All surgery was performed by the author in a state-licensed ambulatory surgery center, with anesthesia administered by an anesthesiologist or certified nurse anesthetist using a total intravenous anesthetic.4 Sequential compression devices were used. No patient received enoxaparin.
Statistical analyses were performed using IBM SPSS for Windows version 20.0 (IBM Corp., Armonk, N.Y.). Independent t tests were used to compare means of continuous variables for 2 groups of patients. Pearson’s chi-square test of independence was used to compare categorical variables. Correlations were tested using Pearson correlations. A value of P < 0.01 was considered significant. An a priori power analysis was performed for the independent t test. To achieve 80% power for a two-tailed t test, with an α level of 0.01, sufficient to detect a medium-sized treatment difference (d = 0.50), 192 patients would be needed.
The age and follow-up times for each of the 3 groups were similar (Table 1). Most patients (61.5%) underwent simultaneous cosmetic procedures of the face or breasts.
The overall complication rates were 4.2% for liposuction alone and approximately 50% for patients treated with an abdominoplasty (Table 2). There were no deaths. Three patients were admitted to hospital. One patient who developed a deep venous thrombosis after lipoabdominoplasty was hospitalized for anticoagulation. Another patient was hospitalized 3 weeks after surgery to treat a methicillin-resistant staphylococcal infection, likely contracted from her infected partner. This was also the only patient to receive a blood transfusion. A third patient was hospitalized overnight after surgery for suspected negative pressure pulmonary edema, possibly caused by laryngospasm.
The most common complication after abdominoplasty was an umbilical scar deformity (17.4%), treated with a scar revision under local anesthesia in the office. There were 9 clinical seromas after abdominoplasties (5.4%). All of these were treated successfully by needle aspiration in the office. The mean number of aspirations was 5, with a range of 1–12. The mean time of the last aspiration was 28 days after surgery (range, 15–43 d). The mean aspirate volume was 74 cm3 (range, 3–240 cm3).
No significant correlations were detected between the overall incidence of complications and patient age, smoking history, or body mass index. Men had fewer complications than women overall, but this finding was related to the fact that fewer men underwent an abdominoplasty. There were significantly (P < 0.01) more cases of delayed wound healing in smokers (6.2%) than nonsmokers (1.5%).
Large sample sizes increase statistical power and improve reliability.7 For over 2 decades, liposuction and abdominoplasty have been performed together.6,8 However, limited prospective data are available comparing this combination with the individual procedures. Because the patients in this study were scheduled regularly for postoperative blood tests, photographs, and surveys as part of their contemporaneous investigations,1–4 patient follow-up was optimized, improving the reliability of the data, and tracking of complications.
The absence of infection as a complication among the 384 ultrasonic liposuction cases is remarkable but not unusual.9,10 The low overall complication rate after liposuction, 4.2%, is also typical.10–12 Seromas after liposuction were notably absent, likely because ultrasound times were limited (<5 min for the abdomen in primary liposuction; <1 min for the epigastrium in lipoabdominoplasty).
Complication rates after abdominoplasty vary widely, from 0% to 43%, depending largely on the investigator’s definition of a complication.13–27 Although a 50% complication rate is high, a wide net was used in assigning complications. The 10.8% infection rate includes patients with redness, indicating possible cellulitis, that were treated with antibiotics as a precaution. Patients who had minor spreading of the lateral aspect of their umbilical scar or a tiny bump at the end of the abdominoplasty scar were included. If such minor complications treated under local anesthesia in the office (Table 3) are excluded, the complication rate drops to approximately 25%. The author has a low threshold for performing touchups in the office, which are provided at no charge. In many cases, the patients did not mention any concerns regarding their scars; it was their surgeon’s opinion that they could be improved by revision. Patients are informed before surgery that these touchups are common and may be needed to optimize the scar quality. Patients do not typically regard such minor issues as complications. The complication rate as reported by patients after abdominoplasty was 21%.2
Only 3% of patients reported nausea in the recovery room, compared with 35% in plastic surgery in general.28 No patient vomited in the recovery room. No patient required a postoperative hospital admission for treatment of nausea or dehydration.
