Matarasso, Alan M.D.; Schneider, Lisa F. M.D.; Barr, Jason B.A.
The popularity of abdominal contouring procedures continues to increase. The rate of abdominoplasty in the United States nearly doubled from 2009 to 2011.1 As the field of body contouring surgery has matured, there has been a proliferation of new techniques. In addition to these advances in techniques, multiple other factors have resulted in more patients returning for secondary abdominal contouring surgery: the aging of the population, patients’ concern with their appearance at increasingly older ages, and a cohort of patients who years earlier had an abdominal contouring procedure. These secondary procedures include a similar range of abdominal contouring procedures that mirror the spectrum of primary operations. This spectrum varies from liposuction to modified abdominoplasty to full abdominoplasty with or without liposuction (Table 1). The purpose of this study was to examine complete secondary operations, not including procedures for revision surgery. Furthermore, the authors report on considerations for their treatment and management of secondary abdominoplasty and abdominal contouring surgery.
Despite the prevalence of the aforementioned primary procedures, there is a paucity of data in the literature focusing on the incidence and surgical management of complete secondary abdominal procedures.2,3 In 2005, Matarasso et al. published a report on secondary abdominal procedures.2 That series included revision procedures; however, it was not strictly limited to true complete secondary operations. To evaluate the overall incidence and management of secondary abdominal contouring procedures, the authors reviewed the database subsequent to the 2005 publication. The authors report recommendations for five common scenarios in which patients present for secondary abdominal contour surgery—excluding revision surgery.
PATIENTS AND METHODS
A retrospective chart review was performed that included 562 patients undergoing 568 abdominal contouring procedures performed by the senior author (A.M.) from January of 2004 until October of 2012. The primary abdominal and/or secondary abdominal contouring procedures were classified as follows: type I, liposuction alone; limited abdominoplasties (type II, mini abdominoplasty; type III, modified abdominoplasty); and type IV, abdominoplasty with or without liposuction. This is referred to as the abdominolipoplasty system of classification and treatment for abdominal contouring surgery.4 As indicated, liposuction is considered an integral component of type I to III abdominal contouring procedures. Type IV (full abdominoplasty) was performed with (lipoabdominoplasty) or without liposuction of the abdomen. All operations were performed as outpatient procedures.
From the database, a total of 562 patients underwent 568 procedures. Table 1 lists the distribution of procedures performed. Secondary abdominal contouring surgery was defined as any type of additional abdominal contouring surgery of the abdomen in a patient who had previously undergone abdominal contouring surgery, excluding revisions (e.g., scars or dog-ear revisions). The same definition was used in prior publications.4 The senior author (A.M.) performed the primary abdominal contouring procedure on some of the patients. Included in this cohort are patients who had two or more abdominal contouring procedures. Patients whose first abdominal procedure was nonsurgical (e.g., energy-based treatments) were excluded, as these procedures were not considered secondary, nor were massive weight loss or revision patients included. All statistical evaluations were performed using a two-tailed t test.
Incidence and Patient Characteristics
Secondary abdominal contouring procedures were performed at a rate of 13.0 percent (73 of 562 total patients). The charts of 46 of 73 patients who underwent secondary abdominal contouring surgery were available to be analyzed in detail. Eighty-nine percent of these patients (n = 41) were women with an average age of 50.1 years (range, 32 to 66 years) and an average body mass index of 25.5 kg/m2 (range, 19.5 to 30 kg/m2). In addition, 11 percent of patients (n = 5) were active smokers (average pack-years, 21; range, 10 to 30) and 7 percent (n = 4) were former smokers (average pack-years, 24; range, 10 to 35). Twenty-seven of 41 women had children, with an average of 1.88 children per patient (range, 0 to 4 children). The average time between primary and revision surgery was approximately 18 months, and the average time between primary abdominal contouring surgery and a complete new secondary operation was approximately 4.98 years.
Primary and Secondary Abdominal Procedures
There were a total of 35 secondary liposuction procedures and 11 or more secondary, tertiary, or quaternary full abdominoplasty procedures. These occurred at 3.16 and 8.35 years after the initial procedures, respectively.
