Costa-Ferreira et al. report the findings of their level I study and conclude that preservation of the Scarpa fascia significantly reduces the incidence of seromas after abdominoplasty.1 Patients were randomized, with 80 patients in each group. These authors report a seroma rate of 18.8 percent among control patients and 2.5 percent for the study group. Among measured parameters, there were no other significant differences between groups. It would seem the authors’ conclusions, which confirm their a priori hypothesis,2 are undeniable. Or are they?
This article was of great interest to me because I perform essentially a traditional abdominoplasty, with simultaneous liposuction of the epigastrium and flanks in most cases (the authors treat the flanks only). My seroma rate is 5.4 percent—only marginally higher than the rate reported by these investigators—yet I do not preserve the Scarpa fascia on the lower abdominal wall.3 The authors’ findings and my own, both obtained from prospective studies of large patient groups, appear contradictory. How might the difference be explained?
The authors’ previous study illustrates their operative technique.2 The authors use electrodissection for their subfascial dissection. However, they use a manual distraction (“avulsion”) technique in patients treated with Scarpa fascia preservation. It would appear that the extent of electrodissection is a variable that was not applied equally between the authors’ two study groups and therefore represents a confounding factor. In my abdominoplasties, the abdomen is infused with up to 1 liter of anesthetic solution containing bupivacaine (0.025%) and epinephrine (1:526,000) at least 20 minutes before abdominal liposuction. The flap is raised subfascially by scalpel dissection. Electrocautery with pinch-activated forceps is used only to treat individual blood vessels, not for tissue dissection. Because bleeding is greatly reduced by the wetting solution, Bovie dissection is unnecessary. The mean estimated additional blood loss from abdominoplasty performed at the same time as liposuction is a modest 290 cc.4
Costa-Ferreira et al. postulate that lateral preservation of the Scarpa fascia preserves deep lymphatic drainage channels and therefore reduces the risk of fluid accumulation.1,2 This explanation has no known physical basis. This superfluous tissue—the Scarpa fascia and deep fat—is removed in the traditional technique so that its lymphatic drainage is irrelevant. Furthermore, seroma fluid is more accurately characterized as an inflammatory exudate,5 rather than a collection of purely lymphatic fluid. One need not speculate as to the mechanism of increased seromas in patients treated with electrodissection. The cause has a simple explanation. Electrodissection produces an internal burn, inciting an inflammatory response that causes increased capillary permeability and fluid accumulation. This uncontrolled variable explains both the authors’ findings and the increased frequency of this complication when electrodissection is used for flap elevation.6 There is no evidence that the nature of the healing surfaces (fat or fascia) is relevant to seroma formation.
One might consider whether to preserve this tissue layer on the abdominal wall out of an abundance of caution. However, there are disadvantages in doing so. The thickness of the abdomen is increased by stacking the fascial layers. The authors comment that they were surprised that their surveys did not reveal an inferior aesthetic result, evidently anticipating one from their own observations. However, they should not be overly reassured; their surveys are probably insufficient to detect such a difference. The fact that no before-and-after photographs are provided with either this publication or the authors’ original article is not reassuring.1,2
In addition to creating excessive thickness, Scarpa fascia preservation on the abdominal wall may compromise the quality of the wound closure, and perhaps account for an increased propensity for wound healing problems.1 A deep fascial repair is needed to anchor the flap inferiorly and prevent upward migration of the scar and the hair-bearing mons pubis (Fig. 1). The key to patient satisfaction is not the length of the scar but its vertical level. If the scar is kept within the bikini line, patients report low rates of scar dissatisfaction (4.3 percent).3 A flexed position of the operating table (not so much “beach chair” as “jackknife”) is essential to allow a secure deep fascial repair and keep the scar low.
Seromas can be a source of frustration for the patient and surgeon. The remedy is not particularly difficult but does involve changing a surgical habit. Reducing the need for seroma treatment would seem to justify such a change. There is no need to adopt a different dissection plane that creates aesthetic compromises. The goal is to reduce the risk of complications while maintaining an optimal aesthetic result.
The author has no financial interests to disclose in relation to the content of this communication. This study received no outside funding.
Eric Swanson, M.D.
11413 Ash Street
Leawood, Kans. 66211
1. Costa-Ferreira A, Rebelo M, Silva A, Vásconez LO, Amarante J. Scarpa fascia preservation during abdominoplasty: Randomized clinical study of efficacy and safety. Plast Reconstr Surg. 2013;131:644–651
2. Costa-Ferreira A, Rebelo M, Vásconez LO, Amarante J. Scarpa fascia preservation during abdominoplasty: A prospective study. Plast Reconstr Surg. 2010;125:1232–1239
3. Swanson E. Prospective outcome study of 360 patients treated with liposuction, lipoabdominoplasty, and abdominoplasty. Plast Reconstr Surg. 2012;129:965–978 discussion 979–980.
4. Swanson E. Prospective study of lidocaine, bupivacaine, and epinephrine levels and blood loss in patients undergoing liposuction and abdominoplasty. Plast Reconstr Surg. 2012;130:702–722 discussion 723–725
5. Prado A, Andrades P. Composition of postabdominoplasty seroma. Aesthetic Plast Surg. 2007;31:514–518
6. Kim J, Stevenson TR. Abdominoplasty, liposuction of the flanks, and obesity: Analyzing risk factors for seroma formation. Plast Reconstr Surg. 2006;117:773–779
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