Nausea is a major cause of patient dissatisfaction after surgery,18,29 and it is the most frequent cause of delayed discharge16 and unplanned hospital admissions.18 Avoiding an inhalational agent reduces the risk of nausea and vomiting,4 which is particularly important after abdominoplasty to avoid disrupting the muscle diastasis repair. Reducing the use of narcotics and benzodiazepines also reduces nausea and shortens recovery time. The mean length of stay in the recovery room was 50.7 minutes (range, 20–159 min), much shorter than reported stays for patients treated with conscious sedation using midazolam and fentanyl (mean, 235 min; range, 95–520 min).16 An improved balance of greater anesthesia at the tissue level and less anesthesia systemically improves patient comfort, expedites recovery, and reduces troublesome side effects from systemic analgesics.4
Nine patients (5.4%) developed a seroma after an abdominoplasty, lower than the rate reported in most other series (range, 3.5–32%).5,13,18–21,25,27,30–36 In all cases, this problem was successfully treated with needle aspirations in the office, without a need for reoperation. In several patients this amounted to a nuisance (1 patient had a single aspiration of 3 cm3), not necessarily rising to the level of a complication as perceived by patients. Only 4 of these patients reported a seroma as a specific complication separate from delayed wound healing in 2 patients and an infection in 3 patients.2 Preservation of a layer of areolar tissue above the abdominal wall has long been recommended to reduce seroma rates.16,31,37,38
Saldanha et al39 describe a technique of performing abdominoplasty that limits tissue undermining and preserves the Scarpa fascia, as originally proposed by Le Louarn.38 These authors report a greatly reduced rate of seromas.39 Costa-Ferreira et al40 recently published a prospective randomized study of abdominoplasty patients, examining seroma risk in patients treated with and without preservation of the Scarpa fascia, reporting a significantly reduced rate of this complication in patients treated with preservation of the Scarpa fascia.
The physical basis for preservation of the Scarpa fascia on the abdominal wall on each side of the lower abdomen (this fascia is resected in the midline) is unclear. Any claim of improved lymphatic function or less opportunity for leak of lymphatic fluid by dissecting above this fascial plane does not have a known basis in anatomy or physiology.41 After traditional removal of the Scarpa fascia and deep fat, there would theoretically be no need for its lymphatic drainage. In fact, leaving behind this partially dissected layer of fat and connective tissue, which may be subjected to the additional trauma of open liposuction,39 might be expected to cause more exudate to leak into the wound. There is no evidence that the nature of the healing surfaces (fat or fascia)40 is relevant to seroma formation. Quilting sutures have also been recommended to reduce seromas,42–45 although there is a substantial extra commitment in operating time.44
Some investigators report an increased risk of seromas in patients treated with simultaneous liposuction27,36; others find no increased risk.21,46 The absence of seromas among patients treated with liposuction alone in this study attests to its safety. Today, most surgeons recognize the importance of treating the flanks with liposuction to eliminate the unattractive “muffin top” deformity. If the epigastrium is not treated with liposuction at the time of abdominoplasty, many patients will complain of persistent excessive fullness of the upper abdomen, which may appear even fuller in contrast to the reduced lower abdomen. Simultaneous liposuction of the flanks and epigastrium optimizes the surgical benefit and reduces the need for subsequent surgery. Limiting epigastric ultrasound (<1 min) and liposuction times (<2 min) minimizes risk.
A problem with preservation of the Scarpa fascia and deep fat on the abdominal wall is increased abdominal thickness as the superior abdominoplasty flap is transposed over the lower abdomen, stacking the 2 fascial layers. The quality of the wound closure may be compromised. Costa-Ferreira et al40 report a trend toward more wound healing problems among patients treated with Scarpa fascia preservation. Some proponents of lipoabdominoplasty recommend discarding the lower abdominal Scarpa fascia.47
Avoidance of Electrodissection
The use of Bovie dissection has been implicated as a possible cause of increased tissue necrosis and seromas.16,37 Electrodissection has long been recommended to reduce blood loss8 (before infusion of the abdomen with epinephrine solution was commonly performed) and is used by most plastic surgeons for flap dissection. However, cutting electrocautery produces an internal burn injury, with the usual pathophysiology of such an injury consisting of increased capillary permeability leading to fluid accumulation. Electrodissection causes more tissue destruction and seroma formation than scalpel dissection.48 When the seroma fluid is examined, it is found to resemble an exudate, containing proinflammatory cytokines,48 distinguishing it from purely lymphatic fluid.48,49
The author uses a scalpel exclusively for tissue dissection and a 9 ½ inch (24 cm) Potts-Smith monopolar, insulated, serrated, 2.0 mm handswitch cautery forceps (Kirwan Surgical Products, Marshfield, Mass.) for individual vessels. This technique is facilitated by a wetting solution that is given sufficient time to provide its hemostatic effect (at least 20 min).4 Doubling the concentration of epinephrine (1:526,000) makes vasoconstriction more effective without increasing the risk of skin loss or toxicity.4 The effects of this pretreatment can be profound; even the large superficial inferior epigastric vessels may constrict to the point that they sometimes do not bleed after scalpel transection (but are cauterized regardless). Estimations of blood loss reveal a mean additional blood loss of 290 cm3 from abdominoplasty performed at the time of liposuction.4 Reduced bleeding makes electrodissection unnecessary and avoids a major risk factor for seroma formation. It is also noteworthy that there were no hematomas in this large series of patients, suggesting that rebound bleeding after vasoconstriction is not a clinical problem. Only 4 of the 9 patients who developed a seroma reported it as a complication on their surveys,2 suggesting the problem did not have a major impact on their recovery and result.