Thirty-nine percent of patients (18 of 46) had previously undergone abdominal liposuction. Of the group who initially underwent liposuction, 83 percent (15 of 18) had secondary liposuction and three patients had secondary surgery with a full abdominoplasty. At the first operation, 61 percent (28 of 46) had either a mini (n = 1) or full abdominoplasty (n = 27). Of the group who initially underwent abdominoplasty, 69 percent (19 of 28) had secondary liposuction and nine patients (31 percent) had secondary full abdominoplasty. There were no major systemic complications (Fig. 1).
These groups were also analyzed according to body mass index. In 26 patients with a body mass index less than 25 kg/m2 (mean body mass index, 20.5 kg/m2), 30 percent (three of 10) who had primary liposuction and 44 percent (seven of 16) who had primary abdominoplasty underwent secondary abdominoplasty. In 20 patients with a body mass index greater than 25 kg/m2 (mean body mass index, 28.6 kg/m2), the only secondary procedure performed was liposuction. The difference in the average body mass index between these two groups was statistically significant (p < 0.0001) (Fig. 2). The average lipoaspirate in patients with a body mass index greater than 25 kg/m2 was 2025 ml, which was 820 ml greater than the average in patients with a body mass index less than 25 kg/m2 (1205 ml) (p = 0.09).
The average time between primary and secondary abdominal procedures for all 46 patients was 4.98 years (range, 6 months to 15 years). Thirty-four patients underwent secondary liposuction on average 3.16 years after the initial procedure, and 11 patients underwent secondary abdominoplasty 8.35 years after the initial procedure (p = 0.002). In patients who underwent liposuction, the average volume aspirated during all secondary procedures was 1675 ml (range, 300 to 5700 ml). The average volume of lipoaspirate was greater if a patient had previously undergone a type I procedure (1885 ml) compared with a type IV procedure (1483 ml). The average weight of the abdominoplasty flap removed in all secondary abdominoplasty procedures was 389.5 g (range, 198 to 512 g). The average weight was similar whether the patient had previously had a type I procedure (liposuction alone, −399 g) or a type IV procedure (abdominoplasty, −388 g) (Table 2).
In the senior author’s earlier report, revision surgery (e.g., dog-ear excisions) was included, and early versus late timing of surgery was assessed.2 In this report, only patients who underwent full secondary operations were included. Cormenzana et al. reviewed their experience with 21 patients who underwent secondary abdominoplasty. The majority of these secondary operations were for patients who were dissatisfied with their initial procedure because of inadequacy or asymmetry, whereas four patients, because of aging, required secondary procedures over 10 years after their initial procedures.3 In that article, Cormenzana also argued against wide lateral undermining of the abdominoplasty flaps because of concerns about blood supply and viability.3,5 The authors of this study believe that, because the flap has undergone a “delay phenomenon” from the primary procedure, undermining may be safely performed even more extensively during the secondary procedure.6 This is often necessary in secondary full abdominal contouring procedures to recruit sufficient tissue to ensure appropriate wound location and closure. A recent report by Kenkel et al. debunks the notion that even primary lipoabdominoplasty flaps require narrow (inverted V) flap undermining to preserve the blood supply.7
The limitations of this study include the fact that not all secondary patients were captured and evaluated because of patient compliance and record maintenance. Forty-six of the 73 secondary patients were evaluated in detail, which could impact some of the conclusions. The 13 percent incidence of secondary surgery includes patients that were the senior author’s primary patients and patients who came to our practice after a primary procedure performed by another surgeon. It does not include the senior author’s primary patients who went elsewhere for secondary surgery. Therefore, it represents the total percentage of secondary procedures of all patients who were operated on during this period by the senior author.
In addition, the patient demographic data were not stratified according to procedures or other characteristics but rather by the entirety of the group. We did not report patient weight at the time of surgery. Finally, to our knowledge, based on the fact that none of these patients has yet returned for further abdominal surgery to our practice, they are satisfied with the results.
Common Scenarios of Secondary Abdominolipoplasty and Abdominal Contour Surgery
We found an overall rate of 13.0 percent of secondary abdominal contouring procedures. Given that over 300,000 abdominal contouring procedures are performed every year in the United States, this represents a substantial potential population of approximately 39,000 patients annually.1 Each of these secondary procedures creates its own challenges for the surgeon performing secondary abdominal contouring.
