of the adipose flap. The width of the operative specimen and patient height are not useful as well. Approximately 9% more weight of operative specimen can be removed, from an average of 157 g, up to around 500 g. The main vessels for the vascularization of this removed extra fat are in a plane superficial to Scarpa’s fascia, so its excision may even improve perfusion to the remaining tissues. It is also noteworthy that there was no flap necrosis, demonstrating the safety of this additional procedure. In addition, this study’s population included individuals with a significantly high BMI and shows that, given proper care and conservative dissection, this technique can also be applied to them with no increase in the complication rate.
The 2-month follow-up end point may not be long, but it is enough to clearly define the studied early complication rates. Besides the typical redness of the scar still present in many patients at 2 months, we believe that, overall, it is an acceptable length of time to evaluate the results, as most of the edema has reverted, and there are no long-term biases like weight gain or further surgery.
An acceptable seroma rate (14.9%) was achieved, although the “nonobese” showed a lesser rate (11.5%). The removal of drains was as early as 2 days, comparing with other series’ means of 3 to 5 days11,12 up to 14 to 17 days,13 only because the drainage volume was low at that point. The preservation of infraumbilical Scarpa’s fascia and deep fat is likely related to the low drainage registered after 48 hours, although it did not lower the seroma rate as expected. We also acknowledge that there are other techniques that may reduce the total drainage volume and seroma rate, such as quilting sutures or fibrin sealant.
This study measured for the first time the average dimensions of the extended operative specimen’s adipose flap. We believe that the excision of this extra adipose flap may help balance the thickness of the abdominal wall in the lower third of the abdomen, especially in heavier patients where the fat below Scarpa’s fascia is considerable (Figs. 6–8). Thus, we are able to achieve an abdominal contour that looks slimmer and in harmony with the pubic region.
There are now 2 options to remove this adipose tissue: liposuction and direct excision. Both are supported by multiple publications, showing nice results with a good safety record. It can be argued that direct excision of this deep fat has less risk than blind liposuction of the abdominal flap; although in experienced hands, liposuction can be solely and safely performed below Scarpa’s fascia, the average surgeon, during his/her learning curve will most likely, more than once, violate the superficial fat pad with the liposuction cannula because the thickness of the deep fat pad is variable and can be quite thin in some cases. On the other hand, the fact that liposuction preserves abdominal perforators adds to the vascularization of the flap, increasing its safety.
1. Gradinger GP, Rosenfield LK, Nahai FR. Abdominoplasty. In Nahai F, ed. The Art of Aesthetic Surgery. St Louis, MO: Quality Medical Publishing; 2005:2355,2380.
2. Brink RR, Beck JB, Anderson CM, et al. Abdominoplasty with direct resection of deep fat. Plast Reconstr Surg
3. Saldanha OR, De Souza Pinto EB, Mattos WN, et al. Lipoabdominoplasty with selective and safe undermining. Aesthetic Plast Surg
4. Brauman D, Capocci J. Liposuction abdominoplasty: an advanced body contouring technique. Plast Reconstr Surg
5. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg
6. Hester TR Jr, Nahai F, Beegle PE, et al. Blood supply of the abdomen revisited, with emphasis on the superficial inferior epigastric artery. Plast Reconstr Surg
7. Worseg AP, Kuzbari R, Hübsch P, et al. Scarpa's fascia flap: anatomic studies and clinical application. Plast Reconstr Surg
8. Schaverien M, Saint-Cyr M, Arbique G, et al. Arterial and venous anatomies of the deep inferior epigastric perforator and superficial inferior epigastric artery flaps. Plast Reconstr Surg
9. Harley OJ, Pickford MA. CT analysis of fat distribution superficial and deep to the Scarpa's fascial layer in the mid and lower abdomen. J Plast Reconstr Aesthet Surg
10. Le Louarn C. Partial subfascial abdominoplasty. Aesthetic Plast Surg
11. Costa-Ferreira A, Rebelo M, Silva A, et al. Scarpa fascia preservation during abdominoplasty: randomized clinical study of efficacy and safety. Plast Reconstr Surg
12. Fang RC, Lin SJ, Mustoe TA. Abdominoplasty flap elevation in a more superficial plane: decreasing the need for drains. Plast Reconstr Surg
13. Neaman KC, Armstrong SD, Baca ME, et al. Outcomes of traditional cosmetic abdominoplasty in a community setting: a retrospective analysis of 1008 patients. Plast Reconstr Surg
abdominoplasty; Scarpa's fascia; deep abdominal fat; extended abdominoplasty
Supplemental Digital Content
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.