The study by Costa-Ferreira et al40 attempts to definitively answer the question regarding any benefit of Scarpa fascia preservation,40 as hypothesized in their earlier study.50 The fact that the present study that does not include Scarpa fascia preservation also features a low seroma rate speaks against the conclusion that Scarpa fascia preservation alone is responsible for the reduced seroma rate. How can the study results be reconciled? Costa-Ferreira et al50 illustrate subfascial tissue resection using Bovie dissection. However, in the group treated with fascial preservation, the superficial tissue is mechanically distracted from the deep layer (“avulsed”), without electrodissection.50 The authors’ conclusions might therefore be explained by this confounding variable. There is no need for conjecture about lymphatic drainage patterns. Simply reducing the tissue burn explains the lower seroma rate and can explain the results of the present study, which otherwise seem contradictory. A reduced risk of seromas with scalpel dissection is not limited to abdominoplasty surgery; fewer seromas are also documented after mammaplasty.51,52
Any benefit from techniques that restrict undermining to a central strip in the upper abdomen may actually be a consequence of reduced tissue injury from electrodissection rather an improved blood supply to the abdominal flap. By overly limiting the degree of tissue undermining, flap mobilization and ultimately scar quality are compromised.
Deep Fascial Anchoring
One might reasonably ask why not preserve the Scarpa fascia out of an abundance of caution. There are 2 reasons: One is the increased abdominal thickness, as discussed above. The other reason is that the deep fascial repair can anchor the superior flap and prevent upward migration of the mons pubis (Figs. 4 and 5). Saldanha et al39 redrape the superior flap using a two-layer superficial fascial and skin closure with no deep fascial repair. These authors rely on their lateral wound closure to reduce central wound tension rather than a deep fascial repair. They remove additional skin at the end of the procedure in an attempt to lower the incision line. This method does not seem to be effective in avoiding a scar that is too high and difficult to conceal in a bikini. The hair-bearing pubic skin is displaced on to the lower abdomen (Fig. 6). This issue a practical concern for women and their clothing.
The vertical level of the scar is more important than its horizontal length. It is essential to keep the scar low so that it may be concealed. Liposuction of the mons pubis avoids a contour mismatch with the reduced lower abdomen. A layered repair ideally causes temporary eversion of the tissues48 and avoids a depressed scar. With these measures, patient scar dissatisfaction may be limited to 4.3%.2
Preservation of the Scarpa fascia on the abdominal flap is needed to allow deep fascial closure, and may also better preserve the vascularity of the abdominal flap, explaining the low rate of delayed wound healing encountered in the present study. Flexed positioning of the operating table is important. It has long been appreciated that intraoperative patient positioning with the hips flexed (the “beach chair” position) is helpful.53 The author uses a more flexed position, a supine jackknife position. Simultaneous Trendelenburg positioning of the operating table and back elevation provide hip flexion up to 90 degrees (Fig. 3). This position may seem peculiar in the operating room, with the lower extremities elevated 45 degrees and one might reasonably wonder how long it will take for the patient to resume a fully erect position after surgery. The mean time for fully erect standing is 3 weeks.2 In the author’s experience, all women will trade an extra week of walking in a slightly stooped position for a scar that may be tucked within their panty line. Another advantage of such maximum intraoperative flexion is that an unattractive vertical midline scar (inverted-T) may be avoided in almost all cases.
Deep Venous Thrombosis
Chemoprophylaxis is being increasingly recommended to prevent thromboembolism.54 However, there are safer ways to reduce the risk of this complication, and ones that are aimed at the root of the problem—venous stasis.4,55
Limitations of the Study
Conclusions are applicable to liposuction and abdominoplasty performed using a superwet technique and ultrasonic assistance under a total intravenous anesthetic with scalpel dissection. Other surgical and anesthesia techniques are likely to have different outcomes.
Strengths of the Study
Because of its prospective nature, large sample sizes, consecutive patients, and the consistency of 1 surgeon and technique, this study benefits from a high degree of reliability and little opportunity for confounding factors that might affect the conclusions.
Liposuction and abdominoplasty, individually and in combination, may be performed safely with appropriate measures to reduce complications by minimizing tissue trauma. Scalpel dissection is preferred. Scarpa fascia preservation is unnecessary. A deep fascial repair can assist in keeping the abdominoplasty scar within the bikini line. Flexed patient positioning in surgery is essential. Deep venous thrombosis and other complications may be minimized using safe precautions without anticoagulation. Scar revisions, particularly of the umbilicus, remain common. (For the full video, see video 6, which demonstrates a patient undergoing liposuction of the abdomen, flanks, and inner thighs, followed by an abdominoplasty and medial thigh lifts. It includes preoperative marking, the preparation of the patient, details of the total intravenous anesthetic and infusion solutions, body positioning including the jackknife position, and details of the wound closure including deep fascial anchoring sutures. A short segment on the medial thigh lifts is provided and the patient is also seen in follow-up 24 h after surgery. The full video is available in the “Related Videos” section of the full-text article at http://www.PRSGO.com.)
The author thanks Jane Zagorski, PhD, for statistical analyses; Lindsey Kroenke, BSN, for data collection; and Gwendolyn Godfrey for the illustration.
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