Secondary operations by their very nature are fundamentally different from the primary procedure. Inasmuch as abdominal contouring surgery represents a group of different operations (albeit in the same anatomical region), the secondary operation can therefore be a completely different procedure than the first. This might be considered more akin to a primary breast augmentation patient later having a secondary breast procedure that is a mastopexy, in contrast to a face-lift patient undergoing a second face lift.
The following are five common scenarios for which primary and then secondary abdominal contouring surgery is performed (Table 3). Potential problems that may be encountered are identified and the following recommendations made.
Primary Liposuction with Secondary Liposuction
An issue in this group is any scarring and contour irregularities from the initial surgical procedure or whether the aesthetic units of the abdomen were treated incompletely or unevenly (Fig. 3). That may be exacerbated if the primary liposuction incorporated devices that transmit energy (e.g., laser or ultrasound), although the long-term consequences of these devices have not been elucidated. Patients who present with irregularities can be treated according to the “hill-valley” concept corresponding to the nature of the deformity: autologous fat grafting to fill in contour abnormalities or secondary liposuction to treat any pseudodivots in areas of excess fat. Depending on the severity of the deformity, these patients may be candidates for the SAFELipo technique described by Wall.8 SAFE (an acronym for fat separation, aspiration, and equalization) relies on an angled exploded tip (basket) cannula. In this three-step process, fat is broken up by the cannula (separation), areas of excess fat are removed (aspiration), and postunneling is used to leave behind a smoothed area of separated fat, acting as a local fat graft.8
If the problem is attributable to significant skin laxity, damaged skin, or diastasis recti, full abdominoplasty with or without liposuction may be an appropriate alternative (see later under Primary Liposuction with Secondary Abdominoplasty). The quality of the results from secondary liposuction varies according to the nature of the defect encountered. Anecdotally, the most gratifying results occur when the secondary deformity encountered is excess fat that requires additional liposuction.
Power-assisted liposuction was used for both primary and secondary liposuction when performed by the senior author. The least satisfactory results occurred in patients whose problem from prior liposuction resulted in the abdomen being so severely oversuctioned that it had the appearance of a skin graft on top of the rectus muscle (Fig. 3).
Primary Liposuction with Secondary Abdominoplasty
The most common reasons for secondary surgery in patients who have previously undergone liposuction and who then require an abdominoplasty are complaints of skin laxity or bulging caused by rectus muscle diastasis. Patients who have previously undergone abdominal suction-assisted lipectomy may develop small subcutaneous pseudobursas and subcutaneous scarring.6 The scarring from prior surgery and these pseudobursas can restrict an undermined skin flap from fully unfurling. This should be accounted for when demarcating the planned skin excision to avoid overresection of the abdominal flap and difficulty with wound closure in secondary procedures. This is particularly germane because the senior author performs a vest-over-pants or preexcision of the pannus technique (the superior incision is made first), somewhat committing himself to final suture line position. To maximize the flap expansion, it is useful to widely undermine and possibly score the Scarpa fascia on the underside of the abdominoplasty flap. The final suture line may also need to be raised from an otherwise optimal lower level (Fig. 4) to close the wound. Figure 5 demonstrates the maneuver that can be performed preoperatively to estimate the extent of resection in these situations.
In addition, patients in this group are at increased risk for prolonged drainage and seroma formation postoperatively. In our opinion, all of these patients (primary liposuction followed by secondary abdominoplasty) are at a significantly greater risk of hematoma formation. Our data bear this out, although the sample size of hematomas that occurred is too small for statistical verification. Therefore, we ascertain that a history of prior liposuction in an abdominoplasty patient represents an independent risk factor for hematoma formation, similar to the risk of nonsteroidal antiinflammatory drugs, aspirin, nutraceuticals, among others, although by a different mechanism of action.
No patients who had primary liposuction required secondary mini or modified abdominoplasty, although this is theoretically possible. There were no secondary limited abdominoplasties. However, if a patient presented with lower diastasis or minimal excess skin, they were a candidate for a limited abdominoplasty.
Primary Modified Abdominoplasty with Secondary Full Abdominoplasty
The umbilicus has a dual blood supply, from the surrounding skin and the stalk itself. If during the primary modified abdominoplasty the umbilical stalk was severed (detached or “floated”), the umbilicus would be deriving its blood supply from the surrounding skin. Consequently, during a secondary full abdominoplasty when the umbilicus is circumscribed, the remaining blood supply is sacrificed, potentially leading to vascular compromise of the umbilicus. We advise obtaining earlier surgical records to determine what was done at the primary operation if possible and clearly communicating this risk to the patient. An alternative would be to perform a lower abdominoplasty (where the umbilicus is not manipulated surgically; instead, just the lower one-fourth of abdominal skin or the equivalent of approximately half of the skin between the umbilicus and pubis is removed, with repair of the lower rectus muscle as indicated), which avoids most umbilical issues. In this scenario of prior umbilical transection, other maneuvers such as surgically “delaying” the umbilicus may also be useful.
Liposuction is an integral component of the success of most primary modified abdominoplasties. Consequently, these patients have had liposuction as part of their first procedure and rarely require secondary surgery for liposuction alone (Fig. 6).
Primary Abdominoplasty with Secondary Liposuction
Liposuction may be necessary as a secondary procedure after abdominoplasty. The need for a secondary abdominal contouring procedure by liposuction most commonly occurs because liposuction was not performed or was not available during the initial procedure, because of patient or surgeon preference or because it was insufficiently performed (Fig. 7). No specific treatment recommendations are necessary that would be different from those ordinarily recommended for liposuction. Our observation in these secondary situations is that there is less fat to be suctioned than would have been estimated preoperatively. We have not noticed any trends in which areas of the abdomen require secondary liposuction following a primary abdominoplasty.
Primary Abdominoplasty with Secondary Abdominoplasty
In the entire group of secondary contour patients (n = 73), there were at least four tertiary full abdominoplasties (Fig. 8). There are multiple reasons for a secondary full abdominoplasty: aging, additional pregnancies, or inadequate primary treatment. There are often four “common concerns” of patients requesting a secondary abdominoplasty after a prior abdominoplasty: (1) excess skin laxity, often of the upper abdomen or flanks; (2) rectus diastasis, frequently of the upper abdomen; (3) excess lipodystrophy; and (4) desire for the removal of vertical scar resulting from closure of the original umbilicus site. Grazer and Goldwyn wrote about the importance of removing the umbilical-site scar in their landmark 1977 article.9 Removal of this vertical scar has been the most common reason for patients presenting for secondary abdominoplasty in our series.
Often in these secondary or more abdominoplasty patients, there is enough loose skin to trouble patients but not an overabundance of abdominal skin, which allows all of the tissue below the umbilicus (thereby removing the umbilicus scar) to be readily removed. Consequently, there are several strategies that are useful for maximizing flap mobilization. Given the presence of scar tissue on the undersurface of a previously operated abdominoplasty flap, it may be useful to score the undersurface of the flap to maximize expansion, similar to scoring the galea in a scalp flap.6 The operating room table should also be maximally flexed during closure to optimize resection (Miami Beach chair position). It is essential to have an open line of communication with the anesthesiologist for intraoperative patient positioning. Furthermore, because the flap has been effectively delayed, unlike during the primary abdominoplasty where it may be recommended to undermine narrowly in an inverted-V pattern, in secondary operations, wide flap undermining may in fact be necessary and useful. In addition, the new secondary incision may have to be placed higher than ideal to completely remove the old umbilical-site scar and the first incision.
Nahas and Ferreira10 have reported recurrence of the diastasis over time, as demonstrated by computed tomographic scanning following abdominoplasty. In our experience, most of the secondary abdominoplasty patients do benefit from reinforcement of their earlier diastasis repair, similar to what would be done in a primary abdominoplasty (Figs. 9 and 10). This is done by vertical rectus muscle closure, from xiphoid to the pubis. Often, the first repair leaves the appearance of a “fused” layer of scarred rectus muscle fascia and thus the diastasis does not appear as it would in the unoperated abdomen.
Complete secondary abdominal surgery procedures, rather than revision surgery, can be expected to be increasingly more common.11 In this series, secondary procedures occurred at a rate of 13.0 percent. The rate could exceed 13 percent because this does not account for patients lost to follow-up or those primary abdominal procedures that were nonsurgical. The authors report on five common scenarios in which patients present for secondary abdominoplasty and abdominal contour surgery, their pitfalls, and technical recommendations for each of these situations.
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